Sleep measures as a predictor of suicidal ideation among high-risk adolescents

Suicide is the second leading cause of death among youth aged 15-24 years. Identifying modifiable risk factors relevant to adolescents is crucial for suicide prevention. Sleep patterns have been linked to suicidality in adults, but lack sufficient study in youth. This ecological momentary assessment (EMA) study aimed to explore the relationship between objectively and subjectively measured sleep characteristics and next-day suicidal ideation in high-risk youth. We included 29 adolescents (12-18 years old) admitted to the inpatient psychiatric ward post-suicide attempt or due to suicidal intent within the previous month. We conducted objective (actigraphy) and subjective (sleep diary) sleep pattern assessments over ten consecutive days. Daily suicidal ideation was evaluated using a questionnaire based on the validated C-SSRS interview. A significant positive association was observed between sleep onset latency (SOL) and expressing a "death wish" the following day (OR = 1.06, 95% CI [1-1.11], p = .04), with each minute of longer SOL increased the risk for a death wish the following day by 6%. In addition, a marginally significant negative association was observed between total sleep time (TST) and expressing a "death wish" the following day (OR = 0.57, 95% CI [0.3-1.11], p = 0.1), with each one-hour decrease in objectively measured TST increasing the odds of a death wish by 43%. Our study highlights the interplay between sleep patterns and suicidal ideation, with SOL and TST playing a significant role that may function as proximal risk factors for suicidality and as a target for intervention while treating suicidal youth.

Decreased mononuclear cell NR3C1 SKA2 and FKPB5 expression levels among adult survivors of suicide bombing terror attacks in childhood are associated with the development of PTSD

Life threatening trauma and the development of PTSD during childhood, may each associate with transcriptional perturbation of immune cell glucocorticoid reactivity, yet their separable longer term contributions are less clear. The current study compared resting mononuclear cell gene expression levels of the nuclear receptor, subfamily 3, member 1 (NR3C1) coding the glucocorticoid receptor, its trans-activator spindle and kinetochore-associated protein 2 (SKA2), and its co-chaperon FKBP prolyl isomerase 5 (FKBP5), between a cohort of young adults first seen at the Hadassah Emergency Department (ED) after surviving a suicide bombing terror attack during childhood, and followed longitudinally over the years, and matched healthy controls not exposed to life threatening trauma. While significant reductions in mononuclear cell gene expression levels were observed among young adults for all three transcripts following early trauma exposure, the development of subsequent PTSD beyond trauma exposure, accounted for a small but significant portion of the variance in each of the three transcripts. Long-term perturbation in the expression of immune cell glucocorticoid response transcripts persists among young adults who develop PTSD following life threatening trauma exposure in childhood, denoting chronic dysregulation of immune stress reactivity.

The effect of distinct dietary interventions on proximal aortic stiffness; the DIRECT-PLUS randomized controlled trial

Background

Proximal aortic stiffness (PAS) reflects arterial aging and is strongly associated with increased cardiovascular risk. Plant-rich, specifically Mediterranean-style, diets are associated with reduced cardiovascular risk. The effect of dietary interventions on PAS remains unclear.

Methods

We randomized participants with abdominal-obesity/dyslipidemia to healthy-dietary-guidelines (HDG), Mediterranean, or green-Mediterranean diets combined with physical activity (PA). Both Mediterranean diets were similarly hypocaloric and included 28g/day walnuts. The green-Mediterranean group also consumed green tea (3–4 cups/day) and a Wolffia-globosa (Mankai) plant green-shake. PAS was estimated based on aortic-arch pulse-wave-velocity using magnetic resonance imaging (MRI) at baseline and after 18-months.

Results

Among 294 participants [age=51±10.6 years, body-mass-index 31.3±4.0 kg/m2, PAS = 6.1±2.7 m/sec, retention rate = 89.8%], 281 had valid PAS measurements. Higher PAS was mostly associated with aging, hypertension, dyslipidemia, diabetes, and increased visceral adiposity (p<0.05 for all). After 18-months of intervention, all diet groups significantly reduced their PAS ([HDG: −4.8% (interquartile-range [IQR]: −22.3 to 8.7); Mediterranean: −7.3%, IQR (−20.8 to 11.9); green-Mediterranean: −14.0%, IQR (−27.0 to 2.4); p<0.05 for within-groups changes).

Green-Mediterranean dieters had significantly greater PAS reduction than HDG dieters (p=0.007), also after controlling for age, sex, baseline-PAS, and Δweight. Further adjustment to baseline dyslipidemia, diabetes, and hypertension also revealed significant differences in PAS reduction between green-Mediterranean and Mediterranean groups (p=0.027). Specifically, greater green tea consumption was associated with greater PAS regression (p=0.04). ΔPAS was significantly associated with improvements in Δlow-density-lipoprotein cholesterol and Δtotal-cholesterol (p<0.05, multivariable models). All lifestyle intervention showed aortic age regression as compared to the expected (1.8±0.14 years vs.: HDG: −2.9±7.5 years; MED: −4.1±7.4 years; green-MED:-4.9±8.0 years; p<0.001).

Conclusions

Higher PAS is strongly related to aging and is associated with traditional cardiovascular risk factors. Lifestyle intervention promotes PAS reduction. Green-Mediterranean diet may be associated with more remarkable aortic rejuvenation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Deutsche Forschungsgemeinschaft (DFG, German Research Foundation); the Israel Ministry of Health

Resting mononuclear cell NR3C1 and SKA2 expression levels predict blunted cortisol reactivity to combat training stress among elite army cadets exposed to childhood adversity

Childhood adversity (CA) may alter reactivity to stress throughout life, increasing risk for psychiatric and medical morbidity, yet long-term correlates of milder CA levels among high functioning healthy adolescents are less studied. The current study examined the prevalence and impact of CA exposure among a cohort of healthy motivated elite parachute unit volunteers, prospectively assessed at rest and at the height of an intensive combat-simulation exposure. We found significantly reduced gene expression levels in resting mononuclear cell nuclear receptor, subfamily 3, member 1 (NR3C1), and its transactivator spindle and kinetochore-associated protein 2 (SKA2), that predict blunted cortisol reactivity to combat-simulation stress among CA exposed adolescents. Long-term alterations in endocrine immune indices, subjective distress, and executive functions persist among healthy high functioning adolescents following milder CA exposure, and may promote resilience or vulnerability to later real-life combat exposure.

Metabolic determinants of proximal aortic stiffness among healthy people with abdominal obesity

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): (1) the Deutsche Forschungsgemeinschaft; (2) Israel Ministry of Health

Background

Increased proximal aortic stiffness (PAS) is directly associated with cardiovascular risk. Likewise, metabolic syndrome (MS) and abdominal obesity are associated with cardiovascular risk. The direct association between MS determinants and PAS among a healthy population with abdominal obesity remains to be examined.

Purpose

To examine the association between MS determinants and PAS among healthy participants with abdominal obesity.

Methods

We utilized the cross-sectional baseline data of the DIRECT-PLUS study (clinicaltrials.gov NCT03020186), where we recruited healthy participants with abdominal obesity/dyslipidemia. Along with anthropometric measurements and blood tests, all participants underwent magnetic-resonance-imaging from which PAS we assessed by calculating the aortic arch pulse-wave-velocity (from the ascending to the descending aorta). We defined MS according to the NCEP-ATP-III criteria.

Results

Of 282 participants who had a valid PAS estimation [mean-age: 51.0, 88.3% male, mean-body-mass-index: 31.2kg/m2, mean-waist circumference (WC): 109.5cm] 171 (60.9%) had MS. PAS was mainly associated with age (r = 0.735, p < 0.001). PAS was associated with an increased 10-year Framingham Risk Score (β=0.165,p = 0.008 after adjustment for age and gender). Participants with MS had higher PAS than non-MS participants (6.6m/sec vs. 5.4m/sec, p = 0.002 after adjusting for age and gender). PAS increased along with cumulative number of MS criteria (p-of-trend < 0.001). In multivariate models, adjusted for gender, age, and dichotomous-components of the MS, worse PAS remained significantly associated with high-density lipoprotein cholesterol (HDL-c; β=0.-116,p = 0.007) and increased blood-pressure (β=0.165,p < 0.001), but not with fasting-glucose, waist-circumference or plasma-triglycerides (p > 0.05 for all). In models adjusted for age, gender, and continuous determinants of MS, worse PAS remained associated with mean-arterial pressure (β=0.218,p < 0.001) and HDL-c (β=0.-126,p = 0.004).

Conclusions

Among a healthy population with abdominal obesity, reduced HDL-c levels and increased blood pressure might be the more dominant predictors of poor PAS state, out of the MS components.

Longitudinal course and risk factors associated with psychosis in bipolar youths

OBJECTIVES

To compare the longitudinal clinical course of youths with bipolar disorder (BD) spectrum with lifetime (past, intake, and/or follow-up) psychosis (BDP+) to youths with BD without lifetime psychosis (BDP-). Also, to identify risk factors associated with increased risk of first onset of psychosis during prospective follow-up.

METHOD

Bipolar disorder youths (BDP+ = 137, BDP- = 233), aged 7-17 years old, were followed on average every 7 months for 11.7 years and were evaluated using standardized instruments. Data were analyzed using linear and generalized linear models for the full sample, as well as for youths who developed first period of psychosis (n = 55).

RESULTS

After adjusting for confounders, BDP+ youths with one, and in particular ≥2 lifetime psychotic episodes, had higher rates and more severe mood and anxiety symptoms, higher rates of suicidality, psychiatric hospitalizations, and sexual/physical abuse, and poorer psychosocial functioning than BDP- youths. Even before the first onset of psychosis during follow-up, BDP+ youths showed more psychopathology and had more family history of psychiatric illness than those who never developed psychosis. First-onset psychosis was associated with low socioeconomic status (SES), living with one parent, bipolar disorder type one and type two, comorbid anxiety, history of hospitalizations, and family history of mania and suicidality.

CONCLUSION

BDP+ is associated with poor prognosis and worse clinical picture, even before the onset of psychosis, indicating the need for prompt identification and treatment of these youths. Studies aimed to treat acute symptoms of psychosis, as well as prevent the onset of psychosis, including risk factors amenable to change, are warranted.

A Longitudinal Study of Family Functioning in Offspring of Parents Diagnosed With Bipolar Disorder

OBJECTIVE

To compare the longitudinal course of family functioning in offspring of parents with bipolar disorder (BD), offspring of parents with non-BD psychopathology, and offspring of healthy control (HC) parents.

METHOD

Offspring of parents with BD (256 parents and 481 offspring), parents without BD (82 parents and 162 offspring), and HC parents (88 parents and 175 offspring) 7 to 18 years of age at intake, from the Bipolar Offspring Study (BIOS), were followed for an average of 4.3 years. Family functioning was evaluated using the child- and parent-reported Family Adaptability and Cohesion Scale-II and the Conflict Behavior Questionnaire. The data were analyzed using multivariate multilevel regression, generalized linear estimating equation models, and path analysis.

RESULTS

Families of parents with BD and parents with non-BD psychopathology showed lower cohesion and adaptability and higher conflict compared with HC families. There were no significant differences in cohesion and adaptability between families of parents with psychopathology. The effect of parental psychopathology on family functioning was mediated by parental psychosocial functioning and, to a lesser extent, offspring disorders. In all 3 groups, parent-reported family conflict was significantly higher than child-reported conflict. Across groups, family cohesion decreased over follow-up, whereas conflict increased.

CONCLUSION

Any parental psychopathology predicted family impairment. These results were influenced by the offspring's age and were mediated by parental psychosocial functioning and, to a lesser degree, by offspring psychopathology. These findings emphasize the need to routinely assess family functioning in addition to psychopathology and provide appropriate interventions to parents and offspring.

Cortisol response to stress as a predictor for suicidal ideation in youth

OBJECTIVE

To examine the association between cortisol response to stress and suicidal ideation (SI) cross-sectionally and longitudinally in our sample of bereaved and non-bereaved youth.

METHODS

The sample included 114 youth bereaved by sudden parental death and 109 non-bereaved controls, mean age of 12.3 (SD = 3.6), evaluated at four time-points over an average follow-up period of 7 years. The Trier Social Stress Test (TSST) was conducted on average 6 years after bereavement. We used latent class analyses to examine the trajectories of SI over follow-up and up to the time of the TSST and compare them on cortisol measures. We examined whether cortisol measures predicted future SI at 18.5 months on average after the TSST.

RESULTS

Bereavement was associated with higher cortisol reactivity after controlling for covariates [β = 0.96, 95% CI (0.28, 1.65), p < 0.01, d = 0.41]. Cortisol reactivity to stress was higher in those belonging to the high SI trajectory [β = 1.23, 95% CI (0.41, 2.06), p = 0.004, d = 0.23] compared to the low SI trajectory. Higher baseline cortisol showed small to medium effect size in predicting future SI [β = 2.34, 95% CI (0.17, 4.51), p = 0.03, d = 0.38].

CONCLUSION

The persistence of SI is associated with higher cortisol reactivity to stress, and higher baseline cortisol may predict future SI. These results emphasize the importance of HPA-axis activity in youth exposed to major stressors, and those with SI. More research is needed to further clarify biological mechanisms linking SI and behavior, bereavement, and HPA axis response to stress, to better identify at-risk subjects for targeted prevention and intervention efforts.

Retreating From Life: The Boy Whose Body Experienced His Pain

The expression of psychological distress through somatic symptoms is most prevalent among children. Somatic symptom disorders represent a difficult category of disorders to treat and they are often misdiagnosed due to their physical symptomology and dismissed due to their malingering stigma. The current case report follows the treatment of David, a 10-year-old Caucasian male, admitted into the pediatric psychiatric ward of a general hospital, uncommunicative, showing little signs of responsiveness, and dependent on nursing staff for basic needs. Following a complex treatment protocol which integrated key elements of psychodynamic and cognitive-behavior (CBT) treatment recommendations for somatic disorders, David was discharged after 6 months as an inpatient. This in-depth case study provides a synthesis of the varied research on somatic symptom disorders and an acute understanding of how to combine the understanding of complex family dynamics and individual personality structure with empirically reinforced treatment strategies.

Long-Term Immune Alterations Accompanying Chronic Posttraumatic Stress Disorder following Exposure to Suicide Bomb Terror Incidents during Childhood

BACKGROUND AND AIM

Long-term immune alterations have been proposed to play a mechanistic role in posttraumatic stress disorder (PTSD) as well as in its associated increase in medical morbidity and mortality. Better characterization of altered immune function may help identify diagnostic and prognostic biomarkers and potentially targets for preventive intervention.

METHODS

As part of an ongoing study, we conducted a preliminary case-control comparison of resting immune inflammatory profiles between terror victims treated in childhood at the emergency department over the previous decade, who developed chronic PTSD upon long-term follow-up, and healthy controls.

RESULTS

Our preliminary results in a subsample of this ongoing study support and extend elevated resting levels of granulocyte colony-stimulating factor, interleukin-4, and regulated on activation, normal T cell expressed and secreted in childhood onset chronic PTSD.

CONCLUSION

Chronic immune alterations may participate in inflammatory activation and signal to the CNS through the neurovascular unit, as well as modulate the neuroendocrine axis. Better characterization and understanding of these preliminary findings may point to diagnostic and prognostic biomarkers and potentially elucidate mechanistic involvement of immune activation in PTSD.

The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium

BACKGROUND

Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs.

METHOD

General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure.

RESULTS

Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types - witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury - accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events.

CONCLUSIONS

Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.

[Implementing mindfulness based therapies as part of the comprehensive treatments in the Beer Sheba Mental Health Center]

In recent years, there has been a growing interest and popularity in mindfulness-based therapies. Theories and practices that, until lately, have been considered esoteric and practiced in private by only a few therapists, are now progressively becoming part of mainstream establishment therapies and are gaining greater interest and recognition. The therapies can be carried out either in an individual or in a group setting and most include formal mindful sitting practice, developing awareness, mindful movement, psycho-education and often include a cognitive component. Furthermore, these therapies are becoming increasingly validated by widespread research pointing to promising results in the treatment of various cLinicaL disorders including anxiety, depression and relapse prevention, personality disorders, attention disorders and psychotic disorders, in both an in-patient and out-patient setting. The aim of this overview is to describe the deveLopment that has taken place in the fast decades within the field of mindfulness-based therapies and to present the most up-to-date research in this area: to show which therapeutic interventions have been proven to be effective; the background of the ideas; and the relevance of these approaches to the mental health system in Israel.

A painful train of events: increased prevalence of fibromyalgia in survivors of a major train crash

OBJECTIVES

To evaluate the prevalence of fibromyalgia in survivors of a major train crash in southern Israel, three years after the event.

METHODS

Survivors were contacted by mail and telephone. Individuals consenting to participate in the study underwent physical examination, including a tender point count and dolorimetry, as well as extensive evaluation of parameters relating to quality of life, presence of widespread pain, fatigue, physical and social function, posttraumatic symptoms and symptoms related to anxiety, dissociation, depression, somatisation, etc.

RESULTS

Fifteen percent of survivors participating in the study met ACR criteria for the classification of fibromyalgia. Significantly lower rates of physical and emotional functioning were found among survivors with fibromyalgia compared with those not meeting the classification criteria. Survivors with fibromyalgia rated significantly higher on scales of somatisation, obsessive-compulsive ideation, interpersonal sensitivity, depression, anger and hostility, phobic and general anxiety, paranoid ideation and psychoticism. Survivors with fibromyalgia also rated significantly higher on scales of posttraumatic symptoms including intrusion, avoidance and arousal. These individuals also rated significantly higher on the Peritraumatic Dissociative Experiences Questionnaire (PDE-Q) and the Dissociative Experiences Scale (Hebrew version) (DES-H).

CONCLUSION

Fibromyalgia was found to be highly prevalent, three years after a major train crash, among individuals exposed to the combination of physical injury and extreme stress. This finding is in accordance with previous data regarding the association of fibromyalgia with both physical and emotional trauma and calls attention to studying the underlying susceptibility factors which may partake in this association.

Conservative management of implantable cardioverter defibrillator-related endocarditis due to Bacillus spp

Endocarditis is a devastating complication of implantable cardioverter-defibrillator (ICD) therapy. Partial or complete device removal has been advocated for the treatment of this condition although controlled data are lacking. We present a case of ICD-related endocarditis caused by Bacillus spp. that occurred following coronary angiography. To the best of our knowledge, Bacillus spp. has not been previously described in such context. Moreover, conservative treatment with device retention was successful (no recurrence during a 6-year follow-up). Conservative management may be attempted in selected cases of ICD-related endocarditis, especially, those involving low-virulence organisms and rapid response to antibiotic therapy. This case also suggests that coronary angiography may be associated with transient bacteremia and subsequent infection of indwelling cardiac devices.

Saccharomyces cerevisiae protein Pci8p and human protein eIF3e/Int-6 interact with the eIF3 core complex by binding to cognate eIF3b subunits

Mammalian, plant, and Schizosaccharomyces pombe eukaryotic initiation factor-3 (eIF3) contains a protein homologous to the product of int-6 (eIF3e), a frequent integration site of mouse mammary tumor viruses. By contrast, Saccharomyces cerevisiae does not encode a protein closely related to eIF3e/Int-6. Here, we characterize a novel S. cerevisiae protein (Pci8p, Yil071cp) that contains a PCI (proteasome-COP9 signalosome-eIF3) domain conserved in eIF3e/Int-6. We show that both Pci8p and human eIF3e/Int-6 expressed in budding yeast interact with the yeast eIF3 complex in vivo and in vitro by binding to a discrete segment of its eIF3b subunit Prt1p and that human eIF3e/Int-6 interacts with the human eIF3b segment homologous to the Pci8p-binding site of yeast Prt1p. These results refine our understanding of subunit interactions in the eIF3 complex and suggest structural similarity between human eIF3e/Int-6 and yeast Pci8p. However, deletion of PCI8 had no discernible effect on cell growth or translation initiation as judged by polysome analysis, suggesting that Pci8p is not required for the essential function of eIF3 in translation initiation. Motivated by the involvement of Int-6 in transcriptional control, we investigated the effects of deleting PCI8 on the total mRNA expression profile by oligonucleotide microarray analysis and found reduced mRNA levels for a subset of heat shock proteins in the pci8Delta mutant. We discuss possible dual functions of Pci8p and Int-6 in transcriptional and translational control.

Effects of glucagon-like peptide 1 (7-36 amide) on glucose kinetics during somatostatin-induced suppression of insulin secretion in healthy men

Glucagon-like peptide 1 (GLP-1) is known to stimulate insulin secretion and biosynthesis, but has also been shown to decrease insulin requirements in type 1 diabetic subjects suggesting insulin-independent effects. To assess whether GLP-1 exerts also direct effects on whole-body glucose metabolism, 6,6-D2-glucose kinetics were measured in 8 healthy volunteers receiving once GLP-1, once saline during hyperglycemic glucose clamping, while somatostatin with replacement amounts of insulin, glucagon and growth hormone was infused. Even though endogenous insulin secretion could not be blocked completely (increased plasma concentrations of C-peptide and proinsulin), somatostatin infusion resulted in stable insulin and glucagon plasma levels in both protocols (GLP-1 vs. placebo: NS). After 3 h of GLP-1 infusion, peripheral glucose disappearance significantly increased compared to placebo (p < 0.03) despite of somatostatin-induced suppression of insulin and glucagon secretion. Thus, GLP-1 infusion seems to have direct stimulatory effects on peripheral glucose metabolism in man.

A multifactor complex of eukaryotic initiation factors, eIF1, eIF2, eIF3, eIF5, and initiator tRNA(Met) is an important translation initiation intermediate in vivo

Translation initiation factor 2 (eIF2) bound to GTP transfers the initiator methionyl tRNA to the 40S ribosomal subunit. The eIF5 stimulates GTP hydrolysis by the eIF2/GTP/Met-tRNA(i)(Met) ternary complex on base-pairing between Met-tRNA(i)(Met) and the start codon. The eIF2, eIF5, and eIF1 all have been implicated in stringent selection of AUG as the start codon. The eIF3 binds to the 40S ribosome and promotes recruitment of the ternary complex; however, physical contact between eIF3 and eIF2 has not been observed. We show that yeast eIF5 can bridge interaction in vitro between eIF3 and eIF2 by binding simultaneously to the amino terminus of eIF3 subunit NIP1 and the amino-terminal half of eIF2beta, dependent on a conserved bipartite motif in the carboxyl terminus of eIF5. Additionally, the amino terminus of NIP1 can bind concurrently to eIF5 and eIF1. These findings suggest the occurrence of an eIF3/eIF1/eIF5/eIF2 multifactor complex, which was observed in cell extracts free of 40S ribosomes and found to contain stoichiometric amounts of tRNA(i)(Met). The multifactor complex was disrupted by the tif5-7A mutation in the bipartite motif of eIF5. Importantly, the tif5-7A mutant is temperature sensitive and displayed a substantial reduction in translation initiation at the restrictive temperature. We propose that the multifactor complex is an important intermediate in translation initiation in vivo.

Childhood imaginary companionship and mental health in adolescence

An imaginary companion (IC) is a frequently encountered childhood fantasy, invisible to anyone but the child, who may be named, addressed or played with. Whether the presence of an IC is a normal developmental feature has not been determined. We examined psychometric measures and the presence/absence of childhood IC in a sample of 850 mentally healthy adolescents. 17.6% of our subjects, more often females, reported having had such a companion. Subjects who reported having had an IC in childhood exhibited higher levels of distress and emotional discontrol, displayed prolonged transitional object attachment and immature modes of coping with stress. Thus, although childhood imaginary companionship is not indicative of psychopathology, it may denote a vulnerability for adolescent perturbation and difficulty in coping with emotionally laden situations.

Predictors of chronic post-traumatic stress disorder. A prospective study

BACKGROUND

Most individuals who, shortly after trauma, express symptoms of post-traumatic stress disorder (PTSD) recover within one year of their traumatic experiences. In contrast, those who remain ill for one year rarely recover completely. The early identification of the latter is, therefore, very important.

AIMS

To prospectively evaluate predictors of PTSD at four months and one year.

METHOD

We followed 236 trauma survivors recruited from admissions to a general hospital's emergency room for four months, at which point 41 (17.4%) met diagnostic criteria for PTSD. Twenty-three of these individuals, and 39 individuals without PTSD at four months, were assessed again at one year.

RESULTS

Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peri-traumatic dissociation were better at predicting four-month PTSD than one-year PTSD.

CONCLUSIONS

The occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

[Chylothorax as the initial manifestation of malignant Hodgkin lymphoma]

A 22 year-old man complaining of slight thoracic pain, was found to have a right pleural effusion in his chest X-ray. The pleural aspiration yielded chylous fluid and radiological examination and biopsy of a mediastinal mass led to the diagnosis of Hodgkin's disease of the nodular sclerosis type with supra- and radiologically infradiaphragmatic disease and a pathological fracture of the sternum. After complete initial aspiration of the pleural effusion the chylothorax did not recur following initiation of a combination chemotherapy, and a clear regression of the lymphoma was found after the first 3 cycles. This case provides an example of an oligosymptomatic, right sided chylothorax as the first manifestation of Hodgkin's disease in a young immuno-competent patient.

A novel one-step, highly sensitive fluorometric assay to evaluate cell-mediated cytotoxicity

In this study, a fluorometric method using alamarBlue has been developed for detecting cell-mediated cytotoxicity in vitro. AlamarBlue is a non-toxic metabolic indicator of viable cells that becomes fluorescent upon mitochondrial reduction. Specific lysis of targets by effector cells is quantified by comparing the total number of viable cells in wells containing effector and targets together, with wells where target and effector cells were separately seeded. Cell-mediated cytotoxic activity by alloreactive T cells and natural killer cells has been detected using a novel application of the alamarBlue technique. The assay that we have developed to detect cell-mediated cytotoxicity is extremely sensitive and specific and requires a significant lower number of effector cells than the standard 51Cr assay. Since alamarBlue reagent is non-toxic to cells and the assay can be performed under sterile conditions, effector cells may be recovered at the end for further analysis or cell expansion, if desired. Direct comparison of cell-mediated cytotoxicity measured by the alamarBlue method with the standard 51Cr release assay revealed that the former method is as specific and more sensitive than the conventional assay. Moreover, very small inter and intra-assay variations have been observed for alamarBlue cytotoxicity assays. In conclusion, this study shows that the alamarBlue assay is an extremely sensitive, economical, simple and non-toxic procedure to evaluate cell-mediated cytotoxicity that yields accurate results using a limited number of effector cells. Furthermore, since this assay is a one-step procedure, and does not involve any risk for the personnel, it may be useful to analyze automatically cell-mediated cytotoxicity in a large number of samples.

Absence of short-term effects of glucagon-like peptide-1 and of hyperglycemia on plasma leptin levels in man

In rodents, leptin and the incretin glucagon-like peptide-1 (7-36) amide (GLP-1) affect feeding at least in part via interaction with hypothalamic neuropeptide Y (NPY), suggesting that cross talk may exist between GLP-1 and the ob gene product. Besides insulin, acute hyperglycemia has recently been shown to induce ob gene expression. To address the question of whether leptin plasma levels in humans are affected by GLP-1 infusion and/or hyperglycemia, eight healthy volunteers were studied during euglycemia and hyperglycemic clamping with or without GLP-1 administration while insulin levels were kept constant by somatostatin infusion. Under all conditions, leptin plasma levels remained unchanged, demonstrating that in humans leptin plasma concentrations are affected neither by short-term peripheral GLP-1 infusion nor by hyperglycemia, which suggests that postprandial GLP-1 release and hyperglycemia do not modulate secretion of the ob gene product.

Psychophysiologic parameters of traumatic stress disorder in rats

Nonhabituation of the acoustic startle response is used to identify rat subjects with altered alarm responses subsequent to trauma exposure. Subjects (n = 31) were exposed to 30 minutes of intermittent tail shock on 2 days followed by exposure to the apparatus on the third day. Twenty-nine percent of traumatized rats developed nonhabituation of startle over the subsequent 3 weeks of testing. No control rats developed nonhabituation of startle reactions over a similar time period. These data suggest that this system represents a more accurate representation of clinical PTSD than do other animal models.

Effects of glucagon-like peptide 1 (7-36 amide) on whole-body protein metabolism in healthy man

The incretin glucagon-like peptide 1 (GLP-1) shows glucose-dependent insulinotropic activity and may exert anabolic effects. Whole-body protein metabolism was assessed by measuring [1-13C]-leucine kinetics in 13 healthy volunteers during hyperglycaemic clamping with or without pancreatic clamping (somatostatin infusion) in order to differentiate between insulin-mediated and direct GLP-1 effects. During intact pancreatic secretion leucine flux and leucine oxidation rate as parameters of whole-body protein breakdown decreased markedly after 180 min of synthetic GLP-1 infusion (GLP-1 vs. placebo: P < 0.003). Indirect calorimetry showed an increase in energy expenditure and CO2 production during GLP-1 administration (P < 0.0005). Plasma insulin increased after 3h of GLP-1 infusion to 1486 +/- 145 pmol L(-1) vs. 185 +/- 12 pmol L(-1) for saline (P < 0.0001). When plasma insulin levels were kept constant (GLP-1 vs. saline, NS) during pancreatic clamping, GLP-1 effects on both protein metabolism and energy expenditure were abolished. Thus, GLP-1 infusion in man exerts protein anticatabolic and thermic effects, which are mediated by GLP-1-induced stimulation of insulin secretion.

The peroxisome proliferator-activated receptor alpha is a phosphoprotein: regulation by insulin

Peroxisome proliferator-activated receptors (PPARs) are members of the nuclear hormone receptor superfamily implicated in adipocyte differentiation. The observations that PPAR alpha is a regulator of hepatic lipid metabolism and that the insulin-sensitizing thiazolidinediones are ligands for PPAR gamma suggest that cross-talk might exist between insulin signaling and PPAR activity, possibly through insulin-induced PPAR phosphorylation. Immunoprecipitation of endogenous PPAR alpha from primary rat adipocytes prelabeled with [32P]-orthophosphate and pretreated for 2 h with vanadate and okadaic acid demonstrated for the first time that PPAR alpha is a phosphoprotein in vivo. Treatment with insulin induced a time-dependent increase in PPAR phosphorylation showing a 3-fold increase after 30 min. Insulin also increased the phosphorylation of human PPAR alpha expressed in CV-1 cells. These changes in phosphorylation were paralleled by enhanced transcriptional activity of PPAR alpha and gamma. Transfection studies in CV-1 cells and HepG2 cells revealed a nearly 2-fold increase of PPAR activity in the presence of insulin. In contrast, insulin had no effect on the transcriptional activity of transfected thyroid hormone receptor in CV-1 cells, suggesting a PPAR-specific effect. Thus, insulin stimulates PPAR alpha phosphorylation and enhances the transcriptional activity of PPAR, suggesting that the transcriptional activity of this nuclear hormone receptor might be modulated by insulin-mediated phosphorylation.

Chlorpromazine prophylaxis of steroid-induced psychosis

We report a case of successful prophylactic treatment for psychiatric side effects of megadose glucocorticoid therapy by the administration of chlorpromazine. We review currently used prophylactic treatment strategies and discuss the rationale for adding neuroleptic treatment as an alternative to these strategies.

Wide distribution of granulophysin epitopes in granules of human tissues

BACKGROUND

The identification and characterization of granule membrane proteins are becoming increasingly important in understanding the packaging and secretory function of granules and characterizing diseases involving granules. A granule membrane protein, granulophysin, has recently been identified in the membranes of platelet dense granules, organelles that contain stored ADP, ATP, serotonin, and calcium. Antibodies that recognize granulophysin also stain granules of monocytes, neutrophils, and lymphokine activated killer cells.

EXPERIMENTAL DESIGN

In the present study, the distribution of epitopes recognized by antigranulophysin monoclonal antibodies in human tissues was investigated using immunohistochemistry on paraffin sections. Quantitation of the protein was also performed by enzyme-linked immunosorbent assay. The protein was also analyzed in various tissues using Western blotting.

RESULTS

Granulophysin was localized to the granules of skin melanocytes, neurons, endocrine gland cells, exocrine glands (except mucin producing cells), and surface lining cells. Analysis by Western blots revealed a typical staining pattern for granulophysin in lung, adrenal gland, liver, brain, prostate, and pituitary. Atypical bands were present in the pancreas head (47 kDa) and skeletal muscle (34 kDa). A clear distinction was demonstrated between granulophysin and synaptophysin through both immunochemistry and blotting, despite the known cross-reactivity of these two proteins.

CONCLUSIONS

The findings demonstrate that granulophysin is a widely distributed protein that is frequently associated with granules. We speculate that it may be critical in granule function.

The protein CD63 is in platelet dense granules, is deficient in a patient with Hermansky-Pudlak syndrome, and appears identical to granulophysin

The levels and expression of the proteins CD63 and granulophysin in platelets from control and from a Hermansky-Pudlak syndrome subject (a condition characterized by dense granule and lysosomal deficiencies and the accumulation of ceroid-like material in reticuloendothelial cells) were examined. Immunofluorescence studies indicated that anti-CD63 and anti-granulophysin antibodies recognized similar numbers of granules; coapplication of antibodies did not identify more granules than the individual antibodies. Significantly fewer granules were recognized in Hermansky-Pudlak syndrome platelets than in control using either antibody. Immunoblotting studies demonstrated that anti-CD63 and anti-granulophysin antibodies apparently recognize the same protein, which was deficient in Hermansky-Pudlak platelets. Analysis by fluorescence-activated cell sorter (FACS) showed biphasic expression of CD63 and granulophysin after thrombin stimulation of control but not Hermansky-Pudlak platelets. Anti-CD63 effectively blocked detection of the protein by anti-granulophysin using immunofluorescence, ELISA, immunoblotting, and FACS analysis. Amino-terminal sequencing over the first 37 amino acids revealed that granulophysin was homologous to CD63, melanoma antigen ME491, and pltgp40. These results suggest that granulophysin and CD63 are possibly identical proteins. This is the first report of a protein present in platelet dense granules, lysosomes, and melanocytes, but deficient in a patient with Hermansky-Pudlak syndrome.

The relationship between short-term antibiotic treatments and fatigue in healthy individuals

Antibiotic treatment tends sometimes to result in sensations of fatigue and decreased physical performance. The effects of antibiotics were therefore studied in 50 healthy, male trainees, aged 18-25 years, assigned in a random, double-blind fashion to one of the following treatments: tetracycline, ampicillin, trimethoprim/sulphamethoxazole, placebo I and placebo II. Duration of treatment was five times the half-life of each agent and the placebo was matched accordingly. Muscle enzyme activity (serum glutamine oxaloacetate transaminase, lactate dehydrogenase, creatine phosphokinase), maximal aerobic capacity (VO2max), muscle strength (MS), and rating of subjective sensation of fatigue were assessed prior to and upon conclusion of treatment. Compared to pretreatment values, plasma enzymes activity was elevated in all five groups (P < 0.005). No differences in VO2max or in MS were found among the subjects treated with either one of the antibiotics or those given a placebo. A significant difference in VO2max was found between the groups treated for 1 day (antibiotic and placebo) and the groups treated for 3 days (antibiotic and placebo) (P < 0.0001). The rating of subjective sensation was not affected by any of the agents. We concluded that in healthy individuals, a short-term antibiotic treatment had no deleterious effect on aerobic capacity or on muscle strength and was not associated with subjective side effects. The time interval between the two maximal tests could, however, have affected the aerobic capacity. Physiological disturbances associated with a sensation of fatigue following a longer period of antibiotics cannot be excluded.

Poor neuroleptic response in acutely exacerbated schizophrenic patients

Poor neuroleptic response is a major unresolved clinical problem. Precise data concerning the frequency of poor neuroleptic response are not available. The implementation of treatment modalities that are specifically recommended for non-responders (such as clozapine) increases the desirability of such data. This study evaluated the proportion of acutely exacerbated schizophrenics who remained unimproved by consecutive administration of haloperidol, chlorpromazine and perphenazine, in randomly determined order. The overall improvement rate was 95%. The frequency of good responses to the first, second and third drug were 67%, 55%, and 67% respectively. Differences in receptor affinity profile might explain the added beneficial effect of a second or third drug.

Quantification of a novel dense granule protein (granulophysin) in platelets of patients with dense granule storage pool deficiency

An antigen-capture sandwich enzyme-linked immunosorbent assay (ELISA) was developed for a novel protein granulophysin, a constituent of the platelet dense granule (DG) membrane and used to characterize patients with dense granule storage pool deficiency (delta-SPD). The assay uses two monoclonal antibodies against the protein, one of which is conjugated to peroxidase. Purified DGs, an enriched source of the protein, were used for the standard curve. Granulophysin levels were only low in forms of delta-SPD associated with albinism. Granulophysin levels in platelet homogenates of 30 patients with the Hermansky-Pudlak syndrome form of delta-SPD were 1/4 to 1/5 of levels in controls or obligate heterozygotes. Two patients with the Chediak-Higashi form of delta-SPD syndrome also had markedly reduced levels of granulophysin. Patients with other forms of delta-SPD had normal levels of granulophysin. Two sisters with delta-SPD in one family had normal granulophysin present in empty dense granule membrane vesicles. Three members of another family with delta-SPD had low DG counts but normal granulophysin levels, indicating that in this group the level of granulophysin was maintained despite the reduction in granule formation. Thus, granulophysin quantitation facilitates characterization of delta-SPD patients and may provide clues to the nature of defective granules in delta-SPD subtypes.

Sharing of antigenic epitopes between synaptophysin and granulophysin

The immunological crossreactivity between the two granule-specific membrane glycoproteins, synaptophysin and granulophysin, was studied using a series of site-specific monoclonal and polyclonal antibodies. The epitope relatedness of six monoclonal antibodies against granulophysin was examined by competitive ELISA. The antibodies are shown to recognize distinct, but overlapping epitopes within a compact region that is constructed by the three-dimensional configuration of the molecule. All these antibody clones also recognize rat neuronal synaptophysin. Two monoclonal antibodies against synaptophysin, of which one is the well-characterized SY38 antibody, directed against the carboxy terminal of the molecule, are also shown to react with granulophysin. Characterized polyclonal antibodies against different peptide antigens of synaptophysin failed to recognize granulophysin. Synaptophysin and granulophysin are distinctly recognized in brain cell (white matter) and the pituitary both qualitatively and quantitatively. Based on these and other observations, it is suggested that the repeat motif in the cytoplasmic tail of synaptophysin represents an immunodominant construct that is the target for the observed crossreactive antibodies and that a similar tertiary construct has been preserved in granulophysin and in other transmembrane proteins.

Posttraumatic stress disorder: somatic comorbidity and effort tolerance

To explore psychological and somatic distress following trauma, the authors compared 50 combat veterans with chronic posttraumatic stress disorder (PTSD) with 48 age-matched combat veterans without PTSD. Both groups were evaluated on symptom reports, physical examination findings, and laboratory tests. Subjects with PTSD reported significantly more symptoms, but they did not differ from controls on their physical examination and laboratory test findings. Adverse health practices (smoking, alcohol use, and deregulation of food intake) were significantly more frequent in the PTSD group. Low effort tolerance, as has been reported in panic disorder patients, was observed in the PTSD group.

Chlorprothixene-induced hypouricemia: a biologic indicator of drug compliance

Chlorprothixene is a neuroleptic as well as a potent uricosuric drug that consistently lowers the levels of plasma uric acid (PUA). The usefulness of this relative hypouricemia as an indicator of compliance with treatment was evaluated in 17 outpatients treated from 120 to 600 days. Plasma uric acid values were substantially reduced in all patients with all doses within the therapeutic range. Low levels of PUA remained stable as long as the patients were treated and returned to normal within 7 days after treatment was terminated. The authors discuss the advantages and the limitations of PUA as an indicator of chlorprothixene treatment compliance.

Delayed onset PTSD among Israeli veterans of the 1982 Lebanon War

This is an exploratory study of the nature, course and rates of delayed post-traumatic stress disorder (PTSD). We reviewed 150 medical files of Israeli soldiers who sought help between 6 months and 5 years after the 1982 Lebanon War. Results indicated that only 10% of the cases were truly examples of delayed PTSD; in a large proportion of the cases, help-seeking rather than onset was delayed.

Multiple exostosis, brain ventricular enlargement and schizophrenia

Case histories of two family members with multiple exostosis and schizophrenia are presented. There are no previous reports of such an association. The computerized axial tomography scan revealed signs of hydrocephalus in one patient and substantial enlargement of lateral brain ventricles in the other. The mutual occurrence of all three clinical findings (multiple exostosis, ventricular brain enlargement and psychosis) in two family members may suggest a subgroup of patients who manifest schizophrenic symptomatology.

Mortality from neuroleptic malignant syndrome

The authors assess the mortality from the neuroleptic malignant syndrome (NMS) based on an exhaustive review of 202 published case reports, including a differential assessment of risk factors and protective factors. The results indicate a significant (p less than .05) decrease in mortality since 1984 (11.6% vs. 25% before 1984), which occurs independently of the therapeutic use of dopamine agonists and dantrolene. A significantly (p less than .001) lower rate of mortality from haloperidol-induced NMS (7%) and a high rate of mortality (38.5%) among patients with organic brain syndrome were also found. Myoglobinemia and renal failure are strong predictors of mortality, representing a mortality risk of approximately 50%. The authors discuss the implications of these findings.

Khat-induced hypnagogic hallucinations

Khat is a plant whose leaves are chewed for their stimulating effect. This effect is attributed to cathinone, an alkaloid identical to dextroamphetamine. Khat chewing is widespread among eastern African and Yemenite populations and is believed to be innocuous. Our experience shows, however, that a substantial number of chronic khat chewers experience persistent hypnagogic hallucinations - a symptom that has not yet been described. Three vignettes illustrates this phenomena, which often interferes with psychiatric diagnosis. Different explanatory models are discussed, among them chronic suppression of REM sleep.