Do our methods lead to insomniacs' madness?: Daytime testing after laboratory and home-based polysomnographic studies

Complaints of daytime dysfunction are common among chronic insomniacs, but laboratory comparisons of insomniacs and age-matched and gender-matched normal controls have generally failed to document these complaints. However, a few studies, which allowed subjects to sleep in their homes on the nights before daytime testing, have shown some relative diurnal deficits among insomniacs. The current study compared the effects of nocturnal laboratory and home polysomnogram (PSG) studies on subsequent daytime test results among older insomniacs and normal sleepers. Insomniacs (n = 32) and normal sleepers (n = 32) were randomly assigned to first undergo three nights of nocturnal PSG monitoring either in the sleep laboratory (16 insomniacs, 16 normal sleepers) or in their homes (16 insomniacs, 16 normal sleepers). Following the third night of PSG monitoring, subjects spent 1 day in the sleep laboratory, where they completed a four-trial multiple sleep latency test along with four trials of a computer-administered performance test battery. Results showed that insomniacs, as a group, were slightly, albeit consistently, sleepier than were normal sleepers following nights of home sleep monitoring, but a reverse of this trend was found among subjects who underwent nocturnal laboratory PSG before daytime testing. Furthermore, normal sleepers showed faster reaction times on a signal detection task than did insomniacs within the subgroup who underwent home PSGs prior to such testing. However, within the subgroup that underwent nocturnal laboratory PSGs, insomniacs' signal detection reaction times were significantly faster than those shown by normal sleepers. Results provide some support for the speculation that the nocturnal PSG monitoring site, used as a precursor to daytime testing, may systematically affect daytime comparisons between insomniacs and matched controls. Moreover, these results suggest that the use of home-based nocturnal PSG monitoring prior to daytime testing may provide an enhanced understanding of insomniacs' diurnal complaints.     

Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.     

Diagnosis and management of traumatic aorto-right ventricular fistulas

BACKGROUND: Traumatic aorto-right ventricular (Ao-RV) fistulas are rare lesions that result in congestive heart failure if left untreated. Early diagnosis and prompt surgical intervention are required to avoid the natural outcome of cardiac decompensation. METHODS: All cases of traumatic Ao-RV fistula described in the English literature since 1958 were reviewed. The clinical presentation, methods of diagnosis, and treatment strategies were assessed to determine the pathophysiology, natural history, and outcome of surgical intervention. RESULTS: Forty cases of traumatic Ao-RV fistulas were described in the English literature. There were 39 men and 1 woman, with a mean age of 28.3 years (range, 15 to 50 years). Twenty-two (55%) patients had isolated Ao-RV fistulas. Fourteen (35%) had Ao-RV fistulas with aortic insufficiency. Definitive surgical repair was performed in 38 patients. The associated aortic valve injuries were managed with repair techniques or replacement with prosthetic devices. The surgical outcomes in all patients were satisfactory. CONCLUSIONS: The pathophysiology and natural history of Ao-RV fistulas involves the development of congestive heart failure. Traumatic aortic insufficiency frequently is associated with this disorder. Early diagnosis and prompt treatment are necessary to avoid the natural outcome of cardiac decompensation. Definitive repair should be performed with the aid of cardiopulmonary bypass during the same hospitalization.     

Crossroads of L-arginine/arachidonate metabolism

Outcomes of medical care include many dimensions: physical, social, and emotional function; symptoms; and satisfaction. In many cases, these dimensions can be assessed by patient-completed questionnaires with high reliability, sensitivity, and responsiveness. One such questionnaire-the upper extremity disabilities of arm, shoulder, and hand (DASH)-is reviewed.     

Comparison of fatty acid tracers FTHA and BMIPP during myocardial ischemia and hypoxia

To study the sensitivity of two fatty acid tracers to changes in beta-oxidation, the myocardial retention kinetics of 125I-iodine-15-(p-iodophenyl)-3(R,S)-methylpentadecanoic acid (BMIPP) and 14-18F-fluoro-6-thia-heptadecanoic acid (FTHA) were compared in states of oxygen deprivation due to ischemia and hypoxia. METHODS: Nineteen swine were studied by extracorporeal perfusion of the three coronary arteries. Fatty acid beta-oxidation rates were determined by infusion of tritiated palmitate into the left anterior descending artery (LAD) and by measurement of labeled water production in the LAD perfusion bed. After a baseline period of 30 min, animals were divided into three groups and subjected to a 50-min intervention period. For the control group, there was no change in perfusion; for the ischemia group, there was a 60% decrease in LAD perfusion; and for the hypoxia group, the perfusion rate was unchanged, but venous blood was used as the LAD perfusate. Continuous infusion of FTHA and BMIPP into the LAD started 10 min into the intervention period and continued until the end of the intervention period. Retention rates of the two tracers were compared between the LAD and circumflex perfusion beds. RESULTS: No difference in beta-oxidation rate occurred from the baseline to the intervention period in the control group. A 50% reduction in beta-oxidation occurred in the ischemia group, and an 80% reduction occurred in the hypoxia group. No difference in retention of BMIPP or FTHA occurred in the control group. In the ischemia group, reduction in retention of both tracers occurred. However, in the hypoxia group, FTHA uptake was unchanged, whereas BMIPP retention increased compared to the circumflex arterial bed. CONCLUSION: Decreased retention of both BMIPP and FTHA occurred with ischemia, despite the known differences in metabolism of the two tracers. This difference in metabolism was further highlighted in the setting of hypoxia with increased BMIPP uptake. Thus, these results suggest that uptake of both FTHA and BMIPP tracks reduction of fatty acid utilization in myocardial ischemia but fails in tracking reduction of fatty acid oxidation during hypoxia.     

Drug selection in hospitals. A model of reference in self-management of resources

The practice of medicine today must balance the optimal use of new pharmaceutical agents with the need for cost containment. Hospital policy regarding therapeutics and its historical perspective are discussed. Various aspects of the operations of Pharmacy and Therapeutics Committees are presented. The potential benefits of a formulary system are therapeutic, economic and educational and it could lead to a uniformity of drug usage throughout a district. The role of Clinical Pharmacology to provide advice to both Institution and physicians in how therapeutic practice may be optimized is also stressed.     

Role of heat shock proteins in heart transplant rejection

STUDY OBJECTIVE: To study secular trends of placental abruption (PA), the effects of demographic variables and the use of cesarean section (CS) associated with PA. DESIGN: A population based cohort study. SETTING: The Medical Birth Registry of Norway. PATIENTS: 9,592 cases of PA of a total of 1,446,154 births notified, i.e. all births in Norway 1967-1991. MAIN RESULTS: The PA proportion was 6.6 per 1000 births of a gestational age of 16 weeks or more, ranging from 5.3 in 1971 to 9.1 in 1990. Birth order two had the lowest proportion and it increased by maternal age. The PA proportion decreased by gestational age from 86.4 per 1000 below 28 weeks to 3.4 in term pregnancies. The PA proportion per 10,000 pregnancies at risk increased from 1.3 in the 28th week to 14.1 in the 42nd week. A secular trend of a decreasing but still high relative risk of PA in SGA-births at any gestational age increased from 1967 through 1991. The relative risk of PA of Apgar score <7 after five minutes, adjusted for gestational age, was 7.8. CONCLUSIONS: Inspite of an increasing CS rate, an increasing proportion of PA was noted from 1967 through 1991. The proportion was lowest for birth order two and increased by maternal age. To an increasing extent, PA births were centralized. SGA, prematurity and asphyxia were major problems associated with PA. A tendency towards larger infants and a decreasing relative risk of PA in SGA-births might be attributable to improvements in antenatal care.