Self-reported chemical sensitivity and wartime chemical exposures in Gulf War veterans with and without decreased global health ratings

BACKGROUND: The appetite-suppressant drug fenfluramine, usually given in combination with phentermine, has been reported to be associated with cardiac valvular regurgitation. Concern has been raised that the d-enantiomer of fenfluramine, dexfenfluramine, may also cause this problem. We were able to study the question by modifying an ongoing trial comparing dexfenfluramine with regular dexfenfluramine and placebo. METHODS: We modified our randomized, double-blind, placebo-controlled study of dexfenfluramine to include echocardiographic examinations of 1072 overweight patients within a median of one month after the discontinuation of treatment. The patients (approximately 80 percent of whom were women) had been randomly assigned to receive dexfenfluramine (366 patients), investigational sustained-release dexfenfluramine (352 patients), or placebo (354 patients). The average duration of treatment was 71 to 72 days in each of the three groups. Echocardiograms were assessed in a blinded fashion. RESULTS: When all degrees of valvular regurgitation were considered and when the two dexfenfluramine groups were combined, there was a higher prevalence of any degree of aortic regurgitation (17.0 percent vs. 11.8 percent, P=0.03) and any degree of mitral regurgitation (61.4 percent vs. 54.4 percent, P=0.01) in the active-treatment groups than in the placebo group. These differences were primarily due to a higher prevalence of physiologic, trace, or mild regurgitation. Analyses that used the criteria of the Food and Drug Administration for aortic regurgitation of mild or greater severity and mitral regurgitation of moderate or greater severity found no statistically significant difference among the groups (P=0.14 to 0.75). These analyses showed that aortic regurgitation of mild or greater severity occurred in 5.0 percent of the patients in the dexfenfluramine group, 5.8 percent of those in the sustained-release dexfenfluramine group, 5.4 percent of those in the two active-treatment groups combined, and 3.6 percent of those in the placebo group. Mitral regurgitation of moderate or greater severity occurred in 1.7, 1.8, 1.8, and 1.2 percent, respectively. Aortic regurgitation of mild or greater severity, mitral regurgitation of moderate or greater severity, or both occurred in 6.5 percent, 7.3 percent, 6.9 percent, and 4.5 percent, respectively. CONCLUSIONS: The increased prevalence of aortic and mitral regurgitation in patients treated with dexfenfluramine was small, and the degree of regurgitation was usually classified as physiologic, trace, or mild. However, the duration of therapy was short, and whether therapy of longer duration would yield the same or different results is not known.     

Horsemen of the Apocalypse: lessons from the Gulf War

War is a major global threat to human health, not only in the immediate effects of death and injury to the people, but also in the damage to infrastructures such as food, water, and power supplies and to social structures that support families, economies, and governments. Iraq's devastating aftershocks from the Gulf War include the physical and psychologic effects of displacement, poverty, famine, disease, and environmental destruction. Early nursing leaders vocally opposed World War I, and contemporary nurses should consider becoming activists in the primary and secondary prevention of this major global health problem.     

War Zone stress, personal and environmental resources, and PTSD symptoms in Gulf War Veterans: A longitudinal perspective.

Cross-sectional research has demonstrated a link between personal and environmental resources and development of emotional distress after war zone service. Less is known about the longitudinal relationship between resources and distress. The authors addressed this issue in a study of 348 Gulf War returnees tested at 2 time points. Resources decreased and posttraumatic stress disorder (PTSD) symptoms increased over time. Time 1 avoidance and family cohesion predicted PTSD symptoms at Time 2. Regression analyses revealed a bidirectional relationship over time between resources and PTSD symptoms. Time 1 resources predicted Time 2 psychopathology after accounting for Time 1 emotional distress. PTSD symptoms at Time 1 also predicted changes in coping and family relationships, even after accounting for Time 1 resources. Findings are consistent with the concept of a loss spiral (Hobfoll, 1989), in which resource factors and emotional sequelae to war stress exert reciprocal effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identification of Gulf War syndrome: methodological issues and medical illnesses

Administration of 8-methoxypsoralen in a dilute bath water solution is an effective therapeutic alternative to its systemic application, avoiding systemic side effects. Although PUVA bath photochemotherapy is now widely used, standardized guidelines are not yet available. Therefore, the aim of our study was to determine the optimal time interval between 8-methoxypsoralen bath and UVA irradiation and the persistence of photosensitivity after PUVA bath treatment. In volunteers the highest photosensitivity was observed following UVA irradiation immediately after PUVA bath. A sharp increase of the minimal phototoxic dose could be demonstrated after only 1 h, indicating a rapid loss of 8-methoxypsoralen activity. Irradiation 2 h after 8-methoxypsoralen bath failed to induce any PUVA erythema. This indicates that the optimal time for UVA irradiation is immediately after the 8-methoxypsoralen bath. In contrast to systemic PUVA therapy, 2 h after PUVA bath therapy, the remaining phototoxicity is minimal, so that no stringent restrictions of the patient's behaviour are needed.     

Sirens, seals, and containers: Reflections on psychotherapy during the 1991 Gulf War.

Presents clinical observations of the impact of the Persian Gulf War on the themes and processes of psychotherapy among a group of Israeli patients. Metaphors of the war period were analyzed in light of contemporary psychoanalytic thinking, with a particular focus on the significance of the sealed room. Issues of the psychotherapeutic technical stance and resistance vs breach in the frame were also addressed, and 2 case vignettes are included. It is concluded that the therapeutic framework is a representational constituent of early experiences pertaining to boundaries, containment, transitionality, and psychic enclosure, and remains sensitive throughout the treatment to vicissitudes of transference or to the reapportionment of psychic space. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative repellency of commercial formulations of deet, permethrin and citronellal against the mosquito Aedes aegypti, using a collagen membrane technique compared with human arm tests

The plasma concentrations and urinary excretions of bisoprolol enantiomers in four Japanese male healthy volunteers after a single oral administration of 20 mg of racemic bisoprolol were evaluated. The AUC(infinity) and elimination half-life of (S)-(-)-bisoprolol were slightly larger than those of (R)-(+)-bisoprolol in all subjects. The metabolic clearance of (R)-(+)-bisoprolol was significantly (P < 0.05) larger than that of (S)-(-)-bisoprolol (S/R ratio: 0.79+/-0.03), although the difference was small. In contrast, no stereoselective in vitro protein binding of bisoprolol in human plasma was found. An in vitro metabolic study using recombinant human cytochrome P450 (CYP) isoforms indicated that oxidation of both bisoprolol enantiomers was catalyzed by the two isoforms, CYP2D6 and CYP3A4. CYP2D6 metabolized bisoprolol stereoselectively (R > S), whereas the metabolism of bisoprolol by CYP3A4 was not stereoselective. The S/R ratio of the mean clearance due to renal tubular secretion was 0.68, indicating a moderate degree of stereoselective renal tubular secretion. These findings taken together suggest that the small differences in the pharmacokinetics between (S)-(-)- and (R)-(+)-bisoprolol are mainly due to the stereoselectivity in the intrinsic metabolic clearance by CYP2D6 and renal tubular secretion.     

Psychological distress among recent immigrants from the former Soviet Union to Israel, II. The effects of the Gulf War

The psychological effects of the Gulf War were studied on a group of Israeli civilians particularly at risk, viz. recent immigrants from the former Soviet Union. A quasi-experimental design was used. A sample of immigrants who had already been screened for psychological distress just before the war were reassessed after the war with the same instrument (PERI demoralization questionnaire). Various parameters related to the war period were also assessed. Psychological symptoms during the war were significantly associated with pre-war level of distress and with actual physical harm from the missiles, but not with exposure to danger (proximity of residence to areas hit by missiles). Correlates of behaviour in the face of life-threatening danger during the war (change of residence and help-seeking behaviour) were also identified. Overall the level of post-war psychological distress was not found to be higher than pre-war levels. This was explained by the immigrants' feelings of shared fate, belonging and sense of cohesion, which characterize the general Israeli population during war time.     

Attachment styles, coping strategies, and posttraumatic psychological distress: The impact of the Gulf War in Israel.

Examines the association between adult attachment style and the way people reacted to the Iraqi missile attack on Israel during the Gulf War. 140 Israeli students were interviewed 2 wks after the war and classified according to their attachment style (secure, avoidant, or ambivalent) and residence area (dangerous vs less dangerous). Ambivalent people reported more distress than secure people. Avoidant persons reported higher levels of somatization, hostility, and trauma-related avoidance than secure persons. These results characterized Ss living in dangerous areas. In addition, secure people used relatively more support-seeking strategies in coping with the trauma, ambivalent people used more emotion-focused strategies, and avoidant people used more distancing strategies. Findings are discussed in terms of attachment working models. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mediation of deet repellency in mosquitoes (Diptera: Culicidae) by species, age, and parity

Diabetes insipidus (DI) is an uncommon but important complication in the neurosurgical population. This retrospective study aimed to determine the incidence, profile and outcome of patients admitted to an 18-bedded neurosurgical intensive care unit who developed DI. The overall incidence was 3.7% (29/792 admissions). Aetiologies included subarachnoid haemorrhage (12/29), severe head injury (11/29), post-surgical excision of craniopharyngioma or pituitary adenoma (5/29) and acute haemorrhagic stroke (1/29). All patients were treated with a regime of fluid replacement, electrolyte correction, parenteral or intranasal desmopressin (DDAVP), or parenteral pitressin. Overall mortality was 72.4%. There were no deaths in the patients who underwent excision of tumours. Complications included acute pulmonary oedema, hypernatremia and hypokalaemia. The development of DI was found to be associated with impending brain death and mortality in the majority of patients with subarachnoid haemorrhage and severe head injury. However, careful diagnosis and management of DI after hypothalamo-neurohypophyseal surgery did not result in any permanent neurological sequelae.     

Musculoskeletal manifestations, pain, and quality of life in Persian Gulf War veterans referred for rheumatologic evaluation

OBJECTIVE: Pain in the joints and other areas has been a frequent complaint among veterans of Operation Desert Storm who are experiencing unexplained illness. We characterized the rheumatic manifestations of a group of veterans of the Persian Gulf War who were referred to a rheumatology clinic. METHODS: Consecutive South Texas veterans of the Persian Gulf War who were referred for evaluation of rheumatic manifestations underwent a comprehensive evaluation of their musculoskeletal symptoms, pain, and health related quality of life. RESULTS: Of 928 veterans evaluated in a screening clinic for unexplained symptoms, 145 had rheumatic manifestations (15.6%) and were referred to a rheumatology clinic. The most common diagnosis was fibromyalgia, present in 49 patients (33.8%), followed by various soft tissue problems in 25 (17.2%), nonspecific arthralgias in 14 (9.6%), and clinical or radiographic osteoarthritis in 16 (11.0%). In 39 patients (26.9%), no symptoms were present at the time of the evaluation, a careful musculoskeletal examination and laboratory tests were normal, and no diagnosis was possible. Two patients had Reiter's syndrome. Four had a positive rheumatoid factor and 3 had antinuclear antibodies, but none of these had clinical evidence of rheumatoid arthritis or systemic lupus erythematosus. Pain was present in nearly all patients and was widely distributed, with no body area spared in this group of patients. The most frequent painful areas were the knees in > 65%, the lower back in > 60%, the shoulders in 50%, and the hands and wrists in 35%. Widespread body pain was present in 65.1% of the veterans. Average values of all 8 scales measured by the SF-36 health survey were below the 25th percentile of published national norms, with pain and the number of nonarticular rheumatic symptoms explaining most of the decreased health related quality of life in the veterans we evaluated. CONCLUSION: No specific rheumatic diagnosis is characteristic of Gulf War veterans with unexplained illness referred to a rheumatology clinic. However, pain is common and widespread in these patients, and their health related quality of life is poor. Further research is necessary to determine the cause of the symptoms of veterans of the Gulf War.     

Course and predictors of posttraumatic stress disorder among Gulf War veterans: A prospective analysis.

Rates and predictors of posttraumatic stress disorder (PTSD) over time are not well understood. This study is the first to look at the rates of PTSD immediately following war and 2 years later using a large cohort (N?=?2,949) of Gulf War veterans. Using a cut score to indicate presumptive PTSD, 3% of participants exceeded the cutoff at Time 1 compared with 8% at Time 2. Those who exceeded the cutpoint at Time 1 were up to 20 times more likely to exceed the cutpoint at Time 2 than those who did not exceed the cutpoint at Time 1. Women and those with high levels of combat exposure were at increased risk for PTSD at both times. Being young, being single, and having previous combat experience were associated with increased risk at Time 1 only, whereas reservists and enlisted personnel were at increased risk at Time 2 only. These findings indicate that, although low initially, rates of PTSD increased substantially over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mass human exposure to rabies in New Hampshire: exposures, treatment, and cost

OBJECTIVES: This study assessed the rabies exposure and treatment that at least 665 persons in Concord, NH, received as a result of one proven rabid pet-store kitten in October 1994. METHODS: All treatment recipients were interviewed by person or phone. RESULTS: The median age of the treatment recipients was 14 years; 58% were female. The most common exposures were low risk (e.g., picking up, petting, nuzzling, or being scratched by a potentially rabid kitten). Local reactions to vaccine or immune globulin were reported by 76.5% of recipients, while 48.8% reported at least one systemic reaction. Cost for the biologicals was estimated at more than $1.1 million. CONCLUSIONS: Because of the inadequacy of pet store records, the inconsistent application of treatment guidelines, and other factors, many people received postexposure treatment as a result of contacts that were unlikely to transmit rabies. The rates of local and systemic adverse reactions experienced were consistent with previous reports.     

Human exposures to arsenic from consumption of well water in West Bengal, India

The authors visited the State of West Bengal, India, in August 1996, as consultants to the World Health Organization (WHO). The general mandate of the mission was to formulate recommendations to the Government of India regarding its efforts to assist the Government of West Bengal in remedying health problems arising from the presence of arsenic in groundwater in excess of the WHO guideline limit of 0.05 mg/L in eight districts of the State. The authors held discussions with Government of India and Government of West Bengal officials, as well as scientists, engineers, and physicians studying the analytic, medical, engineering, and hydrogeologic facets of the problem. They conducted field visits to arsenic-affected villages; inspected health centers, including the laboratories conducting the analytic and clinical studies; and interviewed and examined local lay people, including many arsenic-poisoned patients. This overview of the arsenic contamination problem in West Bengal is based upon a review of the scientific literature and government reports and the authors direct, firsthand assessment. The authors hope that their recommendations will assist in the development of a comprehensive infrastructure and plan of action, which are necessary to control the epidemic of chronic arsenic poisoning now afflicting West Bengal.     

Posttraumatic stress disorder and depression symptomatology in a sample of Gulf War veterans: A prospective analysis.

The authors examined the relationship over time of posttraumatic stress disorder (PTSD) and depression symptoms in a sample of Gulf War veterans. A large sample (N?=?2,949) of Gulf War veterans was assessed immediately following their return from the Gulf region and 18–24 months later. Participants completed a number of self-report questionnaires including the Mississippi Scale for Combat–Related PTSD (T. M. Keane, J. M. Caddell, & K. L. Taylor, 1988) and the Brief Symptom Inventory (L. R. Derogatis & N. Melisaratos, 1983) at both time points and an extended and updated version of the Laufer Combat Scale (M. Gallops, R. S. Laufer, & T. Yager, 1981) at the initial assessment. A latent-variable, cross-lag panel model found evidence for a reciprocal relation between PTSD and Depression. Followup models examining reexperiencing, avoidance-numbing, and hyperarousal symptoms separately showed that for reexperiencing and avoidance-numbing symptoms, the overall reciprocal relation held. For hyperarousal symptoms, however, the association was from early hyperarousal to later depression symptoms only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chamber exposures of children to mixed ozone, sulfur dioxide, and sulfuric acid

To help assess acute health effects of summer air pollution in the eastern United States, we simulated ambient "acid summer haze" as closely as was practical in a laboratory chamber. We exposed young volunteers who were thought to be sensitive to this pollutant mixture on the basis of previous epidemiologic evidence. Specifically, we exposed 41 subjects aged 9-12 y to mixed ozone (0.10 ppm), sulfur dioxide (0.10 ppm), and 0.6-microm sulfuric acid aerosol (100 +/- 40 microg/m3, mean +/- standard deviation) for 4 h, during which there was intermittent exercise. Fifteen subjects were healthy, and 26 had allergy or mild asthma. The entire group responded nonsignificantly (p > .05) to pollution exposure (relative to clean air), as determined by spirometry, symptoms, and overall discomfort level during exercise. Subjects with allergy/asthma showed a positive association (p = .01) between symptoms and acid dose; in healthy subjects, that association was negative (p = .08). In these chamber-exposure studies, we noted less of an effect than was reported in previous epidemiologic studies of children exposed to ambient "acid summer haze."     

Biases resulting from the use of indexes: An application to attributional style and depression.

The use of arbitrary indexes, including the commonly used equal-weight index, leads to biases in many studies. The appropriate index depends on the research question (dependent variable) and the population, so no single index is correct for all studies. If an incorrect index is used, tests of the relation between the construct measured by the index and a dependent variable are biased. We present three tests for bias and show how an unbiased index can be calculated by using a multiple regression. Using data from a study of attributional style and depression in psychiatric inpatients, we found that the widely used equal-weight indexes of attributional style produce large (up to 112%) biases in the estimated coefficients. Similarly, the use of equal-weight indexes biases the hypothesis tests. Finally, contrary to Wainer's (1976) contention that the inappropriate use of equal-weight indexes does not greatly reduce the explanatory power of the estimating equation, we found that the use of an index lowers the R–2 33%. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond imitation: Complex behavioral and affective linkages resulting from exposure to leadership training models.

Examined the influence of modeling interventions in a training situation on short-term leader behavior and on subsequent subordinate affective response using 40 leader–subordinate dyads. Ss read scenarios describing setting and 4 performance objectives; then they role-played as supervisor, subordinate, or observer. Three separate videotapes of a supervisor–subordinate interaction were prepared for supervisors that emphasized positive reward, reprimand, or goal-setting behavior. Ss viewed 1 of the videotapes or were assigned to a control condition in which no videotape was used. Results of subsequent role-playing indicate a significant overall change in leader behavior in response to the videotape modeling interventions. In addition, positive reward behavior was most responsive to the reprimand intervention, reprimand behavior was most responsive to the goal-setting intervention, and goal-setting behavior was most responsive to the reprimand intervention. Findings suggest that the modeling process should be viewed as a complex phenomenon involving multiple behavioral and affective linkages that go beyond a simplistic imitation or demand effect interpretation. (37 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exposure to missile attacks: the impact of the Persian Gulf War on physical health behaviours and psychological distress in high and low risk areas in Israel

The purpose of this study was to compare residents of an area (Tel-Aviv), which was severely afflicted by SCUD missiles during the Persian Gulf War (high risk region), to residents of a low-risk region (Jerusalem) in terms of: (a) changes in physical health, in use of medical or psychological services, and in health behaviours during the period of the war compared to the preceding month; (b) levels of psychological distress (somatization and anxiety) during the war; (c) characteristics of persons at highest risk for psychological distress. Respondents were randomly chosen and interviewed by telephone (N = 545 in Tel-Aviv, N = 406 in Jerusalem). The respondents in both regions reported significant yet similar deterioration in physical health status, and an increase in detrimental health behaviours during the Gulf War. Tel-Aviv residents had significantly higher levels of psychological distress as compared to residents of Jerusalem: in somatization 18 vs 12% respectively (OR = 2.44, CI = 1.39-4.28), in anxiety 34 vs 26% respectively (OR = 1.62, CI = 1.1-2.42). In addition to place of residence, age, ethnicity, religiosity and self-assessed health were identified as characteristics of persons at greater risk for psychological distress.