Genetic and environmental influences on alpha amylase stress reactivity and shared genetic covariation with cortisol

Salivary alpha amylase (sAA) is a common measure of stress reactivity, primarily reflecting sympathetic nervous system activity. Salivary cortisol is also a reliable, frequently used biomarker of stress and reflects the hypothalamic-pituitary-adrenal (HPA) axis response. This study examined heritability across varying metrics of sAA in response to a social evaluative stressor, the Trier Social Stress Test (TSST). The goal of this study was to estimate genetic and environmental influences on measurements of sAA stress reactivity. Moreover, we evaluated the shared genetic covariation between sAA and cortisol. Participants included twins aged 15-20 years (54% female). We measured alpha amylase and cortisol reactivity to the TSST via serial salivary cortisol samples collected pre- and post-TSST. Modest to moderate heritability estimates (11-64%) were observed across measures purported to capture alpha amylase stress reactivity (peak, area under the curve, baseline-to-peak change). Findings also indicate that sAA baseline and peak are primarily influenced by a shared genetic factor. There was no evidence of shared genetic influences between sAA and cortisol. These findings suggest the genetic control of the HPA and Sympathetic Adreno-Medullar axis are genetically independent of one another despite both playing a role in response to stressors.

An Update on Precision Medicine Advances In Neurodevelopmental Disorders

Neurodevelopmental disorders, including autism spectrum disorder (ASD) and attention-deficit/hyper-activity disorder (ADHD), represent a group of conditions that manifest early in child development and produce impairments across multiple domains of functioning. Although a number of pharmacological and psychosocial treatments exist to improve the symptoms associated with these syndromes, treatment advances have lagged. The Precision Medicine Initiative was launched with the goal of revolutionizing medicine by progressing beyond the historical one-size-fits-all approach. In this review, we evaluate current research efforts to personalize treatments for ASD and ADHD. Most pharmacogenetic testing has focused on the cytochrome P450 enzyme family with a particular focus on CYP2D6 and CYP2C19, which are genes that produce an enzyme that acts as a key metabolizer of many prescribed medications. This article provides an update on the state of the field of pharmacogenetics and "therapy-genetics" in the context of ASD and ADHD, and it also encourages clinicians to follow US Food and Drug Administration recommendations regarding pharmacogenetic testing.

Quantifying Dispositional Fear as Threat Sensitivity: Development and Initial Validation of a Model-Based Scale Measure

The Research Domain Criteria initiative aims to reorient the focus of psychopathology research toward biobehavioral constructs that cut across different modalities of measurement, including self-report and neurophysiology. Constructs within the Research Domain Criteria framework are intentionally transdiagnostic, with the construct of "acute threat," for example, broadly relevant to clinical problems and associated traits involving fearfulness and stress reactivity. A potentially valuable referent for research on the construct of acute threat is a structural model of fear/fearlessness questionnaires known to predict variations in physiological threat reactivity as indexed by startle potentiation. The aim of the current work was to develop an efficient, item-based scale measure of the general factor of this structural model for use in studies of dispositional threat sensitivity and its relationship to psychopathology. A self-report scale consisting of 44 items from a conceptually relevant, nonproprietary questionnaire was first developed in a sample of 1,307 student participants, using the general factor of the fear/fearlessness model as a direct referent. This new Trait Fear scale was then evaluated for convergent and discriminant validity with measures of personality and psychopathology in a separate sample (n = 213) consisting of community adults and undergraduate students. The strong performance of the scale in this criterion-validation sample suggests that it can provide an effective means for indexing variations along a dispositional continuum of fearfulness reflecting variations in sensitivity to acute threat.

The relationship between on-campus service utilization and common mental health concerns in undergraduate college students

Little research exists into the trends associated with on-campus service utilization for mental health concerns of college students. Rates of broad service utilization exist, but no published study has examined the direct relationship between a range of common mental health symptoms and on-campus service utilization. The aims of the present study are to explore (1) which common mental health concerns are associated with specific on-campus service utilization in undergraduate students and (2) whether endorsement of more mental health concerns will predict a higher number of services utilized. Data were utilized from 3,734 undergraduates at a large (more than 20,000 undergraduates), urban university (Mage = 19.94 years, SD = 0.55 years; female = 66%). Four on-campus services (University Counseling Services, University Health Services, The Wellness Resource Center, and Disability Support Services) were regressed onto mental health concerns associated with symptoms of three disorders (anxiety, depression, alcohol use disorder [AUD]) and two mental health risk factors (stressful life events [SLEs], antisocial behaviors [ASBs]). AUD symptoms predicted the most overall and specific service utilization, followed by depression symptoms and SLEs. Anxiety symptoms and ASBs were not significant predictors when combined with other variables. This is the first study to investigate trends specific to on-campus college student service utilization. Findings will be helpful to mental health professionals on similar college campuses by providing insight into programming and outreach initiatives for these or related services. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Heritability, stability, and prevalence of tonic and phasic irritability as indicators of disruptive mood dysregulation disorder

BACKGROUND

Little is known about genetic and environmental influences on the components of disruptive mood dysregulation disorder (DMDD), tonic irritability (i.e., irritable mood) and phasic irritability (i.e., temper outbursts). This study examined prevalence, stability, and heritability of tonic irritability, phasic irritability, and a DMDD proxy (pDMDD) based on DSM-5 criteria.

METHODS

pDMDD was derived using data from clinical interviews of parents and their twins (N = 1,431 twin pairs), ages 8-17, participating in Waves 1 and 2 of the Virginia Twin Study of Adolescent Behavioral Development. Biometrical modeling was used to compare a common pathway model (CPM) and an independent pathway model (IPM), and heritability estimates were obtained for pDMDD using the symptoms of irritable mood (tonic irritability; DMDD Criterion D), intense temper outbursts (phasic irritability; DMDD Criterion A), and frequent temper outbursts (phasic irritability; DMDD Criterion C).

RESULTS

Lifetime prevalence of pDMDD was 7.46%. The stability of DMDD symptoms and the pDMDD phenotype across approximately one year were moderate (.30-.69). A CPM was a better fit to the data than an IPM. Phasic irritability loaded strongly onto the pDMDD latent factor (.89-.96) whereas tonic irritability did not (.28). Genetic influences accounted for approximately 59% of the variance in the latent pDMDD phenotype, with the remaining 41% of the variance due to unique environmental effects. The heritability of tonic irritability (54%) was slightly lower than that of frequent and intense temper (components of phasic irritability; 61% and 63%, respectively).

CONCLUSIONS

Compared to tonic irritability, phasic irritability appears to be slightly more stable and heritable, as well as a stronger indicator of the latent factor. Furthermore, environmental experiences appear to play a substantial role in the development of irritability and DMDD, and researchers should seek to elucidate these mechanisms in future work.

Genetic underpinnings of callous-unemotional traits and emotion recognition in children, adolescents, and emerging adults

BACKGROUND

Callous-Unemotional (CU) and psychopathic traits are consistently associated with impaired recognition of others' emotions, specifically fear and sadness. However, no studies have examined whether the association between CU traits and emotion recognition deficits is due primarily to genetic or environmental factors.

METHODS

The current study used data from 607 Caucasian twin pairs (N = 1,214 twins) to examine the phenotypic and genetic relationship between the Inventory of Callous-Unemotional Traits (ICU) and facial emotion recognition assessed via the laboratory-based Facial Expression Labeling Task (FELT).

RESULTS

The uncaring/callous dimension of the ICU was significantly associated with impaired recognition of happiness, sadness, fear, surprise, and disgust. The unemotional ICU dimension was significantly associated with improved recognition of surprise and disgust. Total ICU score was significantly associated with impaired recognition of sadness. Significant genetic correlations were found for uncaring/callous traits and distress cue recognition (i.e. fear and sadness). The observed relationship between uncaring/callous traits and deficits in distress cue recognition was accounted for entirely by shared genetic influences.

CONCLUSIONS

The results of the current study replicate previous findings demonstrating impaired emotion recognition among youth with elevated CU traits. We extend these findings by replicating them in an epidemiological sample not selected or enriched for pathological levels of CU traits. Furthermore, the current study is the first to investigate the genetic and environmental etiology of CU traits and emotion recognition, and results suggest genetic influences underlie the specific relationship between uncaring/callous traits and distress cue (fear/sadness) recognition in others.

Fear-potentiated startle response as an endophenotype: Evaluating metrics and methods for genetic applications

The modulation of the startle response (SR) by threatening stimuli (fear-potentiated startle; FPS) is a proposed endophenotype for disorders of the fearful-fearlessness spectrum. FPS has failed to show evidence of heritability, raising concerns. However, metrics used to index FPS-and, importantly, other conditional phenotypes that are dependent on a baseline-may not be suitable for the approaches used in genetic epidemiology studies. Here, we evaluated multiple metrics of FPS in a population-based sample of preadolescent twins (N = 569 from 320 twin pairs, M_age = 11.4) who completed a fear-conditioning paradigm with airpuff-elicited SR on two occasions (~1 month apart). We applied univariate and multivariate biometric modeling to estimate the heritability of FPS using several proposed standardization procedures. This was extended with data simulations to evaluate biases in heritability estimates of FPS (and similar metrics) under various scenarios. Consistent with previous studies, results indicated moderate test-retest reliability (r = 0.59) and heritability of the overall SR (h² = 34%) but poor reliability and virtually no unique genetic influences on FPS when considering a raw or standardized differential score that removes baseline SR. Simulations demonstrated that the use of differential scores introduces bias in heritability estimates relative to jointly analyzing baseline SR and FPS in a multivariate model. However, strong dependency of FPS on baseline levels makes unique genetic influences virtually impossible to detect regardless of methodology. These findings indicate that FPS and other conditional phenotypes may not be well suited to serve as endophenotypes unless such codependency can be disentangled.

Confirmatory factor structure and psychometric properties of the Multidimensional Peer Victimization Scale

The Multidimensional Peer Victimization Scale (MPVS; Mynard & Joseph, 2000) is a 16-item self-report scale that captures peer victimization across four dimensions: physical victimization, verbal victimization, social manipulation, and attacks on property. Performance of the scale has not been evaluated among older adolescents. We examined the factor structure, internal consistency reliability, and performance of the scale in two separate epidemiological U.S. samples representing different age groups: 9-14 year olds (N=610) and 15-17 year olds (N=524). The four-factor structure of the scale was affirmed in both samples, however; there was not metric invariance by gender in the younger age group. The scale and its subscales were found to have good internal consistency. Expected relationships between the MPVS and measures of irritability, anxiety, and depression were affirmed. Results support continued use of the MPVS among child and adolescent samples.

Polygenic prediction of the phenome, across ancestry, in emerging adulthood

BACKGROUND

Identifying genetic relationships between complex traits in emerging adulthood can provide useful etiological insights into risk for psychopathology. College-age individuals are under-represented in genomic analyses thus far, and the majority of work has focused on the clinical disorder or cognitive abilities rather than normal-range behavioral outcomes.

METHODS

This study examined a sample of emerging adults 18-22 years of age (N = 5947) to construct an atlas of polygenic risk for 33 traits predicting relevant phenotypic outcomes. Twenty-eight hypotheses were tested based on the previous literature on samples of European ancestry, and the availability of rich assessment data allowed for polygenic predictions across 55 psychological and medical phenotypes.

RESULTS

Polygenic risk for schizophrenia (SZ) in emerging adults predicted anxiety, depression, nicotine use, trauma, and family history of psychological disorders. Polygenic risk for neuroticism predicted anxiety, depression, phobia, panic, neuroticism, and was correlated with polygenic risk for cardiovascular disease.

CONCLUSIONS

These results demonstrate the extensive impact of genetic risk for SZ, neuroticism, and major depression on a range of health outcomes in early adulthood. Minimal cross-ancestry replication of these phenomic patterns of polygenic influence underscores the need for more genome-wide association studies of non-European populations.

Resting Heart Rate Variability (HRV) in Adolescents and Young Adults from a Genetically-Informed Perspective

Reduced heart rate variability (HRV) is associated with cardiac morbidity, mortality, and negative psychopathology. Most research concerning genetic influences on HRV has focused on adult populations, with fewer studies investigating the developmental period of adolescence and emerging adulthood. The current study estimated the genetic and environmental contributions to resting HRV in a sample of twins using various HRV time domain metrics to assess autonomic function across two different time measurement intervals (2.5- and 10-min). Five metrics of resting HRV [mean interbeat interval (IBI), the standard deviation of normal IBIs (SDNN), root square mean of successive differences between IBIs (RMSSD), cardiac vagal index (CVI), and cardiac sympathetic index (CSI)] were assessed in 421 twin pairs aged 14-20 during a baseline electrocardiogram. This was done for four successive 2.5-min intervals as well as the overall 10-min interval. Heritability (h²) appeared consistent across intervals within each metric with the following estimates (collapsed across time intervals): mean IBI (h² = 0.36-0.46), SDNN (h² = 0.23-0.30), RMSSD (h² = 0.36-0.39), CVI (h² = 0.37-0.42), CSI (h² = 0.33-0.46). Beyond additive genetic contributions, unique environment also was an important influence on HRV. Within each metric, a multivariate Cholesky decomposition further revealed evidence of genetic stability across the four successive 2.5-min intervals. The same models showed evidence for both genetic and environmental stability with some environmental attenuation and innovation. All measures of HRV were moderately heritable across time, with further analyses revealing consistent patterns of genetic and environmental influences over time. This study confirms that in an adolescent sample, the time interval used (2.5- vs. 10-min) to measure HRV time domain metrics does not affect the relative proportions of genetic and environmental influences.

Genetic and Environmental Contributions of Negative Valence Systems to Internalizing Pathways

The genetic and environmental contributions of negative valence systems (NVS) to internalizing pathways study (also referred to as the Adolescent and Young Adult Twin Study) was designed to examine varying constructs of the NVS as they relate to the development of internalizing disorders from a genetically informed perspective. The goal of this study was to evaluate genetic and environmental contributions to potential psychiatric endophenotypes that contribute to internalizing psychopathology by studying adolescent and young adult twins longitudinally over a 2-year period. This report details the sample characteristics, study design, and methodology of this study. The first wave of data collection (i.e., time 1) is complete; the 2-year follow-up (i.e., time 2) is currently underway. A total of 430 twin pairs (N = 860 individual twins; 166 monozygotic pairs; 57.2% female) and 422 parents or legal guardians participated at time 1. Twin participants completed self-report surveys and participated in experimental paradigms to assess processes within the NVS. Additionally, parents completed surveys to report on themselves and their twin children. Findings from this study will help clarify the genetic and environmental influences of the NVS and their association with internalizing risk. The goal of this line of research is to develop methods for early internalizing disorder risk detection.

Opportunities for an enhanced integration of neuroscience and genomics

Neuroimaging and genetics are two rapidly expanding fields of research. Thoughtful integration of these areas is critical for ongoing large-scale research into the genetic mechanisms underlying brain structure, function, and development. Neuroimaging genetics has been slow to evolve relative to psychiatric genetics research, and some may be unaware that new statistical methods allow for the genomic analysis of more modestly-sized imaging samples. We present a broad overview of the extant imaging genetics literature, provide an interpretation of the major problems surrounding the integration of neuroimaging and genetics, discuss the influence and impact of genetics consortia, and suggest statistical genetic analyses that expand the repertoire of imaging researchers amassing rich behavioral data in modestly-sized samples. Specific attention is paid to the creative use of polygenic risk scoring in imaging genetic analyses, with primers on the most current risk scoring applications.

Age of onset and family history as indicators of polygenic risk for major depression

BACKGROUND

The extent to which earlier age of onset (AO) is a reflection of increased genetic risk for major depression (MD) is still unknown. Previous biometrical research has provided mixed empirical evidence for the genetic overlap of AO with MD. If AO is demonstrated to be relevant to molecular polygenic risk for MD, incorporation of AO as a phenotype could enhance future genetic studies.

METHODS

This research estimated the SNP-based heritability of AO in the China, Oxford and VCU Experimental Research on Genetic Epidemiology (CONVERGE) case-control sample (N = 9,854; MD case, n = 4,927). Common single nucleotide polymorphism heritability of MD was also examined across both high and low median-split AO groups, and best linear unbiased predictor (BLUP) scores of polygenic risk, in split-halves, were used to predict AO. Distributions of genetic risk across early and late AO were compared, and presence of self-reported family history (FH) of MD was also examined as a predictor of AO.

RESULTS

AO was not significantly heritable and polygenic risk derived from the aggregated effects of common genetic variants did not significantly predict AO in any analysis. AO was modestly but significantly lower in cases with a first-degree genetic FH of MD.

CONCLUSIONS

Findings indicate that AO is associated with greater self-reported genetic risk for MD in cases, yet not associated with common variant polygenic risk for MD. Future studies of early MD may benefit more from the examination of important moderating variables such as early life events.

Life course persistent and adolescence limited conduct disorder in a nationally representative US sample: prevalence, predictors, and outcomes

PURPOSE

The course of conduct disorder (CD) is heterogeneous. Moffitt proposed the heuristic of life course persistent (LCP) and adolescence limited (AL) to differentiate etiologically distinct forms of antisocial behavior (AB), each with distinct predictors and consequences, although a few studies have assessed this demarcation within the context of CD. The objective of this study was to apply Moffitt's taxonomy in a nationally representative US sample to investigate the prevalence, predictors, and outcomes of LCP and AL CD.

METHODS

Data come from the Collaborative Psychiatric Epidemiology Studies, a set of population-based nationally representative cross-sectional surveys (N = 20,130). Predictors included harsh discipline, maternal and paternal closeness, poverty in childhood, history of learning disability, parental deviance, and nativity. Outcomes included substance use, employment status, education attainment, marital status, income level, and self-rated mental and physical health.

RESULTS

The prevalence of LCP and AL CD was 0.5 and 4.6%, respectively, for females, and 1.9 and 5.1%, respectively, for males. Low childhood SES [Odds Ratio (OR) = 3.49], lack of maternal closeness (OR = 2.50), and history of harsh discipline (OR = 2.17) increased odds of LCP group membership. The LCP group had higher odds of developing substance use disorders (OR = 2.00) relative to AL.

CONCLUSIONS

LCP CD is more strongly influenced by childhood environment and confers increased odds for substance use problems in adulthood relative to AL CD.

Psychiatric outcomes of bullying victimization: a study of discordant monozygotic twins

BACKGROUND

Bullying victimization in childhood is associated with a broad array of serious mental health disturbances, including anxiety, depression, and suicidal ideation and behavior. The key goal of this study was to evaluate whether bullying victimization is a true environmental risk factor for psychiatric disturbance using data from 145 bully-discordant monozygotic (MZ) juvenile twin pairs from the Virginia Twin Study of Adolescent Behavioral Development (VTSABD) and their follow-up into young adulthood.

METHOD

Since MZ twins share an identical genotype and familial environment, a higher rate of psychiatric disturbance in a bullied MZ twin compared to their non-bullied MZ co-twin would be evidence of an environmental impact of bullying victimization. Environmental correlations between being bullied and the different psychiatric traits were estimated by fitting structural equation models to the full sample of MZ and DZ twins (N = 2824). Environmental associations were further explored using the longitudinal data on the bullying-discordant MZ twins.

RESULTS

Being bullied was associated with a wide range of psychiatric disorders in both children and young adults. The analysis of data on the MZ-discordant twins supports a genuine environmental impact of bullying victimization on childhood social anxiety [odds ratio (OR) 1.7], separation anxiety (OR 1.9), and young adult suicidal ideation (OR 1.3). There was a shared genetic influence on social anxiety and bullying victimization, consistent with social anxiety being both an antecedent and consequence of being bullied.

CONCLUSION

Bullying victimization in childhood is a significant environmental trauma and should be included in any mental health assessment of children and young adults.

Potentially traumatic events, personality, and risky sexual behavior in undergraduate college students

OBJECTIVE

Impulsivity and extraversion have demonstrated associations with risky sexual behavior (RSB) and potentially traumatic events (PTEs). In addition, interpersonal trauma appears to be associated with RSB, but research on the relationship between RSB and noninterpersonal PTEs (e.g., accidental) is lacking. The current study aims to investigate the relationships between personality (i.e., impulsivity, extraversion), RSB and multiple types of PTEs (i.e., accidental, physical, or sexual).

METHOD

Personality and demographic characteristics were assessed during participants' (N = 970) first semester of college, past-12 month PTEs and RSB were assessed during the second semester of participants' junior year. Multiple linear regression was used to examine the relationship between PTEs, personality factors, and RSB. Analyses were also conducted to examine the potential mediating effect of interpersonal PTEs on the relationship between personality and RSB.

RESULTS

Impulsivity and extraversion were significantly positively associated with RSB. Both physical and sexual PTEs, but not accidental PTEs, were also significantly positively associated with RSB. Sexual PTEs significantly mediated the relationship between impulsivity and RSB.

CONCLUSIONS

This is the first study to date to simultaneously examine the relationship between personality, RSB, and types of PTEs in a large sample of young adults. Exposure to interpersonal trauma appears to be a salient factor in the relationship between personality, specifically impulsivity, and RSB. These results indicate that college students may benefit from education regarding the potential negative outcomes of RSB, and that individuals with a history of interpersonal PTEs may be at increased risk for sexual risk taking. (PsycINFO Database Record

Substance Use and Depression Symptomatology: Measurement Invariance of the Beck Depression Inventory (BDI-II) among Non-Users and Frequent-Users of Alcohol, Nicotine and Cannabis

Depression is a highly heterogeneous condition, and identifying how symptoms present in various groups may greatly increase our understanding of its etiology. Importantly, Major Depressive Disorder is strongly linked with Substance Use Disorders, which may ameliorate or exacerbate specific depression symptoms. It is therefore quite plausible that depression may present with different symptom profiles depending on an individual’s substance use status. Given these observations, it is important to examine the underlying construct of depression in groups of substance users compared to non-users. In this study we use a non-clinical sample to examine the measurement structure of the Beck Depression Inventory (BDI-II) in non-users and frequent-users of various substances. Specifically, measurement invariance was examined across those who do vs. do not use alcohol, nicotine, and cannabis. Results indicate strict factorial invariance across non-users and frequent-users of alcohol and cannabis, and metric invariance across non-users and frequent-users of nicotine. This implies that the factor structure of the BDI-II is similar across all substance use groups

Age of onset and the subclassification of conduct/dissocial disorder

BACKGROUND

Conduct Disorder (CD) is a markedly heterogeneous psychiatric condition. Moffitt (1993) proposed that subclassification of CD should be according to age of onset. Our goals were to compare childhood-onset and adolescent-onset CD in terms of differences in phenotypic risk factors, genetic analyses, and factors associated with the persistence of antisocial behavior into young adulthood.

METHODS

The data are from the Virginia Twin Study of Adolescent Behavioral Development (VTSABD) and Young Adult Follow-Up (YAFU). Childhood-onset CD was defined as CD beginning at or before age 11. Adolescent-onset CD was defined as having CD onset between ages 14 and 17. These subgroups were compared on ADHD, young adult antisocial behavior (ASB), family dysfunction, and parental depression. Genetic analyses compare childhood-onset and adolescent-onset CD, as well as their cooccurrence with ADHD and ASB. Finally, predictors of persistence were examined.

RESULTS

Childhood-onset CD was significantly associated with ADHD, ASB, family dysfunction, and parental depression. Adolescent-onset CD was marginally associated with parental depression (p = .05) but not with any of the other risk factors. Univariate genetic models showed that both childhood-onset and adolescent-onset CD involve a large genetic liability accounting for 62% and 65% of the variance, respectively. A common genetic factor (as well as an ADHD-specific factor) accounted for the cooccurrence of childhood-onset CD and ADHD. The cooccurrence of childhood-onset CD and ASB are reflected by a common genetic factor with genetic specific effects on ASB. There was no etiological link between adolescent-onset CD and either ADHD or ASB. Both ADHD and family dysfunction were significantly associated with the persistence of antisocial behavior into young adulthood.

CONCLUSIONS

Phenotypic findings differentiated between childhood-onset and adolescent-onset CD. ADHD and family dysfunction predicted persistence of antisocial behavior into young adulthood.

Substance use disorders and treatment utilization among MDMA users: Results from The National Epidemiologic Survey on Alcohol and Related Conditions

The study examined the prevalence and correlates of substance use disorders and treatment utilization among lifetime MDMA users. Secondary analyses were conducted on data from the 2001-2002 NESARC, a nationally representative survey of adults in the United States. Lifetime MDMA use was assessed, and MDMA users (n = 562) were compared to a matched sample of non-MDMA users. Substance use diagnoses were made using the AUDADIS - DSM-IV, and data on treatment utilization were collected. MDMA use was significantly related to lifetime and past year substance use disorders as well as treatment utilization in bivariate analyses. Multivariate analysis, however, showed that MDMA use was not related to lifetime substance use diagnosis or to treatment utilization. MDMA use still had the strongest association with past year substance use disorders.

Testing the effect of specific orders to provide oral liquid nutritional supplements to nursing home residents: a quality improvement project

OBJECTIVES

To improve nursing home (NH) staff delivery of oral liquid nutritional supplements between meals to residents with a history of weight loss.

DESIGN

Pre-Post intervention study.

SETTING

Two skilled nursing homes.

PARTICIPANTS

Eighteen long term care residents.

INTERVENTION

At baseline all participants had a non-specific physician's order to receive a nutritional supplement. The intervention consisted of specifying the physician's order as follows: "Give 4 oz high protein supplement at 10 am, 2 pm, and 7 pm".

MEASUREMENTS

Research staff conducted direct observations for two days during and between meals for a total of 4 days, or 12 possible observation periods per participant before and one week following the intervention. Research staff documented NH staff delivery of snacks (including high protein supplements) and amount consumed (fluid ounces) for the high protein supplements using a standardized protocol during each observation period.

RESULTS

Before the specific order was written participants were offered any type of snack an average of 1.82 times per day and a high protein supplement 0.59 times per day. After the specific order was written participants were offered any type of snack an average of 1.59 times per day and a high protein supplement 0.91 times per day. There were no statistically significant differences in the average number of times snacks or supplements were offered before and after the specific order was written. The proportion of snacks offered that were high protein supplements did increase after the specific order was written (p<0.001). When a high protein supplement was provided, most residents consumed 100% of it.

CONCLUSIONS

Oral liquid nutritional supplements were not provided consistent with orders in NH practice. The specificity of the order related to type of supplement and time of delivery did not influence when and how often supplements are provided to residents but it did influence the type of nutritional supplement offered.

Expanding the role of mammographers: a training strategy to enhance mammographer-patient interaction

The use of routine mammography screening is associated with earlier breast cancer detection and decreased mortality. Several researchers have identified mammographers as potentially effective agents for encouraging patients to engage in routine screening. Mammographers are particularly well situated within the health care system to address patients' knowledge, psychological, and cultural barriers to routine screening. Few opportunities exist, however, for mammographers to acquire skills in providing culturally-sensitive patient education and emotional assessment to help women overcome such barriers. In 1997 the North Carolina Breast Cancer Screening Program (NC-BCSP) developed and implemented an innovative, two-hour training program to help mammographers address the educational and psychosocial needs of rural, African American women in eastern North Carolina. NC-BCSP's extensive survey data (n=2000), as well as qualitative data from 25 focus groups conducted with more than 200 rural African American women, were used to develop a curriculum titled Expanding the Role of Mammographers. It was the first American Society of Radiologic Technologists (ASRT) accredited training program for mammographers in North Carolina that solely addressed psychosocial topics. The curriculum emphasized mammographers' potential impact on women's attitudes and behavioral intentions, and taught communication strategies to enhance mammographer-patient interaction. It included supplemental learning materials, skill-building exercises, and patient education materials to assist participants in applying new skills and knowledge. Of the 33 mammographers invited to the training, 19 attended. A structured evaluation form, completed by 18 participants, conveyed positive reactions to the intervention. This training workshop was conducted as part of NC-BCSP's much larger, community-based intervention; as such, it was not independently evaluated. NC-BCSP's broader intervention appears to be associated, however, with positive population-level changes in breast cancer awareness and mammography use.

Using data to enhance the expert panel process. Rating indications of alcohol-related problems in older adults

OBJECTIVE

To enhance the validity of a well-known expert panel process, we used data from patient surveys to identify and correct rating errors.

METHODS

We used the two-round RAND/UCLA panel method to rate indications of harmful (presence of problems), hazardous (at risk for problems), and nonhazardous (no known risks) drinking in older adults. Results from the panel provided guidelines for classifying older individuals as harmful, hazardous, or nonhazardous drinkers, using a survey. The classifications yielded unexpectedly high numbers of harmful and hazardous drinkers. We hypothesized possible misclassifications of drinking risks and used the survey data to identify indications that may have led to invalid ratings. We modified problematic indications and asked three clinician panelists to evaluate the clinical usefulness of the modifications in a third panel round. We revised the indications based on panelist response and reexamined drinking classifications.

RESULTS

Using the original indications, 48% of drinkers in the sample were classified as harmful, 31% as hazardous, and 21% as nonhazardous. A review of the indications revealed framing bias in the original rating task and vague definitions of certain symptoms and conditions. The modified indications resulted in classifications of 22% harmful, 47% hazardous, and 31% nonhazardous drinkers.

CONCLUSIONS

Analysis of survey data led to identification and correction of specific errors occurring during the panel-rating process. The validity of the RAND/UCLA method can be enhanced using data-driven modifications.

Are older hazardous and harmful drinkers less likely to participate in health-related behaviors and practices as compared with nonhazardous drinkers?

OBJECTIVES

To describe the (1) prevalence of at-risk drinking and participation in health-related behaviors and practices and (2) associations of at-risk drinking with other health-related behaviors and practices among older persons completing a health-risk appraisal for the elderly (HRA-E).

DESIGN

Cross-sectional study using data from a self-administered, mailed survey sample.

SETTINGS

Persons from three organizations were surveyed: (1) the American Association of Retired Persons; and (2) a large medical group and (3) a community-based senior health center in southern California.

PARTICIPANTS

1,889 persons age 55 years and older.

MEASUREMENTS

The HRA-E included items on health characteristics, drinking behaviors (including amount of alcohol use and two alcoholism screening measures: the CAGE (Cut down, Annoyed, Guilty, Eye opener) and Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G), and participation in selected health-related behaviors and practices. Social drinkers were defined as those who drank fewer than 14 drinks weekly and screened negative on the CAGE (defined as two or more "no" responses) and SMAST-G. Hazardous drinkers drank fewer than 14 drinks weekly and screened negative. Harmful drinkers drank fewer than 14 drinks weekly and screened positive. Possible at-risk drinkers drank 14 or more drinks weekly and screened positive. Least squares regression models were used to assess the effects of hazardous, harmful, and possible at-risk drinking on each of the health-related practices and behaviors. We also conducted these analyses using three other definitions of social, possible at-risk, hazardous, and harmful drinking.

RESULTS

Of all respondents, 40% were social drinkers, 3% were harmful drinkers, 2% were hazardous drinkers, and 11% were possible at-risk drinkers. Hazardous, harmful, and possible at-risk drinkers commonly reported driving after drinking or being driven by someone who had been drinking (67%, 76%, and 64% respectively). Harmful and possible at-risk drinkers were more likely than social drinkers to smoke and were less likely to use seatbelts regularly. These findings were observed regardless of how the drinking groups were defined.

CONCLUSION

All groups of at-risk drinkers more commonly engaged in selected adverse health-related behaviors and practices than did social drinkers.

Using a criterion standard to validate the Alcohol-Related Problems Survey (ARPS): a screening measure to identify harmful and hazardous drinking in older persons

We compared the Alcohol-Related Problems Survey (ARPS), a new screening measure targeted at harmful and hazardous drinking among older individuals, to a criterion standard (CS) among 22 persons aged 65 and older who reported consuming at least one drink of alcohol in the previous 12 months. The CS was conducted by a study physician and research assistant. It assessed risks from alcohol use, and consisted of a structured review of each subject's medical record, clinical interview, physical examination, and an interview with a collateral informant. Analyses included descriptive statistics for demographic and health characteristics, inter-rater reliability, agreement between the ARPS and the CS, reasons for disagreement, and sensitivity and specificity of the ARPS as compared to the CS. Using Landis and Koch criteria, inter-rater reliability between two physicians for 11 subjects was substantial (weighted kappa 0.79), but agreement between the ARPS and the CS was only fair (weighted kappa 0.28). Reasons for disagreement included problems with ARPS' questions and classification rules, and problems with study physicians' assessments of drinking risk. Based on these reasons for disagreement, we made revisions in the ARPS and its classification rules. Agreement between the revised ARPS and the CS improved substantially (weighted kappa 0.62). Sensitivity and specificity of the original ARPS were 80% and 50%, respectively, and both improved to 82% after revisions. The revised ARPS is sensitive and specific for identifying harmful and hazardous drinking in older persons as determined by clinicians.

A nurse's guide to hormone replacement therapy

Menopause is a natural event most women experience as they enter their 5th decade. As human life expectancy has lengthened, health issues concerning women in mid-life have become a major focus in holistic, preventive health care, which is heavily influenced by nurses. Controversy continues about the risks and benefits of hormone replacement therapy for women during their years of perimenopause and postmenopause. Evidence is compiling, however, that indicates the benefits of exogenous hormones may outweigh these concerns. As nurses, we must have a current knowledge of hormone replacement therapy to counsel our patients effectively. This article presents information to assist the nurse in meeting this goal.

The prognostic value of sensory impairment in older persons

OBJECTIVES

To determine the relationships between visual and hearing impairment and subsequent functional dependence and mortality among community-dwelling older persons.

DESIGN

A Prospective, cohort study.

SETTING

Community-based.

PARTICIPANTS

A total of 5444 men and women aged 55 to 74 years at baseline.

MEASUREMENTS

Self-reported and measured visual impairment, self-reported and measured hearing impairment, self-reported and measured combined sensory impairment, 10-year mortality, and dependency in activities of daily living (ADL), instrumental ADL (IADL), and Rosow-Breslau (RB) function.

RESULTS

In multiply-adjusted models, adjusting for length of follow-up, socio-demographic characteristics, and chronic conditions, only measured visual impairment was predictive of mortality. Measured visual impairment was also predictive of 10-year ADL and IADL dependence; measured hearing impairment was predictive of RB dependence. Self-reported visual impairment predicted functional impairment on all scales at 10 years, although self-reported hearing impairment predicted only subsequent RB dependence. Measured combined impairment was associated with the highest risk of 10-year functional dependence.

CONCLUSIONS

Sensory impairment is predictive of subsequent functional impairment in older persons.

Drinking habits among older persons: findings from the NHANES I Epidemiologic Followup Study (1982-84). National Health and Nutrition Examination Survey

OBJECTIVES

To describe alcohol use and its sociodemographic correlates among persons aged 65 years and older in a US probability sample.

DESIGN

Cross-sectional analysis of a national probability sample-based cohort study.

SETTING

Multiple sites throughout the United States.

PARTICIPANTS

A total of 3448 persons aged 65 and older who participated in the first wave of the NHANES I Epidemiologic Followup Study (1982-84).

MEASUREMENTS

We describe the alcohol use behaviors and demographic characteristics of 3448 persons aged 65 and older. Least squares regression models were used to assess associations between older persons' sociodemographic characteristics and alcohol use.

RESULTS

Sixty percent of the sample reported having 12 or more drinks of alcohol in at least 1 year of their lives. Seventy-nine percent of these older drinkers were currently drinking. Twenty-five percent of all drinkers drank daily (31% men, 19% women). Using gender-specific definitions (men >2 drinks/day; women >1 drink/day), 16% of men drinking alcohol and 15% of women drinking alcohol were heavy drinkers. Younger age, male gender, and higher income were associated with greater alcohol use.

CONCLUSIONS

Most older persons who ever drank alcohol in their lifetimes were currently drinking. In addition, a substantial number of older persons were drinking currently at levels that may place them at risk of adverse health consequences.

A new paradigm for alcohol use in older persons

BACKGROUND

Current paradigms for conceptualizing alcohol-related problems typically focus on persons who are abusing or dependent on alcohol. These paradigms may not apply to older drinkers whose alcohol use, regardless of consumption-level, can cause problems because of age-related changes in physiology and interactions with increased morbidity, medication use, and functional limitations.

OBJECTIVE

We convened an expert panel# to develop clinical indications of harmful, hazardous, and nonhazardous drinking in persons 65 years of age and older.

RESEARCH DESIGN AND SUBJECTS

Nine panelists with expertise in psychiatry, geriatrics, internal medicine, and alcohol research were provided with epidemiological data and a published explicit literature review of alcohol use in the elderly. The RAND/UCLA two-round panel method was used to develop the indications. After the second round, the authors wrote a draft statement that was circulated to the panelists whose comments were incorporated into a final document.

RESULTS

Panelists agreed on 215 scenarios in which older peoples' use of alcohol either alone or in the presence of chronic medical conditions, medication use, symptoms, smoking, and functional limitations are hazardous or harmful. Panelists' ratings of risk did not differ significantly between persons aged 65 to 74 years and those aged 75 years and older.

CONCLUSION

Alcohol use may be hazardous or harmful for older persons, particularly in conjunction with physical or emotional illnesses, medication use, functional limitations, smoking, and driving after drinking. When asking about alcohol use in older persons, clinicians need to be aware of these factors to assist in identifying and managing potential or actual alcohol-related problems.

Hearing loss in community-dwelling older persons: national prevalence data and identification using simple questions

OBJECTIVE

To estimate the prevalence of hearing loss among community-dwelling older persons according to clinical criteria and to develop a brief self-report screening instrument to detect hearing loss.

DESIGN

Survey.

SETTING

National probability sample of noninstitutionalized older persons.

PARTICIPANTS

A total of 2506 persons aged 55 to 74 who participated in the National Health and Nutrition Examination Survey.

MAIN OUTCOME MEASURES

Hearing loss as defined by Ventry and Weinstein (VW) criteria and by the High Frequency Pure-Tone Average (HFPTA) scale.

RESULTS

Hearing loss by VW criteria was present in 14.2% and by HFPTA criteria in 35.1% of those surveyed. The prevalence increased with advancing age and was higher among men and those with less education. A logistic regression model identified six independent factors for hearing loss by VW criteria: age > or = 70 years (adjusted odds-ratio (AOR) 2.7, 95% confidence interval (95% CI) 1.6, 4.4), male gender (AOR 3.0, 95% CI 1.9, 4.8), < or = 12th grade education (AOR 3.8, 95% CI 1.8, 7.7), having seen a doctor for deafness or hearing loss (AOR 8.9, 95% CI 5.3, 14.9), unable to hear a whisper across a room (AOR 3.2, 95% CI 2.0, 5.1), and unable to hear a normal voice across a room (AOR 6.2, 95% CI 2.6, 14.9). A clinical scale based on the logistic model had 80% sensitivity and 80% specificity in predicting hearing loss using VW criteria and 59% sensitivity and 88% specificity in predicting hearing loss using HFPTA criteria.

CONCLUSIONS

Hearing loss, as defined by two clinical criteria, is common and can be screened for accurately using simple questions that assess sociodemographic and hearing-related characteristics.

Correlates of hypoalbuminemia in community-dwelling older persons

To identify easily ascertainable sociodemographic and health characteristics that are associated with hypoalbuminemia in community-dwelling older persons, we used data from the first National Health and Nutrition Examination Survey. This population-based stratified probability sample survey included 4728 persons aged 55-74 y. We defined hypoalbuminemia in two ways: < 35 g/L (1.2% of the sample) or < or = 38 g/L (7.9% of the sample) and used multivariate logistic models to identify independent predictors of hypoalbuminemia. Older age; receiving welfare; a condition interfering with eating; vomiting > or = 3 d/mo; previous surgery for gastrointestinal tumor; self-reported heart failure; recurring cough attacks; feeling tired or wornout; edentulous, fair, or poor condition of teeth; little or no exercise; a low-salt diet; trouble chewing meat; self-reported protein albumin, blood, or sugar in urine; and current cigarette smoking were independently associated with albuminemia (< or = 38 g/L) or progressively lower albumin concentrations < 40 g/L. Persons with 3-5 of these factors (51.5% of the sample) had an odds ratio of 2.73 (95% CI: 1.64, 4.54) and those with > or = 6 factors (9.4% of the sample) had an odds ratio of 6.44 (95% CI: 3.49, 11.86) of albuminemia < or = 38 g/L compared with those with 0-2 risk factors (39.1% of the sample). These findings suggest that several easily assessed sociodemographic, lifestyle, and disease-related factors are associated with hypoalbuminemia and might be valuable items to include on general health surveys to identify older persons who have this marker of poor health status.

Development of a health risk appraisal for the elderly (HRA-E)

The purpose of this project is to develop a health risk appraisal for the elderly (HRA-E) and test its application in both medical and nonmedical settings. The HRA-E system consists of a questionnaire and software for computer-generation of personalized reports to participants, 55 years and older, and their physicians. Items in the questionnaire cover a comprehensive range of content domains relevant to health promotion in the elderly. The goal of the HRA-E system is to prevent functional decline. Samples of eligible subjects from the American Association of Retired Persons (AARP), a group practice, and a senior center were extended invitations to participate. Those responding affirmatively to the invitation were given a questionnaire and evaluation form. Each person who returned the questionnaire received his or her personal report and a second evaluation form. Four months after receiving their reports, respondents were questioned about behavior changes during the interim. Preliminary findings, based on 1895 respondents, indicate that nearly all participants found the questionnaire easy to complete and were pleased with its overall length. In addition, most participants read their reports, and many planned to take action, based on report recommendations. In the next phase of this project, the intent is to refine the questionnaire, extend the intervention protocols for longitudinal application, and evaluate its impact on health-related behaviors, medical care utilization, and functional decline.

A randomized trial of office-based screening for common problems in older persons

PURPOSE

To test the effectiveness of a 10-minute office-staff administered screen to evaluate malnutrition/weight loss, visual impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical limitations, and reduced leg mobility among older persons seen in office practice. This screen was coupled with clinical summaries to assist the physician in further evaluating and managing the screen-included problems.

PATIENTS AND METHODS

Twenty-six community-based office practices of internists and family physicians in Los Angeles were randomized to intervention or control groups. Two hundred and sixty-one patients aged > or = 70 years and seeing these physicians for a new visit or a physical examination participated in the study. At the enrollment visit intervention group patients were administered the screening measure and their physicians were given the pertinent clinical summaries. Outcome measures were detection of, and intervention for conditions screened, and health status 6 months after the intervention.

RESULTS

Hearing loss was both more commonly detected (40% intervention versus 28% control) and further evaluated (29% versus 16%) by physicians in the intervention group (P < 0.05). No other differences in the frequency of problem detection or intervention were noted between groups. Six months after the intervention no differences were noted in health status between groups.

CONCLUSIONS

A brief measure to screen for common conditions in older persons was associated with more frequent detection and follow-up assessment of hearing loss. Although the measure was well accepted by physicians and their staffs, it did not appear to affect detection and intervention in regard to the other screen-included conditions, or health status at 6 months.

Does estrogen prevent skin aging? Results from the First National Health and Nutrition Examination Survey (NHANES I)

OBJECTIVE

To evaluate the relation between noncontraceptive estrogen use and skin wrinkling, dryness, and atrophy.

DESIGN

Cross-sectional analysis of a national probability sample-based cohort study.

SETTING

Multiple community sites throughout the United States.

PARTICIPANTS

Postmenopausal women (n = 3875) aged 40 years and older at baseline.

MEASUREMENTS

Skin conditions (wrinkling, dryness, and atrophy) were ascertained using a uniform clinical examination by trained dermatology resident physicians. Self-reported use of estrogen before the baseline examination, sunlight exposure, and smoking history were obtained by standardized interview. Body mass index, a measure of weight in kilograms divided by the square of the height in meters, was evaluated in uniform examination clothing.

RESULTS

Mean (+/-SD) age of the participants was 61.6 (+/-9.0) years and mean (+/-SD) number of years since menopause was 15.6 (+/-9.4). Most were white (83.7%), the remainder being African American (15.9%) or another race (0.4%). Atrophy was present in 499 (16.2%), dry skin in 1132 (36.2%), and wrinkled skin in 880 women (28.2%). The prevalence of all 3 skin conditions was lower in African American women compared with white women. Information on hormone use was available for 3403 participants (88%). Among all women, after adjustment for age, body mass index, and sunlight exposure, estrogen use was associated with a statistically significant decrease in the likelihood of senile dry skin (odds ratio, 0.76; 95% confidence interval, 0.60-0.97). The odds of wrinkling were substantially lower in estrogen users, adjusted for age, body mass index, and sun exposure (odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and additionally for smoking (odds ratio, 0.67; 95% confidence interval, 0.44-1.01). In multivariable models, estrogen use was not associated with skin atrophy.

CONCLUSION

These results strongly suggest that estrogen use prevents dry skin and skin wrinkling, thus extending the potential benefits of postmenopausal estrogen therapy to include protection against selected age- and menopause-associated dermatologic conditions.

Development of an immunomagnetic assay system for rapid detection of bacteria and leukocytes in body fluids

Immunomagnetic (IM) separation and concentration of specific target ligands or particles, such as bacteria or leukocytes, from complex mixtures, such as bone marrow, blood and other body fluids, is now a widely accepted technique. IM methodologies require high affinity antibodies or other receptors, but are potentially as effective as density gradient separations. Thus, a computer-controlled first-generation immunomagnetic assay system (IMAS) biodetector is being developed for clinical diagnostics. This system is fully automated and affords the advantage of rapid flow-through capture of all types of magnetic beads (MBs) and obviates operator contact with body fluid samples during the collection and analysis phases. In the present work, biotinylated capture antibodies were bound to streptavidin-coated MBs for capture of E. coli O157:H7, T cells and T cell subsets. Samples were automatically vortex mixed with antibody-coated MBs, stained with an acridine dye or fluorescent antibody and collected in a specially designed flow cell containing multiple steel pins, which concentrate external magnetic field lines. IM complexes were rapidly (within minutes), separated from their media in the magnetic field. Magnetically captured particles were automatically rinsed in the flow cell to remove unwanted materials and detection was achieved via a flow-through fluorimeter. Samples can be subsequently captured on a microbiological filter for microscopic visualization and image analysis. Preliminary results demonstrate that rapid detection of target bacteria and leukocytes at low concentrations in body fluids is possible with a total assay time under 1 h. This IM technology has many other potential clinical, industrial and environmental monitoring applications.

Alcohol-related problems in older persons. Determinants, consequences, and screening

Demographic trends reveal the elderly to be the fastest growing segment of the population. Physicians can therefore anticipate encountering increasing numbers of older patients with alcohol-related problems. These problems include liver disease, dementia, confusion (masquerading as dementia), peripheral neuropathy, insomnia, late-onset seizure disorder, poor nutrition, incontinence, diarrhea, myopathy, inadequate self-care, macrocytosis, depression, fractures, and adverse reactions to medications. Despite the prevalence of alcohol use in older people, their risks and problems are often unrecognized. We reviewed published literature on the determinants and consequences of alcohol-related problems in persons aged 65 years and older and the usefulness of available screening measures. Thirteen of 25 eligible studies on determinants and consequences met quality criteria and were reviewed. Nine additional studies on screening tests were also evaluated. Determinants include history of alcohol use and abuse, social isolation, and reduced mobility; consequences consist of risks of hip fracture from falls, neoplasms, and psychiatric illness. Currently accessible screening tests focus on high levels of alcoholic beverage use and abuse and dependence. They are not useful in screening for hazardous consumption that may result from relatively low levels of alcohol use alone or in combination with medications, medical illness, or preexisting diminished physical, emotional, or social function. Research is needed on the consequences of lower levels of alcohol consumption on the physical and psychosocial health of older individuals and on methods for distinguishing alcohol-related from age-related problems. Existing screening tests should be expanded or new screening methods developed in anticipation of a growing public health problem.

Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument

PURPOSE

To develop a test that will be administered by nonphysician office staff to screen elderly persons seen in ambulatory settings for problems commonly contributing to functional disability.

METHODS

We reviewed the literature to identify problems that reduce function and screening measures appropriate for use in office settings. Using this information, we developed an instrument including screening items for malnutrition/weight loss, visual impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical disability, and reduced leg mobility. This instrument was tested on 109 new patients at a university-based ambulatory geriatrics medicine clinic and validated using two standards: blinded and unblinded geriatricians' assessments. For each of the individual items on the screening instrument, we calculated sensitivity and specificity using both the blinded and unblinded geriatricians' evaluations as the reference standards, prevalence of the disorders, positive and negative predictive values, inter-rater reliability, and the direct annual costs of administering the test for an individual physician's office.

RESULTS

The screen was administered in 8 to 12 minutes. Inter-rater agreement varied by item from 77% to 100%. The sensitivities of the items varied between 0.65 to 0.93 (blinded) and 0.70 to 0.95 (unblinded). Specificities ranged between 0.50 to 0.95 (blinded) and 0.64 to 0.95 (unblinded). Problem prevalences varied from 21% to 72%. Positive and negative predictive values were 0.60 to 0.91 and 0.77 to 0.96, respectively. Direct annual costs for a clinical practice include a one-time $530 fee for equipment and, depending on the screening administrator's salary, between $1 to $7 per patient screened.

CONCLUSIONS

The screening instrument is relatively inexpensive and brief and easy to use in the ambulatory setting. It is good validity and reliability when compared to the assessment of a geriatrician. We are currently conducting a randomized trial to assess the effectiveness of the screen among older persons seen in community physicians' offices.

A nurse's guide to hormone replacement therapy

Menopause is a natural event most women experience as they enter their 5th decade. As human life expectancy has lengthened, health issues concerning women in mid-life have become a major focus in holistic, preventive health care, which is heavily influenced by nurses. Controversy continues about the risks and benefits of hormone replacement therapy for women during their years of perimenopause and postmenopause. Evidence is compiling, however, that indicates the benefits of exogenous hormones may outweigh these concerns. As nurses, we must have a current knowledge of hormone replacement therapy to counsel our patients effectively. This article presents information to assist the nurse in meeting this goal.

In vivo and in vitro studies of a chronic oxygen saturation sensor

An oxygen saturation sensor, for the purpose of chronically controlling the heart rhythm produced by a pacemaker, should be specific to oxygen saturation and should be minimally affected by the harsh blood environment. For the sensor type we tested we found: (1) one sensor failure in 205.5 canine-months of chronic implantation (n = 11, range 4 to 50 months); (2) hematocrit-induced error of less than 5 percentage points of SvO2 over the range of 50% to 80% SvO2 and 15% to 45% hematocrit; (3) carboxyhemoglobin (HbCO)-induced error of less than 4 percentage points of SvO2 with HbCO up to 20%; (4) a fibrotic sheath-induced error of less than 3 percentage points of SvO2 in the range of 50% to 80% SvO2 due to fibrotic sheath thicknesses up to 0.22 mm; (5) no significant error induced by velocity variations local to the sensor; (6) no significant error due to temperature in the range of 30 degrees to 42 degrees C; and (7) that the sensor could be as close as 0.3mm to the ventricular wall and still only produce an error of 5% SvO2.

Sensors in pacing

Sensor driven pacing is emerging as a powerful therapeutic tool to provide paced patients with a more natural heart rhythm, and, additionally, piezoelectricity is one technology that can provide sensed information to the pacemaker--and shows promise in controlling that rhythm.

Successive asexual life cycles of starved amoebae in the cellular slime mould, Dictyostelium mucoroides var. stoloniferum

Dense masses of spores of Dictyostelium mucoroides var. stoloniferum have the ability to germinate and aggregate rapidly in the absence of food. This is made possible by the presence of a dominant, self-produced spore germination activator. The germination-aggregation cycle can be repeated in as many as six successive generations. In each generation the spore size is reduced so that ultimately they are only a fraction of the size of those produced by the parental, bacteria-fed amoebae.

Computer-aided real-time acquisition of physiological data: technical design and selection constraints

For many years, physiological investigations have utilized the power and speed of analogue, digital and hybrid computers. Complex protocols often require the recording of large amounts of data in short periods, typically with simultaneous fine control of multiple experimental variables. Current systems often include data analysis in the same program which controls data acquisition. Although this is convenient from a package point of view, acquisition and analysis routines have different and sometimes conflicting purposes and requirements. This paper examines acquisition of continuous physiological signals by small dedicated computers in an attempt to separate these processes and to provide guidelines for computer selection, design and development.