The somatoform conundrum: a question of nosological values

This paper critically reviews the values and perspectives evident in the formulation of the category of Somatoform Disorders in the widely used Diagnostic and Statistical Manual-IV (DSM-IV) [1] of the American Psychiatric Association. The conflict of values evident in the DSM Committee's elimination of causal issues and including only descriptive criteria in the final classification is emphasized. In this approach, causation was dismissed and only a description of popular clinical entities was allowed. It becomes clear that there was a conflict between causal and descriptive factors in the formation of the current classifications. The dubious logic and the inconsistencies that underlie the linking of the various diagnoses under the Somatoform Disorder (SD) rubric is presented. A heuristic model of the interaction of psychological and somatic variables is described. These variables act in a causal fashion and should be the basis for any nosological system of the SDs. There is ample evidence to support the importance of causal factors in the development of SDs, and the current descriptive nomenclature does not do justice to the rapidly growing field of Psychosomatic Medicine. A new scheme is proposed, using the presence or absence of stress as the connecting link for the diagnoses offered. The old nosology enhances the perpetuation of the mind-body dichotomy. Stress, representing the way in which the environment impinges on the human being, allows the mind-body dichotomy to be eliminated. The preferred synthesis of mind-body interaction as partly the result of experience in the environment becomes the basis for the new nosology.

Unrearable litters and prenatal reduction of litter size in the common marmoset (Callithrix jacchus)

It is widely believed that common marmosets (Callithrx jacchus) typically give birth to twins under natural conditions. In captivity, however, births of triplets or even larger litters are common, although parents rarely succeed in rearing more than two offspring. The traditional interpretation is that captive conditions, notably the ready availability of food, have led to increased reproductive output, perhaps involving a higher ovulation rate. The present paper provides evidence, combined from ultrasound examinations between ovulation and birth and hysterotomies conducted during the late embryonic and early fetal phase, that the litter size can be progressively reduced during pregnancy without spontaneous abortion. There is an unusually long lag phase prior to the onset of embryonic growth in common marmosets; the fetal stage does not begin until day 80 of the 144-day pregnancy. Reduction in litter size occurs during embryonic stages (up to day 80), and continues into the fetal stages. These results indicate that the common marmoset is adapted for flexible modification of litter size between ovulation and birth. The high incidence of triplet births in captive colonies may therefore be an expression of an adapted natural developmental process under artificial circumstances.

Genetic differentiation within and between isolated Algerian subpopulations of Barbary macaques (Macaca sylvanus): evidence from microsatellites

This study of wild-living Algerian Barbary macaques (Macaca sylvanus) was designed to examine genetic variability in subpopulations isolated in residual forest patches, in an attempt to obtain data on the effects of habitat fragmentation. The wild population of this species (estimated at a maximum of 15,000) is vulnerable and this study therefore has direct relevance for conservation measures. Data from five microsatellite loci were analysed for 159 individuals from nine different groups living in four isolates in Algeria. Genetic polymorphism was found to be relatively high (4-12 alleles per locus) compared with other genetic markers used in previous studies of this species; mean expected heterozygosity was 65%. The four isolates are all genetically distinct (FST = 0; P < 0.001). Indeed, the results suggest that dispersal is limited even between some social groups within a single isolate. Genetic distances based on models not assuming stepwise mutation (FST and chord distance) gave very similar results and are highly correlated with geographical distances within one isolate but not between isolates. This may indicate that isolation by distance exerts a significant influence within an isolate but that genetic drift prevails between the four isolates. After allowing for variation in sample size, we found no evidence of reduced allelic diversity within small isolates that may have been separated for 250 years or more. The surviving population of Algerian Barbary macaques taken as a whole still shows marked variability in microsatellite alleles, but maintenance of genetic variability over the long term will surely require effective protection of all isolates.

Energy intake during reproduction in captive common marmosets (Callithrix jacchus)

Among haplorhine primates, the highly specialized Callitrichidae (marmosets and tamarins) are expected to have comparatively high reproductive costs, a feature that might be related to the evolution of a cooperative breeding system. Costs of reproduction in captivity were investigated on the basis of changes in energy intake and body weight during pregnancy and lactation in pair-living female and male common marmosets (Callithrix jacchus). The experimental design had little effect on carrying behavior, food intake, and body weight of adults, but a negative transitory effect of offspring body weight. Increased energetic requirements during pregnancy did not result in a higher energy intake in females. During lactation, females increased their energy intake up to 100% and gradually lost weight, suggesting even higher costs. Extensive carrying behavior by males, on the other hand, did not result in an increased energy intake in males, or in changes in male body weight. It is suggested that, at least in captivity, increased energetic demands during reproduction are reduced by behavior allocations towards energetically less expensive behaviors.

Creating a benefit management information database

In this case study, a real-life information technology conundrum is fictionalized to illustrate the potential benefits of retaining corporate knowledge through the creation of an information repository in a managed health care plan.

Physiological Responses to parental separation and a strange situation are related to parental care received in juvenile Goeldi's monkeys (Callimico goeldii)

The relationship between parental care received and physiological and behavioral responses to parental separation, isolation, and reunion was investigated in seven juvenile Goeldi's monkey living in their family groups. Physiological responses were measured non-invasively: the hypothalamic-pituitary-adrenal axis via urinary cortisol output and the autonomic nervous system via piloerection on the tail. Parent-infant aggression demonstrated high intergroup variation and predicted: (a) an increase in urinary cortisol output, r(s) = 0.86, p = 0.04, and duration of piloerection, r(s) = 0.71, p = 0.08, at initial separation-isolation; (b) adaptation of piloerection, r(s) = -0.89, p = 0.03, to repeated separation-isolation. Juvenile Goeldi's monkeys that had received high parental aggression were more physiologically responsive to separation; they also sought more contact with their mothers at reunion, rs = 0.93, p = 0.02. We propose that these data are consistent with the hypothesis that high emotional reactivity is related to insecure attachment to aggressive parents in this New world primate.

A reexamination of the phylogenetic position of Callimico (primates) incorporating new mitochondrial DNA sequence data

The New World monkeys are divided into two main groups, Callitrichidae and Cebidae. Callimico goeldii shares traits with both the Cebidae and the Callitrichidae. Recent morphological phyletic studies generally place Callimico as the most basal member of the Callitrichidae. In contrast, genetic studies (immunological, restriction fragment, and sequence data) have consistently placed Callimico somewhere within the Callitrichidae, not basal to this clade. A DNA sequence data set from the terminal 236 codons of the mitochondrial ND4 gene and the tRNA(His), tRNA(Ser), and tRNA(Leu) genes was generated to clarify the position of Callimico. The sequences of 887 base pairs were analyzed by maximum-parsimony, neighbor-joining, and maximum-likelihood methods. The results of these various methods are generally congruent and place Callimico within the Callitrichidae between the marmosets (Callithrix and Cebuella) and the tamarins (Saguinus and Leontopithecus). Combined analyses of all suitable nuclear and mitochondrial gene sequences confirm the position of Callimico between the marmosets and the tamarins. As available molecular evidence indicates that Callimico is more closely related to the marmosets than to the tamarins, a reconsideration of the morphological evidence in light of the consensus tree from DNA sequence analyses is warranted. The marmosets and tamarins share four morphological characters (loss of the third molar, loss of the hypocone, reduced body size, reproductive twinning). Dwarfism may have evolved repeatedly among the Callitrichidae. It is well-known that the loss of a character can occur many times independently. The reproduction of marmosets and tamarins is extremely specialized and it is difficult to imagine that this complex and unique twinning system evolved separately in marmosets and tamarins. However, it is possible that a secondary reversal to single offspring took place in Callimico.

Evidence from urinary cortisol that maternal behavior is related to stress in gorillas

By studying western lowland gorillas (Gorilla gorilla gorilla, n = 8) in zoological gardens via ethological and non-invasive physiological techniques, we have demonstrated that their postpartum maternal behavior is related negatively to their postpartum urinary titers of cortisol. On the basis of this finding, it is proposed that postpartum stress contributes to disrupted maternal behavior in the gorilla in captivity. Morning urine samples were collected with a mean sampling interval of 1.6 days from Day 14 prepartum to Day 14 postpartum (n = 11 pregnancies). Creatinine-indexed (Cr) urinary cortisol titers declined significantly between Day 9 to 1 prepartum (0.634 +/- 0.014 microg/mg of Cr, mean +/- SEM) and Day 1 to 6 postpartum (0.396 +/- 0.030 microg/mg of Cr, mean +/- SEM; p < 0.01-0.001). For each pregnancy, the relative postpartum decline in urinary cortisol was calculated as (microg of cortisol/mg of Cr Day 1 to 4)/(microg of cortisol/mg of Cr Day -4 to -1). Values ranged from 0.35 to 1.12, were independent of absolute prepartum cortisol titers, and were interpreted as evidence of inter-female differences in postpartum hypothalamo-pituitary-adrenal axis activity and, therefore, postpartum stress. This postpartum stress index was negatively correlated with the amount of time (0-100%) that females carried and supported their 0-14 day-old infants in a ventral position during locomotion (r(s) = -0.68, p < 0.05) and tended to be negatively correlated with the total amount of time (0-100%) they spent in ventro-ventral contact with their infants (r(s) = -0.58; p < 0.10). This study provides the first physiological evidence that postpartum stress is an important etiologic factor in gorilla maternal failure in captive environments.

Effectiveness of a teen pregnancy clinic in a managed care setting

We retrospectively examined the effectiveness of a teen pregnancy clinic at a large multispecialty group between 1991 and 1994 using measurements of statistical differences in intervention and outcome variables. The 72 teens in the intervention group attended significantly more prenatal visits, more postpartum visits and gained more weight than the 33 controls. Other outcome variables such as fetal birth weight, Apgar scores, and neonatal intensive care unit admission showed trends toward improvement, but were not significantly different. We conclude that a teen pregnancy clinic in a managed care setting can be a cost-effective intervention in improving mental and neonatal outcome.

Outcomes study of a course in breast-cancer screening

BACKGROUND

The Breast Cancer Screening Module is a professional training course within the Professional Education for Prevention and Early Detection (PEPED) program at the University of Texas M. D. Anderson Cancer Center. An outcomes study was done to determine the module's ability to improve screening practices crucial to breast-cancer control.

METHODS

The five-day course combines 17 hours of class work with 20 hours of hands-on clinical training. Subjects were followed for one year post-training. Six outcome areas were evaluated: 1) knowledge about breast-cancer prevention; 2) clinical skills; 3) changes in routine practice; 4) numbers of patients screened, referred, and diagnosed; 5) trainee satisfaction with the course; and 6) barriers to implementing screening in routine practice. The study population was 63 subjects (all nurse professionals).

RESULTS

Outcomes were positive in all six evaluation areas-significant gains in general and clinical knowledge tests (p < or = 0.05); a significant increase from 54.2% pre-training to 70.5% post-training in risk counseling (p < or = 0.05); a sustained increase in screening practices (4.3 times and 2.8 times greater at 6 and 12 months post-training, respectively); 72% rate of high course satisfaction; and barriers to improved screening practices, such as time limitations among 60.4% of subjects and 57.6% of their employers, were identified.

CONCLUSIONS

This unique training enhances breast-cancer prevention and screening practices and early detection.

Scaling of the Mammalian Brain: the Maternal Energy Hypothesis

Mammalian brain sizes have been linked to specific behavioral or physiological features because of simple scaling correlations. Examination of the correlation network for body size, brain size, basal metabolic rate, and gestation period indicates that the primary link is between maternal metabolic capacity and the developing brain of the offspring.

Longitudinal evaluation of a breast cancer training module. Preliminary results

BACKGROUND

In 1993, the University of Texas M.D. Anderson Cancer Center's Department of Clinical Cancer Prevention began a longitudinal evaluation of its efforts to improve early detection and prevention of breast cancer by training health care professionals in special assessment skills, including how to determine risk and how to teach patients to detect breast cancer early.

METHODS

Sixty-three nurses enrolled in the 1-week training module were studied in this descriptive analysis. Their evaluation incorporated not only pretests and post-tests of knowledge and clinical performance but also an employer survey, pretraining and posttraining patient logs, and an assessment of clinical skills in each participant's practice setting.

RESULTS

Students made statistically significant gains in measures of general knowledge, clinical knowledge and performance, and routine practice of risk assessment, risk counseling, and history taking and physical examination of old (i.e., familiar) patients. Furthermore, the number of patients screened, patients referred, and cancer diagnoses made increased significantly over time, not only between pretraining and posttraining at 6 and 12 months, but also between 6 and 12 months' posttraining.

CONCLUSIONS

After learning and practicing new skills, participants successfully incorporated and maintained them and increased referrals and cancers detected, thereby improving the effectiveness of cancer screening.

Parentage analysis within a semi-free-ranging group of Barbary macaques Macaca sylvanus

This study of a group of semi-free-ranging Barbary macaques Macaca sylvanus aimed to determine paternity, to establish whether any individual male achieved prominent mating success and to assess genetic variability. Analyses involved electrophoresis of 15 blood protein systems and multilocus DNA fingerprinting (isotopic and nonisotopic). Genetic variability was low; only two blood protein systems were polymorphic. Although all DNA-fingerprints were individual-specific, they showed a high average band-sharing index value (0.67). Nevertheless, a combination of all methods permitted inference of paternity in 11 out of 15 (73%) cases tested. Several males from different age classes fathered infants.

Diaspirin crosslinked hemoglobin (DCLHb) does not affect the anesthetic potency of isoflurane in rats

Hemoglobin solutions are being developed as oxygen carrying fluids for multiple clinical indications. Despite an early report of accentuation of ether anesthesia, the effect of hemoglobin on anesthetic potency has not been assessed. We assessed the effect of alpha-alpha diaspirin crosslinked hemoglobin (DCLHb) on the anesthetic requirement of isoflurane necessary to keep rats unresponsive to noxious stimuli (1.0 MAC [minimum alveolar concentration]). During isoflurane administration, each rat received one of the following fluid regimens: 44Hct/N-normal hematocrit and volume; 44Hct/H-8.0 ml of donor blood given as a hypervolemic bolus; 30Hct/H-5.0 ml of DCLHb given as an exchange transfusion and 8.0 ml as a hypervolemic bolus; or 16Hct/H-15.0 ml of DCLHb given as an exchange transfusion and 8.0 ml as a hypervolemic bolus. MAC was determined using a standard tail clamp technique. The isoflurane requirement to achieve 1.0 MAC was not different between the four groups. These results are consistent with a hypothesis that DCLHb does not change the anesthetic state.

Nitrendipine and superoxide dismutase in ischemic renal injury

The effect of the Ca entry blocker nitrendipine, the antioxidant superoxide dismutase (SOD), and a combination of nitrendipine and superoxide dismutase on postischemic renal function was studied in four groups (n = 24) of rats. The rats in group 1 (n = 6) were the ischemic control and received 10 mL of 0.9% NaCl. Group II (n = 6) received SOD 7.0 mg/kg. Group III (n = 6) received nitrendipine 1 mg/kg. Group IV (n = 6) received nitrendipine 1 mg/kg and SOD 7 mg/kg. After administration, both kidneys were rendered ischemic by cross-clamping the renal vessels for 60 min. Comparison of 24-h creatinine clearance (CCr) for 3 days after reversal of ischemia revealed: (a) nitrendipine alone was the most effective in preserving renal function (p < .05); (b) SOD provided some degree of improvement, but only on day 3 (p < .05); (c) a similar result was detected using a combination of nitrendipine and SOD (p < .05); (d) there was no significant difference between SOD and nitrendipine nor between SOD and the combination of nitrendipine/SOD; (e) there was a significant improvement with nitrendipine when compared to the combination of nitrendipine/SOD (p < .05).

Facial fractures

Emergency room physicians frequently see facial fractures that can have serious consequences for patients if mismanaged. This article reviews the signs, symptoms, imaging techniques, and general modes of treatment of common facial fractures. It focuses on fractures of the mandible, zygomaticomaxillary region, orbital floor, and nose.

Primate origins: plugging the gaps

Recent discoveries of fossil primate specimens have produced several surprises and challenged prevailing views of early primate evolution. Plesiadapiformes, long regarded as 'archaic primates', may perhaps be linked to the peculiar colugos instead. Inferred relationships of the earliest known undoubted primates (adapids and omomyids) are in turmoil. Both groups have been proposed as sources for the simian primates. Although the origin of the simian primates is obscure, new fossil evidence could push it further back by at least 10 million years. Such uncertainties reflect the low sampling level of the primate fossil record, which can potentially also lead to underestimation of times of origin within the primate tree.

The role of the bone-gallium scan in sternal osteomyelitis

Sternal osteomyelitis is an uncommon but serious complication of the median sternotomy incision. Between 1982 and 1990, 160 patients with sternal osteomyelitis and wound dehiscence were treated with sternal debridement and pectoral muscle flap closure at The Toronto Hospital. Most of these wound infections were clinically obvious, and the need for surgical treatment apparent. In a small number of patients, however, the extent of the infection was more difficult to determine clinically. In this subset of patients, the interpretation of the bone-gallium scan was important in determining the presence or absence of bone infection and the probability of successful treatment without surgery. In this study, we review our findings at the time of surgery and compare them with the preoperative information available from the bone-gallium scan. The limited literature on this topic is reviewed. In this group of patients, we found the bone-gallium scan was not helpful in clinical management.

Sartorius myoplasty in the treatment of exposed arterial grafts

The long-term success of sartorius myoplasty in 14 of 16 patients who presented with an exposed vascular graft in an infected groin is described. The presenting complications were wound dehiscence (ten patients), hemorrhage (two), skin erosion (two), late bilateral fistulas (one) and false aneurysm (one). Ten grafts were prosthetic and six autogenous. Positive cultures were obtained from 15 wounds; four grew Staphylococcus epidermidis, the remainder mixed or Gram-negative bacteria. Each groin was radically debrided, including the surface of the arterial graft, and, if possible, closed immediately with a sartorius myoplasty applied directly to the graft. Twist, fan and loop myoplasties were equally effective. Grossly infected wounds were debrided initially and obviously infected grafts were replaced in situ before myoplasty. Sartorius myoplasty is recommended as an elegant solution for the infected groin in which there is an exposed arterial graft.

Effects of sex steroids on maternal motivation in the common marmoset (Callithrix jacchus): development and application of an operant system with maternal reinforcement

We developed an operant paradigm for measuring effects of reproductive steroids on maternal motivation in common marmosets (Callithrix jacchus). Conditioned response regulated females' exposure to maternal reinforcement. Nulliparous females (n = 15) with experience with infants in social groups were subjects. The paradigm was validated by examining (a) effects of reinforcing stimuli on affective behavior in a nonoperant paradigm, (b) responsiveness of operant performance to changes in reinforcing stimuli and reinforcement schedule, (c) changes in operant responding due to omission of reinforcement, and (d) relation between operant responding and species-typical maternal behavior. In pregnant females, (n = 4), frequency of bar pressing and estradiol:progesterone ratio were maximal just before birth. Nonpregnant females (n = 3) treated with progesterone and estradiol to mimic late-pregnancy steroid profiles showed increased operant maternal behavior.

Allometry and prediction in hominoids: a solution to the problem of intervening variables

To avoid misinterpretation of allometric exponents determined from interspecific allometric comparisons, specific conditions must be met with respect to the common reference variable. Body weight is considered to be the best general indication of overall size and is hence widely acknowledged to be the most suitable reference variable. However, because of the paucity of recorded body weights for museum specimens, various comparative studies have used other size indicators as intervening variables, although the allometric relationships to body size/weight were often unknown and possibly differed between species. Because of differences in the scaling properties of alternative intervening variables across the species investigated, conflicting conclusions may be drawn if different variables are chosen as substitutes for overall size. This is illustrated with two examples. In this study, series of skeletons with associated body weights of Gorilla, Pan, Pongo, and Homo were investigated. Both ontogenetic and static adult allometric relationships between several widely used reference variables and body weight were determined. Neither these variables nor additional estimators investigated in this study displayed allometric exponents and coefficients similar enough across species to justify direct interspecific comparison. To generate an alternative size estimator for both ontogenetic and static interspecific investigations, equations for combined sexes were derived to predict body weight from various long bone dimensions for individual hominoid species. From a total of 25 predictors, 12 prediction equations per species (six for nonadults and six for adults) were selected according to their relative suitability for reliable prediction of body weight. It is shown that the derived reference variable "predicted body weight" avoids problems of intervening variables, is valid for any interspecific ontogenetic and static allometric comparison, and displays less fluctuation in comparison to actual body weight.