PTSD symptom severity is associated with increased recruitment of top-down attentional control in a trauma-exposed sample

Background

Recent neuroimaging work suggests that increased amygdala responses to emotional stimuli and dysfunction within regions mediating top down attentional control (dorsomedial frontal, lateral frontal and parietal cortices) may be associated with the emergence of anxiety disorders, including posttraumatic stress disorder (PTSD). This report examines amygdala responsiveness to emotional stimuli and the recruitment of top down attention systems as a function of task demands in a population of U.S. military service members who had recently returned from combat deployment in Afghanistan/Iraq. Given current interest in dimensional aspects of pathophysiology, it is worthwhile examining patients who, while not meeting full PTSD criteria, show clinically significant functional impairment.

Methods

Fifty-seven participants with sub-threshold levels of PTSD symptoms completed the affective Stroop task while undergoing fMRI. Participants with PTSD or depression at baseline were excluded.

Results

Greater PTSD symptom severity scores were associated with increased amygdala activation to emotional, particularly positive, stimuli relative to neutral stimuli. Furthermore, greater PTSD symptom severity was associated with increased superior/middle frontal cortex response during task conditions relative to passive viewing conditions. In addition, greater PTSD symptom severity scores were associated with: (i) increased activation in the dorsolateral prefrontal, lateral frontal, inferior parietal cortices and dorsomedial frontal cortex/dorsal anterior cingulate cortex (dmFC/dACC) in response to emotional relative to neutral stimuli; and (ii) increased functional connectivity during emotional trials, particularly positive trials, relative to neutral trials between the right amygdala and dmFC/dACC, left caudate/anterior insula cortex, right lentiform nucleus/caudate, bilateral inferior parietal cortex and left middle temporal cortex.

Conclusions

We suggest that these data may reflect two phenomena associated with increased PTSD symptomatology in combat-exposed, but PTSD negative, armed services members. First, these data indicate increased emotional responsiveness by: (i) the positive relationship between PTSD symptom severity and amygdala responsiveness to emotional relative to neutral stimuli; (ii) greater BOLD response as a function of PTSD symptom severity in regions implicated in emotion (striatum) and representation (occipital and temporal cortices) during emotional relative to neutral conditions; and (iii) increased connectivity between the amygdala and regions implicated in emotion (insula/caudate) and representation (middle temporal cortex) as a function of PTSD symptom severity during emotional relative to neutral trials. Second, these data indicate a greater need for the recruitment of regions implicated in top down attention as indicated by (i) greater BOLD response in superior/middle frontal gyrus as a function of PTSD symptom severity in task relative to view conditions; (ii) greater BOLD response in dmFC/dACC, lateral frontal and inferior parietal cortices as a function of PTSD symptom severity in emotional relative to neutral conditions and (iii) greater functional connectivity between the amygdala and inferior parietal cortex as a function of PTSD symptom severity during emotional relative to neutral conditions.

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Greater PTSD symptoms associated with increased amygdala activation to emotional stimuli

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PTSD symptoms associated with greater top down attention response in task and emotion conditions

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PTSD symptoms were associated with slower reaction times.

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Increased top down attention recruitment may compensate for heightened emotional responses.

The potential of social enterprise to enhance health and well-being: a model and systematic review

In recent years civil society organisations, associations, institutions and groups have become increasingly involved at various levels in the governance of healthcare systems around the world. In the UK, particularly in the context of recent reform of the National Health Service in England, social enterprise - that part of the third sector engaged in trading - has come to the fore as a potential model of state-sponsored healthcare delivery. However, to date, there has been no review of evidence on the outcomes of social enterprise involvement in healthcare, nor in the ability of social enterprise to address health inequalities more widely through action on the social determinants of health. Following the development of an initial conceptual model, this systematic review identifies and synthesises evidence from published empirical research on the impact of social enterprise activity on health outcomes and their social determinants. Ten health and social science databases were searched with no date delimiters set. Inclusion and exclusion criteria were applied prior to data extraction and quality appraisal. Heterogeneity in the outcomes assessed precluded meta-analysis/meta-synthesis and so the results are therefore presented in narrative form. Five studies met the inclusion criteria. The included studies provide limited evidence that social enterprise activity can impact positively on mental health, self-reliance/esteem and health behaviours, reduce stigmatization and build social capital, all of which can contribute to overall health and well-being. No empirical research was identified that examined social enterprise as an alternative mode of healthcare delivery. Due to the limited evidence available, we discuss the relationship between the evidence found and other literature not included in the review. There is a clear need for research to better understand and evidence causal mechanisms and to explore the impact of social enterprise activity, and wider civil society actors, upon a range of intermediate and long-term public health outcomes.

Cell death and the mitochondria: therapeutic targeting of the BCL-2 family-driven pathway

The principal biological role of mitochondria is to supply energy to cells; although intriguingly, evolution has bestowed another essential function upon these cellular organelles: under physiological stress, mitochondria become the cornerstone of apoptotic cell death. Specifically, mitochondrial outer membrane permeabilization (MOMP) allows cell death factors such as cytochrome c to be released into the cytoplasm, thus inducing caspase activation and the eventual destruction of essential cellular components. Proteins of the B-cell lymphoma 2 (BCL-2) family control the tightly regulated pathway that causes MOMP. The equilibrium between pro-survival and pro-apoptotic members of the BCL-2 family dictates the fate of cells, the homeostasis of organs and, by extension, the health of whole organisms. Dysregulation of this equilibrium is involved in a large number of diseases such as cancer, autoimmunity and neurodegenerative conditions. Modulating the activity of the BCL-2 family of proteins with small molecules or peptides is an attractive but challenging therapeutic goal. This review highlights the latest developments in this field and provides evidence that this strategy is likely to have a positive effect on the treatment of still poorly addressed medical conditions.

De-novo designed library of benzoylureas as inhibitors of BCL-XL: synthesis, structural and biochemical characterization

The prosurvival BCL-2 proteins are attractive yet challenging targets for medicinal chemists. Their involvement in the initiation and progression of many, if not all, tumors makes them prime targets for developing new anticancer therapies. We present our approach based on de novo structure-based drug design. Using known structural information from complexes engaging opposing members of the BCL-2 family of proteins, we designed peptidomimetic compounds using a benzoylurea scaffold to reproduce key interactions between these proteins. A library stemming from the initial de novo designed scaffold led to the discovery of ligands with low micromolar potency (KD = 4 μM) and selectivity for BCL-XL. These compounds bind in the canonical BH3 binding groove in a binding mode distinct from previously known BCL-2 inhibitors. The results of our study provide insight into the design of a new class of antagonists targeting a challenging class of protein-protein interactions.

Using functional magnetic resonance imaging to improve how we understand, teach, and assess clinical reasoning

Clinical reasoning is essential to the practice of medicine. There have been many advances in the understanding of clinical reasoning and its assessment, yet current approaches have a number of important limitations. Functional magnetic resonance imaging (fMRI) is promising because it permits investigators to directly view the neuroanatomical changes that occur with thinking. In this article, we briefly review current approaches to assessing clinical reasoning, discuss the emerging role and utility of fMRI in understanding clinical reasoning, and suggest directions for future research, continuing education, and practice.

Compelling Evidence that Exposure Therapy for PTSD Normalizes Brain Function

Functional magnetic resonance imaging (fMRI) is helping us better understand the neurologic pathways involved in posttraumatic stress disorder (PTSD). We previously reported that military service members with PTSD after deployment to Iraq or Afghanistan demonstrated significant improvement, or normalization, in the fMRI-measured activation of the amygdala, prefrontal cortex and anterior cingulate gyrus following exposure therapy for PTSD. However, our original study design did not include repeat scans of control participants, rendering it difficult to discern how much of the observed normalization in brain activity is attributable to treatment, rather than merely a practice effect. Using the same Affective Stroop task paradigm, we now report on a larger sample of PTSD-positive combat veterans that we treated with exposure therapy, as well as a combat-exposed control group of service members who completed repeat scans at 3-4 month intervals. Findings from the treatment group are similar to our prior report. Combat controls showed no significant change on repeat scanning, indicating that the observed differences in the intervention group were in fact due to treatment. We continue to scan additional study participants, in order to determine whether virtual reality exposure therapy has a different impact on regional brain activation than other therapies for PTSD.

Functional Neuroimaging Correlates of Burnout among Internal Medicine Residents and Faculty Members

Burnout is prevalent in residency training and practice and is linked to medical error and suboptimal patient care. However, little is known about how burnout affects clinical reasoning, which is essential to safe and effective care. The aim of this study was to examine how burnout modulates brain activity during clinical reasoning in physicians. Using functional Magnetic Resonance Imaging (fMRI), brain activity was assessed in internal medicine residents (n = 10) and board-certified internists (faculty, n = 17) from the Uniformed Services University (USUHS) while they answered and reflected upon United States Medical Licensing Examination and American Board of Internal Medicine multiple-choice questions. Participants also completed a validated two-item burnout scale, which includes an item assessing emotional exhaustion and an item assessing depersonalization. Whole brain covariate analysis was used to examine blood-oxygen-level-dependent (BOLD) signal during answering and reflecting upon clinical problems with respect to burnout scores. Higher depersonalization scores were associated with less BOLD signal in the right dorsolateral prefrontal cortex and middle frontal gyrus during reflecting on clinical problems and less BOLD signal in the bilateral precuneus while answering clinical problems in residents. Higher emotional exhaustion scores were associated with more right posterior cingulate cortex and middle frontal gyrus BOLD signal in residents. Examination of faculty revealed no significant influence of burnout on brain activity. Residents appear to be more susceptible to burnout effects on clinical reasoning, which may indicate that residents may need both cognitive and emotional support to improve quality of life and to optimize performance and learning. These results inform our understanding of mental stress, cognitive control as well as cognitive load theory.

Heart rate response to fear conditioning and virtual reality in subthreshold PTSD

Posttraumatic stress disorder (PTSD) is a significant health concern for U.S. military service members (SMs) returning from Afghanistan and Iraq. Early intervention to prevent chronic disability requires greater understanding of subthreshold PTSD symptoms, which are associated with impaired physical health, mental health, and risk for delayed onset PTSD. We report a comparison of physiologic responses for recently deployed SMs with high and low subthreshold PTSD symptoms, respectively, to a fear conditioning task and novel virtual reality paradigm (Virtual Iraq). The high symptom group demonstrated elevated heart rate (HR) response during fear conditioning. Virtual reality sequences evoked significant HR responses which predicted variance of the PTSD Checklist-Military Version self-report. Our results support the value of physiologic assessment during fear conditioning and combat-related virtual reality exposure as complementary tools in detecting subthreshold PTSD symptoms in Veterans.

Web-based post-traumatic stress disorder education for military family members

OBJECTIVE

Since post-traumatic stress disorder (PTSD) is common after military deployment and affects both military service members and their families, we sought to both improve PTSD-related knowledge of military family members and to foster actions to help service members with their symptoms.

METHODS

Focus groups were conducted with military family members and their feedback was incorporated into an educational Web site to improve family members' knowledge of PTSD. We pilot-tested the site and a 25-item questionnaire, then used it to assess the knowledge of 497 family members before and after their use of the Web site.

RESULTS

Use of this educational Web site improved military family members' PTSD-related knowledge on a 25-item test, with an increase from a mean 13.9 correct responses beforehand to 18.7 after Web site use (p < 0.001; effect size 1.2). In addition, 217 family members returned to the site > or =10 days after their initial visit; 57% had taken actions such as discussing the service member's symptoms with them or persuading them to get medical attention, and 82 to 95% of them believed their actions to be beneficial.

CONCLUSION

A Web-based intervention can both improve PTSD-related knowledge and foster behavioral changes in military family members.

Psychophysiologic identification of subthreshold PTSD in combat veterans

Posttraumatic stress disorder (PTSD) is linked with adverse health outcomes, and many military service members (SMs) are afflicted with it after they return from combat. Since many SMs have an initial honeymoon period characterized by limited symptoms before the onset of full-blown PTSD, the identification of independent predictors of PTSD upon return from deployment could facilitate early intervention. We measured psychophysiologic responses to stimuli including explosions in a Virtual Iraq/Afghanistan environment, as well as a fear potentiated startle paradigm, in a prospective cohort of SMs who did not meet criteria for PTSD and were within 2 months after return from deployment. We report marked psychophysiologic differences between those with (n = 29) and without (n = 30) subthreshold PTSD symptoms (PTSD Checklist score ≥ 28 vs. &lt; 28). We believe this is evidence that psychophysiologic measures can help to identify individuals at high risk for PTSD.

Improvement in cerebral function with treatment of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are signature illnesses of the Iraq and Afghanistan wars, but current diagnostic and therapeutic measures for these conditions are suboptimal. In our study, functional magnetic resonance imaging (fMRI) is used to try to differentiate military service members with: PTSD and mTBI, PTSD alone, mTBI alone, and neither PTSD nor mTBI. Those with PTSD are then randomized to virtual reality exposure therapy or imaginal exposure. fMRI is repeated after treatment and along with the Clinician-Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores to compare with baseline. Twenty subjects have completed baseline fMRI scans, including four controls and one mTBI only; of 15 treated for PTSD, eight completed posttreatment scans. Most subjects have been male (93%) and Caucasian (83%), with a mean age of 34. Significant improvements are evident on fMRI scans, and corroborated by CGI scores, but CAPS scores improvements are modest. In conclusion, CGI scores and fMRI scans indicate significant improvement in PTSD in both treatment arms, though CAPS score improvements are less robust.

A randomized, double-blind, safety and tolerability study to assess the ophthalmic and renal effects of tafenoquine 200 mg weekly versus placebo for 6 months in healthy volunteers

A randomized, double-blind, placebo-controlled study was conducted to assess the effect of tafenoquine, 200 mg weekly for 6 months on ophthalmic and renal safety. This trial was carried out after observations in previous clinical trials that tafenoquine may be associated with the development of corneal deposits and elevations in serum creatinine. In 120 healthy volunteers who received tafenoquine or placebo in a 2:1 randomization, there was no effect on night vision or other ophthalmic indices measured. Persons taking tafenoquine also showed no difference in mean change in glomerular filtration rate (GFR, mL/s/1.73 m(2)) after 6 months of dosing, with a treatment difference of -0.061 (95% confidence interval, -0.168, 0.045), and non-inferiority margin of -0.247 mL/s/1.73 m(2). Tafenoquine was well tolerated over the course of the study. The results of this study showed no clinically significant effects of tafenoquine on ophthalmic or renal function, and support its continued development as an antimalarial drug.

High performance liquid chromatographic measurement of iothalamate in human serum and urine for evaluation of glomerular filtration rate

A simple and sensitive HPLC-UV assay was developed for the measurement of iothalamate (IOT) in human serum and urine. Chromatographic separation was achieved using an embedded-carbamate-group bonded RP18 column and mobile phase consisting of 50 mM monobasic sodium phosphate and methanol (90:10, v/v) without the addition of ion-pair reagents. The assay demonstrated a high analytical reliability within the IOT concentration range of 1-150 microg/ml in serum and 25-1500 microg/ml in urine. The relative standard deviations (RSDs) for intra- and inter-day analysis were less than 5.1% in all cases. This method has been used for the evaluation of glomerular filtration rate (GFR) in subjects participating in a phase I clinical trial of a novel antimalarial medicine. The average baseline GFR was 100.41+/-19.99 ml/min/1.73 m(2) in 119 healthy volunteers. The assay may also allow the simultaneous measurements of p-aminohippuric acid (PAH), N-acetyl PAH (aPAH), and IOT with some modification. PAH, IOT, aPAH, and beta-hydroxyethyl-theophylline internal standard peaks appeared approximately at 2.5, 3.7, 5.9, and 11.8 min, respectively, in an isocratic run.

Pyridostigmine, diethyltoluamide, permethrin, and stress: a double-blind, randomized, placebo-controlled trial to assess safety

OBJECTIVE

To determine whether short-term human exposure to pyridostigmine bromide, diethyltoluamide, and permethrin, at rest or under stress, adversely affects short-term physical or neurocognitive performance.

PARTICIPANTS AND METHODS

A multicenter, prospective, double-blind, placebo-controlled crossover trial exposing 64 volunteers to permethrin-impregnated uniforms, diethyltoluamide-containing skin cream, oral pyridostigmine, and corresponding placebos was performed. Each participant had 4 separate sessions, ensuring exposure to all treatments and placebos under both stress and rest conditions in random order. Outcomes Included physical performance (handgrip strength and duration, stair climbing, and pull-ups [males] or push-ups [females]), neurocognitive performance (computerized tests), and self-reported adverse effects.

RESULTS

Permethrin was undetectable in the serum of all participants; pyridostigmine levels were higher Immediately after stress (41.6 ng/mL; 95% confidence Interval, 35.1-48.1 ng/mL) than rest (23.0 ng/mL; 95% confidence Interval, 19.2-26.9 ng/mL), whereas diethyltoluamide levels did not significantly differ by stress condition. Heart rate and systolic blood pressure increased significantly with stress compared with rest but did not vary with treatment vs placebo. Physical and neurocognitive outcome measures and self-reported adverse effects did not significantly differ by exposure group.

CONCLUSION

Combined, correct use of pyridostigmine, diethyltoluamide, and permethrin is well tolerated and without evidence of short-term physical or neurocognitive impairment.

A 43-year-old colonel with chills, diaphoresis, and headache

The objectives were to illustrate the ease with which one might attribute concomitant or subsequent illness to an exposure such as the anthrax vaccine and to demonstrate an approach that keeps the significance of such exposures in appropriate perspective. A 43-year-old, active duty, Army officer presents with a variety of nonspecific common symptoms and raises concerns about the relationship of his symptoms to receipt of the anthrax vaccine. He is admitted for an evaluation that includes a series of diagnostic tests and consultations. The course of his illness and the corresponding evaluation are reviewed using a series of questions and accompanying discussions to highlight key points regarding diagnostic considerations, the anthrax vaccine, and the ultimate identification of the correct diagnosis.

Initial evaluation of N,N-diethyl-m-toluamide and permethrin absorption in human volunteers under stress conditions

OBJECTIVES

This was a pilot study to determine (1) whether it is feasible to effectively blind human subjects to the presence of the insect repellents N,N-diethyl-m-toluamide (DEET) and permethrin; (2) whether DEET affects the absorption of permethrin; and (3) whether combat videotape viewing and mental arithmetic are stressful.

METHODS

Ten volunteers were exposed to DEET, permethrin, and stress (1-hour combat videotape plus mental arithmetic) in a double-blind, randomized, placebo-controlled trial. Outcome measurements included hemodynamics, plasma DEET and permethrin levels, and questionnaires to assess blinding.

RESULTS

Highly sensitive serologic assays readily detected DEET but not permethrin. Staff members and subjects were effectively blinded to both. The videotape-math combination was stressful by both self-report and hemodynamic measures.

CONCLUSIONS

It is possible to blind subjects with respect to DEET and permethrin. Permethrin on clothing does not enter the bloodstream at appreciable levels. Combat videotapes and mental arithmetic can be stressful.

Simulation and Virtual Reality in Medical Education and Therapy: A Protocol

Continuing medical education has historically been provided primarily by didactic lectures, though adult learners prefer experiential or self-directed learning. Young physicians have extensive experience with computer-based or "video" games, priming them for medical education--and treating their patients--via new technologies. We report our use of standardized patients (SPs) to educate physicians on the diagnosis and treatment of biological and chemical warfare agent exposure. We trained professional actors to serve as SPs representing exposure to biological agents such as anthrax and smallpox. We rotated workshop participants through teaching stations to interview, examine, diagnose and treat SPs. We also trained SPs to simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked together to treat MASCAL victims, followed by discussion of key teaching points. More recently, we developed computer-based simulation (CBS) modules of patients exposed to biological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, we detail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) exposure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD). PTSD is associated with significant disability and healthcare costs, which may be ameliorated by the identification of more effective therapy.

Rapid Determination of N,N-Diethyl-m-Toluamide and Permethrin in Human Plasma by Gas Chromatography-Mass Spectrometry and Pyridostigmine Bromide by High-Performance Liquid Chromatography

A rapid and highly sensitive gas chromatography-mass spectrometry (GC-MS) method for simultaneous determination of N,N-diethyl-m-toluamide (DEET) and permethrin with (2)H(10)-phenanthrene (98 atom %) as an internal standard and a separate external standard high-performance liquid chromatography (HPLC) method for pyridostigmine bromide (PB) determination in human plasma were developed and validated. The GC-MS method for DEET and permethrin quantification utilizes a one-step extraction with tert-butylmethylether. The HPLC method for PB quantification involves a solid-phase extraction and UV detection. The range of the analytical method for DEET and permethrin was 1 ng/mL to 100 ng/mL and for PB was 5 ng/mL to 100 ng/mL. Recovery from plasma proved to be more than 80%. The intraday precision ranged from 1.3% to 8% for DEET, from 2.1% to 11.4% for permethrin, and from 3.0% to 4.8% for PB. The interday precision was 3% for DEET, ranged from 5% to 9% for permethrin, and from 5% to 9% for PB. The accuracy for the limit of quantification was 92% +/- 8% relative standard deviation (RSD) for DEET, 112% +/- 11% RSD for permethrin, and 109% +/- 5% RSD for PB. All 3 compounds were stable in human plasma at -80 degrees C for at least 12 months and after 2 freeze-thaw cycles with RSD values ranging from 7.1% (DEET, 80 ng/mL) to 8.1% (DEET, 8 ng/mL), from 2.3% (permethrin, 80 ng/mL) to 11.6 % (permethrin, 8 ng/mL), and from 0.2% (PB, 80 ng/mL) to 3.6% (PB, 8 ng/mL). Both methods were successfully applied to pharmacokinetic/ pharmacodynamic studies of combined exposure of DEET (skin application), permethrin (treated uniforms), and PB (30 mg orally three times/day for four doses) in healthy volunteers (n = 81).

Fatigue, Sore Throat, and Cough in a 24-Year-Old Active Duty Man

A 24-year-old active duty male smoker presented with 3 days of fatigue, rhinorrhea, and sore throat. The diagnosis and management of pharyngitis, including a field friendly approach, are reviewed. The impact of the discontinuation of the adenovirus vaccine to military recruits is highlighted. The effects of smoking among military personnel are discussed, and smoking cessation measures are reviewed.

Military unique curriculum: identifying and prioritizing content

We have identified and prioritized a series of objectives that warrant inclusion in the continuum of military medical education. Although participants in the 16th Conference on Military Medicine also discussed whether each objective should be taught at the medical student, resident, or staff physician level, to a large extent this distinction is not helpful, since many, if not most, of these topic areas would likely require incorporation at each of these three levels to achieve the desired level of competence in staff physicians. Incorporation of new curricular elements poses a significant challenge, since it is already difficult to fit the existing curriculum into the available time. It is not reasonable to consider increasing the number of lecture hours. Therefore, it is probable that some elements of the existing curriculum will need to be pared down or eliminated to incorporate new material. In the past, when new material has been added to the existing curriculum, such as when the pathogenesis of human immunodeficiency virus was added, it has generally been done at the individual teacher or at most departmental level. Although this approach has the advantage of having a subject matter expert decide how best to insert new material within the fabric of the existing curriculum, there are a couple of problems with widespread use of this approach. First, some of these new objectives may not fit clearly within an existing course curriculum or department's educational mission. Second, such an approach may not provide the degree of coordination that is necessary to ensure that a new curricular item is adequately covered in all respects, and it may result in unnecessary overlap in instruction when different professors incorporate similar elements. Therefore, the prioritization of newer curricular items, as has been done during this conference, may serve as a useful guide in this process. However, a corresponding effort is needed to identify and prioritize existing curricular components. Decisions need to be made regarding what, within the existing curriculum, should be cut out or reduced to make room for some or all of these new objectives. Finally, a decision needs to be made regarding which of these identified objectives should be inserted and when and within which courses they should be taught. These are important decisions that should not be left to the whims of chance. As the responsible recipients of Uniformed Services University and Health Professions Scholarship Program medical school graduates, the services' Surgeons General need to take an active role in helping to make these decisions. The outcome of these decisions will have a direct impact on the capabilities that these future junior medical officers will bring to the patients they will care for and to the line commanders that they will support.

Improving patient satisfaction with the transfer of care. A randomized controlled trial

OBJECTIVE

To determine whether educational sessions with medical residents, with or without letters to their patients, improve patient satisfaction with transfer of their care from a departing to a new resident in an internal medicine clinic.

DESIGN

Observational study in Year 1 to establish a historical control, with a randomized intervention in Year 2.

SETTING

An internal medicine clinic in a teaching hospital.

PATIENTS/PARTICIPANTS

Patients of departing residents completed questionnaires in the waiting room at their first visit with a new resident, with mail-administered questionnaires for patients not presenting to the clinic within 3 months after transfer of their care. In Year 1, 376 patients completed questionnaires without intervention. The following spring, we conducted interactive seminars with 12 senior residents to improve their transfer of care skills (first intervention). Half of their patients were then randomized to receive a letter from the new doctor informing them of the change (second intervention). We assessed the efficacy of the interventions by administering questionnaires to 437 patients in the months following the interventions.

MEASUREMENTS AND MAIN RESULTS

Multivariate analysis of Year 1 results identified doctors personally informing patients prior to leaving as the single strongest predictor of patient satisfaction (partial R2=.41). In Year 2, our first intervention increased the percentage of patients informed by their doctors from 71% in 1991 to 79% in 1992 (P <.001). Mean satisfaction dramatically improved, with the fraction of fully satisfied patients increasing from 47% at baseline, to 61% with the first intervention alone, and 72% with both interventions (P <.0001).

CONCLUSIONS

Simple methods such as resident education and direct mailings to patients significantly ease the difficult process of transferring patients from one physician to another. This has implications not only for residency programs, but for managed care networks competing to attract and retain patients.

Life-threatening polyneuropathy heralding renal cell carcinoma

OBJECTIVE

To report the occurrence of life-threatening polyneuropathy in association with renal cell carcinoma.

METHODS

Case report and review of the medical literature.

RESULTS

A 65-year-old man developed a fulminant, life-threatening sensory motor polyneuropathy several months before renal cell carcinoma was identified. Dramatic symptomatic improvement ensued after treatment with intravenous immunoglobulin, although the patient succumbed to complications of the tumor years later.

CONCLUSIONS

Chronic sensory motor polyneuropathy is a known paraneoplastic syndrome associated with renal cell carcinoma. This report emphasizes that in rare conditions, the polyneuropathy could take an acute demyelinating form, which is important for clinicians to recognize.

Teaching military medicine: enhancing military relevance within the fabric of current medical training

The education of military medical students and house officers in military-relevant curricular elements is increasingly important given the greater frequency with which military physicians are deployed to field and operational settings. However, the common approaches of either expanded didactic sessions or implementation of operational rotations for trainees face competition from instruction in other aspects of medicine that are essential for all (military as well as nonmilitary) physicians. We describe efforts to integrate military-relevant education within the existing framework of medical education, including current inpatient and ambulatory care rotations. This approach complements the formal, didactic syllabus, avoiding potential conflict engendered by eliminating curricular elements to accommodate military-unique subjects.

Tolerability and immune responses in humans to a PowderJect DNA vaccine for hepatitis B

We are developing a DNA vaccine toward hepatitis-B virus (HBV) using PowderJect's proprietary needle-free technology to deliver DNA-coated gold particles directly into cells of the skin. Preclinical studies in animals showed that (i) microgram doses of the DNA vaccine were sufficient to immunize pigs and non-human primates to antibody levels comparable to those obtained with a commercial recombinant subunit vaccine; (ii) the DNA vaccine was effective in mouse strains that respond poorly to protein subunit vaccines; (iii) the vaccine induces robust cytotoxic T-cell responses, and (iv) the vaccine is non-toxic and well tolerated. Based on these findings, this DNA vaccine was evaluated for safety, tolerability, and the induction of immune responses in phase 1 clinical studies in healthy, hepatitis-naïve human volunteers. Preliminary results indicate that the vaccine is safe and well tolerated, and elicits both humoral and cellular immune responses in man.

Operational experiences during medical residency: perspectives from the Walter Reed Army Medical Center Department of Medicine

The preparation of military primary care physicians for practice in operational environments has taken on greater importance during the past decade. The Department of Defense military-unique curriculum identifies the elements that should be incorporated into residency training programs to accomplish comprehensive training in operational matters. We describe efforts to integrate the military-unique curriculum into internal medicine residency, including obstacles encountered, so that other programs may learn from our experience.

Induction of antigen-specific CD8+ T cells, T helper cells, and protective levels of antibody in humans by particle-mediated administration of a hepatitis B virus DNA vaccine

A DNA vaccine against the hepatitis B virus (HBV) was evaluated for safety and induction of immune responses in 12 healthy, hepatitis-naïve human volunteers using the needle-free PowderJect system to deliver gold particles coated with DNA directly into cells of the skin. Three groups of four volunteers received three administrations of DNA encoding the surface antigen of HBV at one of the three dose levels (1, 2, or 4 microg). The vaccine was safe and well tolerated, causing only transient and mild to moderate responses at the site of administration. HBV-specific antibody and both CD4+ and CD8+ T cell responses were measured before and after each immunization. All the volunteers developed protective antibody responses of at least 10 mIU/ml. In volunteers who were positive for the HLA class I A2 allele, the vaccine also induced antigen-specific CD8+ T cells that bound HLA-A2/HBsAg(335-343) tetramers, secreted IFN-gamma, and lysed target cells presenting a hepatitis B surface antigen (HBsAg) CTL epitope. Enumeration of HBsAg-specific T cells producing cytokine indicated preferential induction of a Type 1 T helper cell response. These results provide the first demonstration of a DNA vaccine inducing protective antibody titers and both humoral and cell-mediated immune responses in humans.

Phase 1 safety and immune response studies of a DNA vaccine encoding hepatitis B surface antigen delivered by a gene delivery device

This study was designed to determine the safety and immunogenicity in volunteers of a DNA vaccine consisting of a plasmid encoding hepatitis B surface antigen delivered by the PowderJect XR1 gene delivery system into human skin. Seven healthy adult volunteers received two immunizations at one of three forces of delivery on day 0 and 56. The vaccine was well tolerated. One of six seronegative volunteers developed high titers of persistent HBsAb after a single immunization. In retrospect, this volunteer may have had previous exposure to hepatitis B. Our study suggests that the hepatitis B DNA vaccine given by this gene delivery system may induce a booster response, but the vaccine at the extremely low DNA dose used (0.25 microg) did not induce primary immune responses.

Signs, symptoms, and ill-defined conditions in Persian Gulf War veterans: findings from the Comprehensive Clinical Evaluation Program

OBJECTIVE

The purpose of this study was to analyze the type and frequency of signs, symptoms, and ill-defined conditions (SSID; International Classification of Diseases-9th Revision, Clinical Modification (ICD-9-CM) codes 780-799) identified by physicians evaluating Persian Gulf War veterans; to determine the influence of the extent of evaluation on the type and frequency of SSID diagnoses; and to search for evidence for a new illness, or illness related to wartime exposures, in veterans with ill-defined conditions.

METHOD

Comprehensive examinations were provided for 21,579 consecutive Persian Gulf War veterans with symptoms or health concerns after the war. Data recorded on all individuals includes demographics, self-reported exposures, symptoms, and physician-assigned ICD-9-CM primary and secondary diagnoses. A detailed psychosocial history, including a multidisciplinary discussion, was incorporated for a subset of participants.

RESULTS

SSID conditions were primary diagnoses for 17.2% of veterans, and either primary or secondary diagnoses for 41.8%. Although some SSIDs were objective conditions (eg, sleep apnea), most were simply symptoms. More comprehensive evaluation, especially the multidisciplinary discussion of findings, decreased the frequency of symptoms as diagnoses and increased the number of DSM-IV psychiatric diagnoses. Ill-defined conditions were not associated with particular self-reported exposures or demographic variables.

CONCLUSIONS

Ill-defined conditions identified by physicians in Gulf War veterans are most often symptoms. More definitive, often psychological, diagnoses can be made by increasing the intensity of the evaluation and by multidisciplinary input. Evidence for a new or unique illness related to wartime exposures did not emerge from this analysis.

Restricted diastolic opening of the mitral leaflets in patients with left ventricular dysfunction: evidence for increased valve tethering

OBJECTIVES

We tested the hypothesis that patients with incomplete systolic mitral leaflet closure (IMLC: apically displaced coaptation) also have restricted diastolic leaflet opening that is independent of mitral inflow volume and provides evidence supporting increased leaflet tethering.

BACKGROUND

Competing hypotheses for functional mitral regurgitation (MR) with IMLC include global left ventricular (LV) dysfunction per se (reduced leaflet closing force) versus geometric distortion of the mitral apparatus by LV dilation (augmented leaflet tethering). These are inseparable in systole, but restricted leaflet motion has also been observed in diastole, and attributed to reduced mitral inflow.

METHODS

Diastolic mitral leaflet excursion and orifice area were measured by two-dimensional echocardiography in 58 patients with global LV dysfunction, 36 with and 22 without IMLC, compared with 21 normal subjects. The biplane Simpson's method was used to calculate LV ejection volume, which equals mitral inflow volume in the absence of aortic regurgitation.

RESULTS

The diastolic mitral leaflet excursion angle was markedly reduced in patients with IMLC compared with those without IMLC, whose ventricles were smaller, and normal subjects (17 +/- 10 degrees vs. 58 +/- 13 degrees vs. 67 +/- 8 degrees, p < 0.0001). Excursion angle was dissociated from mitral inflow volume (r2 = 0.04); excursion was reduced in patients with IMLC despite a normal inflow volume in the larger ventricles with MR (60 +/- 25 vs. 61 +/- 12 ml in normal subjects, p = NS), and excursion was nearly normal in patients without IMLC despite reduced inflow volume (40 +/- 10 ml, p < 0.001 vs. normal subjects). The anterior leaflet when maximally open coincided well with the line connecting its attachments to the anterior annulus and papillary muscle tip (angular difference = 3 +/- 7 degrees vs. 25 +/- 9 degrees vs. 32 +/- 10 degrees in patients with and without IMLC vs. normal subjects, p < 0.0001). In patients with IMLC, the leaflet tip orifice was smaller in an anteroposterior direction but wider than in the other groups, giving a normal total area (6.8 +/- 1.8 vs. 7.1 +/- 1.2 vs. 6.9 +/- 0.8 cm2, p = NS).

CONCLUSIONS

Patients with LV dysfunction and systolic IMLC also have restricted diastolic leaflet excursion that is independent of inflow volume, coincides with the tethering line connecting the annulus and papillary muscle and reflects limitation of anterior motion relative to the posteriorly placed papillary muscles without a decrease in total orifice area. These observations are consistent with increased tethering by displaced mitral leaflet attachments in the dilated ventricles of patients with IMLC that can restrict both diastolic opening and systolic closure.

The value of screening for psychiatric disorders prior to upper endoscopy

Gastrointestinal (GI) complaints are among the most common symptoms in primary care yet are frequently unexplained and often lead to costly diagnostic testing. We sought to determine the prevalence of psychiatric disorders in patients with unexplained GI complaints undergoing upper endoscopy, and the likelihood of endoscopic abnormalities in patients with and without psychiatric diagnoses. We prospectively evaluated 116 adult patients who were undergoing upper endoscopy to evaluate GI complaints. All subjects received a structured psychiatric interview prior to endoscopy using PRIME-MD, and endoscopists were blinded to the PRIME-MD results. Psychiatric disorders were detected in 70 (60%) patients. Overall, there were 113 diagnoses (some patients had multiple disorders) with the most common being somatoform (44%), depressive (29%), and anxiety (19%) disorders. Only 29 patients had major endoscopic abnormalities, including esophageal disease (14), peptic ulcer (9), severe gastritis (4), gastric cancer (1), and esophageal cancer (1). There was a much higher prevalence of psychiatric disorders in patients without major endoscopic abnormalities (74% vs. 21%, p < 0.0001). Psychiatric disease was strongly predictive of endoscopic findings (OR for major abnormality = 0.11 in women, and 0.40 in men), especially if somatoform disorder was present (OR = 0.15). We conclude that, with a simple questionnaire, psychiatric disorders can be diagnosed in a large proportion of patients with unexplained GI complaints who are referred for upper endoscopy. The presence of a psychiatric disorder, particularly if somatoform, makes it unlikely that endoscopy will reveal significant GI disease.

Possibilities for unexplained chronic illnesses among reserve units deployed in Operation Desert Shield/Desert Storm

Because Armed Forces Reserve members, especially combat support units, were rapidly mobilized during Operation Desert Shield/Desert Storm, they were at higher risk for anxiety and stress-related disorders. Personnel in reserve units in the military force structure are at greater risk for psychologic stress due to rapid mobilization and demobilization, which allows minimal time to process adverse experiences or fears. The unexpected disruption of families and careers and resulting financial pressures are magnified in older age groups who have increased personal and family commitments. Personnel in combat support units are at greatest risk when they lack necessary training, cohesion, and leadership. Prevention efforts in reserve units should involve education regarding the potential for activation and associated disruption of family and career plans. Support networks for reserve families should be encouraged. Additional training in an appropriate context regarding risks of biologic and chemical exposure, with the goal of developing confidence in training and equipment, should be stressed. Finally, group processing before demobilization and recall within 90 days of return to emphasize unit cohesion and readjustment to civilian life may be of benefit.