Evaluating Racial Disparities in Implementation and Monitoring of a Remote Blood Pressure Program in a Pregnant Population-A Retrospective Cohort Study

Background: Whether remote blood pressure (BP) monitoring can decrease racial disparities in BP measurement during pregnancy and the postpartum period remains unclear. This study evaluated whether Black and White patients enrolled in the Connected Maternity Online Monitoring (CMOM) program showed improvements in BP ascertainment and interval. Methods: A retrospective cohort of 3,976 pregnant patients enrolled in CMOM were compared to matched usual care patients between January 2016 and September 2022 using electronic health record data. The primary outcomes were BP ascertainment (number of BP measurements) and BP interval (time between BP measurements) during pregnancy and the postpartum period. The proportion of patients with a hypertensive disorder of pregnancy who checked their BP within 7 days of discharge following delivery was also assessed. Results: Enrollment in CMOM was lower among Black patients than White patients (42.1% vs 54.7%, P<0.0001). Patients in the CMOM group had more BP measurements than patients in the usual care group during pregnancy (rate ratio=1.78, 95% CI 1.74-1.82) and the postpartum period (rate ratio=1.30, 95% CI 1.23-1.37), with significant improvements for both Black and White patients enrolled in CMOM compared to patients in usual care. The CMOM intervention did not result in an improvement in 7-day postpartum adherence to checking BP for Black patients (risk ratio=1.03, 95% CI 0.94-1.11) as it did for White patients (risk ratio=1.09, 95% CI 1.01-1.17). Conclusion: Remote BP monitoring programs are a helpful tool to improve the frequency of BP measurements and shorten intervals between measurements during the prenatal and postpartum periods for all patients. Future evaluation is needed to determine the barriers to offering the program to and enrolling Black patients.

A semi-Markov multistate cure model for estimating intervention effects in stepped wedge design trials

Multistate models are useful for studying exposures that affect transitions among a set of health states. However, they can be challenging to apply when exposures are time-varying. We develop a multistate model and a method of likelihood construction that allows application of the model to data in which interventions or other exposures can be time-varying and an individual may to be exposed to multiple intervention conditions while progressing through states. The model includes cure proportions, reflecting the possibility that some individuals will never leave certain states. We apply the approach to analyze patient vaccination data from a stepped wedge design trial evaluating two interventions to increase uptake of human papillomavirus vaccination. The states are defined as the number of vaccine doses the patient has received. We model state transitions as a semi-Markov process and include cure proportions to account for individuals who will never leave a given state (e.g. never receive their next dose). Multistate models typically quantify intervention effects as hazard ratios contrasting the intensities of transitions between states in intervention versus control conditions. For multistate processes, another clinically meaningful outcome is the change in the percentage of the study population that has achieved a specific state (e.g. completion of all required doses) by a specific point in time due to an intervention. We present a method for quantifying intervention effects in this manner. We apply the model to both simulated and real-world data and also explore some conditions under which such models may give biased results.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews

INTRODUCTION

Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening.

METHODS

Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community.

RESULTS

The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status.

DISCUSSION

Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Trends in HPV vaccine administration and HPV vaccine coverage in children by race/ethnicity and socioeconomic status during the COVID-19 pandemic in an integrated health care system in California

BACKGROUND

We sought to evaluate the trends of HPV vaccination between 03/2019-09/2021 and whether the impact of the COVID pandemic on HPV vaccination varied by race/ethnicity and neighborhood deprivation index (NDI).

METHODS

Electronic medical records at Kaiser Permanente Southern California were used to assess monthly volume of HPV vaccine doses administered among children aged 9-12.9yrs, and up-to-date coverage (% vaccinated) by age 13 between 03/2019-09/2021. Modified Poisson models were used to evaluate the interactions between race/ethnicity, NDI and the pandemic periods on HPV vaccine coverage.

RESULTS

HPV vaccine doses administered in 2020/2021 have returned to the 2019 level after the initial drop. The average up-to-date coverage in 05/2021-09/2021 (54.8%) remained lower than the pre-pandemic level (58.5%). The associations between race/ethnicity, NDI and HPV vaccine coverage did not vary due to the pandemic.

CONCLUSION

HPV vaccine promotion efforts are needed to address COVID-19 pandemic's lasting impact on HPV vaccination coverage.

Using a Twitter Chat to Rapidly Identify Barriers and Policy Solutions for Metastatic Breast Cancer Care: Qualitative Study

Background

Real-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes.

Objective

This study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California.

Methods

We provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper.

Results

There were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials.

Conclusions

Rapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

"Mommy Blogs" and the Vaccination Exemption Narrative: Results From A Machine-Learning Approach for Story Aggregation on Parenting Social Media Sites

Background

Social media offer an unprecedented opportunity to explore how people talk about health care at a very large scale. Numerous studies have shown the importance of websites with user forums for people seeking information related to health. Parents turn to some of these sites, colloquially referred to as “mommy blogs,” to share concerns about children’s health care, including vaccination. Although substantial work has considered the role of social media, particularly Twitter, in discussions of vaccination and other health care–related issues, there has been little work on describing the underlying structure of these discussions and the role of persuasive storytelling, particularly on sites with no limits on post length. Understanding the role of persuasive storytelling at Internet scale provides useful insight into how people discuss vaccinations, including exemption-seeking behavior, which has been tied to a recent diminution of herd immunity in some communities.

Objective

To develop an automated and scalable machine-learning method for story aggregation on social media sites dedicated to discussions of parenting. We wanted to discover the aggregate narrative frameworks to which individuals, through their exchange of experiences and commentary, contribute over time in a particular topic domain. We also wanted to characterize temporal trends in these narrative frameworks on the sites over the study period.

Methods

To ensure that our data capture long-term discussions and not short-term reactions to recent events, we developed a dataset of 1.99 million posts contributed by 40,056 users and viewed 20.12 million times indexed from 2 parenting sites over a period of 105 months. Using probabilistic methods, we determined the topics of discussion on these parenting sites. We developed a generative statistical-mechanical narrative model to automatically extract the underlying stories and story fragments from millions of posts. We aggregated the stories into an overarching narrative framework graph. In our model, stories were represented as network graphs with actants as nodes and their various relationships as edges. We estimated the latent stories circulating on these sites by modeling the posts as a sampling of the hidden narrative framework graph. Temporal trends were examined based on monthly user-poststatistics.

Results

We discovered that discussions of exemption from vaccination requirements are highly represented. We found a strong narrative framework related to exemption seeking and a culture of distrust of government and medical institutions. Various posts reinforced part of the narrative framework graph in which parents, medical professionals, and religious institutions emerged as key nodes, and exemption seeking emerged as an important edge. In the aggregate story, parents used religion or belief to acquire exemptions to protect their children from vaccines that are required by schools or government institutions, but (allegedly) cause adverse reactions such as autism, pain, compromised immunity, and even death. Although parents joined and left the discussion forums over time, discussions and stories about exemptions were persistent and robust to these membership changes.

Conclusions

Analyzing parent forums about health care using an automated analytic approach, such as the one presented here, allows the detection of widespread narrative frameworks that structure and inform discussions. In most vaccination stories from the sites we analyzed, it is taken for granted that vaccines and not vaccine preventable diseases (VPDs) pose a threat to children. Because vaccines are seen as a threat, parents focus on sharing successful strategies for avoiding them, with exemption being the foremost among these strategies. When new parents join such sites, they may be exposed to this endemic narrative framework in the threads they read and to which they contribute, which may influence their health care decision making.

Self-Efficacy as a Mediator of the Relationship Between the Perceived Food Environment and Healthy Eating in a Low Income Population in Los Angeles County

While previous studies have described psychosocial and environmental factors that contribute to healthy eating, much remains unknown about the interactions between them. We assessed the relationship between the perceived food environment, self-efficacy and fruit and vegetable consumption, using data from a sample of racially diverse, low-income adult clientele of five public health centers in Los Angeles County (n = 1503). We constructed a negative binomial regression model to examine the association between perceived food environment and the number of fruits and vegetables consumed. For every one point increase on the perceived food environment scale, individuals ate about 5% more fruits and vegetables (95% CI 1.007, 1.089), controlling for other covariates. Self-efficacy was shown to be a significant mediator (mediated effect = 0.010; 95% CI 0.002, 0.020), accounting for 22.9% of the effect. Efforts to increase access to healthy options may not only improve eating behaviors, but also influence individuals' beliefs that they can eat healthfully.

A systematic review of measures used in studies of human papillomavirus (HPV) vaccine acceptability

BACKGROUND

The recent proliferation of studies describing factors associated with HPV vaccine acceptability could inform health care providers in improving vaccine coverage and support future research. This review examined measures of HPV and HPV-vaccine knowledge, attitudes, beliefs and acceptability, described psychometric characteristics, and provided recommendations about their use.

METHODS

A systematic search of Medline, CINAHL, PsychoInfo, and ERIC through May 2008 for English language reports of quantitative data from parents, young adults or adolescents yielded 79 studies.

RESULTS

The majority of studies were cross-sectional surveys (87%), self-administered (67%), conducted before prophylactic vaccines were publicly available (67%) and utilized convenience samples (65%). Most measured knowledge (80%), general attitudes about HPV vaccination (40%), and willingness to vaccinate one's daughter (26%). Two-thirds did not report reliability or validity of measures. The majority did not specify a theoretical framework.

CONCLUSIONS

Use of a theoretical framework, consistent labeling of constructs, more rigorous validation of measures, and testing of measures in more diverse samples are needed to yield measurement instruments that will produce findings to guide practitioners in developing successful community and clinical interventions.

Isolation and characterization of human gingival microvascular endothelial cells

BACKGROUND AND OBJECTIVE

Endothelial cells have a substantial role in maintaining vascular homeostasis, and their dysregulation can contribute to the development of pathology. The plasminogen activators and their inhibitors may, arguably, be the single most important proteolytic system of the endothelium for vascular maintenance by controlling plasminogen activation and other proteolytic cascades that impact on clotting, hemodynamics, angiogenesis and the character of the vascular wall. In chronic periodontal disease, significant changes to the microvasculature occur in association with the severity of the disease. Investigation of the role played by endothelial cells in periodontal health and disease has been limited to in situ immunolocalization or to the use of endothelial cells of nongingival origin, such as human umbilical vein endothelial cells. The objective of this research was to establish a replicable protocol for isolating microvascular endothelial cells from the gingiva.

MATERIAL AND METHODS

From inflamed gingiva, isolated cells were characterized by morphology, the expression of factor VIII-related antigen, the expression of UEA-1 ligand, the uptake of acetylated low-density lipoprotein, network formation on Matrigel, and by the expression levels of urokinase plasminogen activator, tissue plasminogen activator, plasminogen activator inhibitor-1 and collagen IV.

RESULTS AND CONCLUSION

Gingival endothelial cells were most readily obtained from inflamed gingival tissues, and these endothelial cells, when isolated by the protocol established herein, demonstrated endothelial characteristics and constitutively secreted plasminogen activators and plasminogen activator inhibitor-1 in culture.

S-adenosylhomocysteine hydrolase deficiency in a 26-year-old man

This paper reports the third proven human case of deficient S-adenosylhomocysteine (AdoHcy) hydrolase activity. The patient is similar to the only two previously reported cases with this disorder in having severe myopathy, developmental delay, elevated serum creatine kinase (CK) concentrations, and hypermethioninaemia. Although he has been followed from infancy, the basic enzyme deficiency was established only at age 26 years. The diagnosis was based on markedly elevated plasma concentrations of both AdoHcy and S-adenosylmethionine, some 20% of the mean control activity of AdoHcy hydrolase activity in haemolysates of his red-blood cells, and two missense mutations in his gene encoding AdoHcy hydrolase. He had low values of erythrocyte phosphatidylcholine and plasma free choline and marginally elevated excretion of guanidinoacetate, suggesting that the elevated AdoHcy may have been inhibiting methylation of phosphatidylethanolamine and guanidinoacetate. His leukocyte DNA was globally more methylated than the DNA's of his parents or the mean extent of methylation measured in age-matched control subjects.

How important are psychosocial predictors of mammography receipt among older women when immediate access is provided via on-site service?

PURPOSE

The purpose of the study was to examine the relative importance of psychosocial variables (i.e., health beliefs, knowledge, barriers) in predicting mammogram receipt compared with providing access through a mobile mammography unit among older women who participated in a mobile mammography intervention.

DESIGN

The data were collected during a randomized trial involving 499 women (60 to 84 years old) recruited from 60 community sites.

SETTING

The study was conducted at 60 sites in Los Angeles where seniors gather, including meal sites, senior centers, and recreational clubs.

SUBJECTS

Participants were older women (60 to 84 years old) who spoke English or Spanish, had a telephone, had no significant cognitive deficits, and had not received a mammogram during the past 12 months.

MEASURES

The baseline survey assessed demographics and psychosocial factors (i.e., health beliefs, knowledge, barriers). A follow-up telephone survey at 3 months assessed mammography receipt.

RESULTS

Results support the importance of behavioral intentions in predicting mammogram receipt, even among women able to access a mammogram through the mobile unit. However, other recognized psychosocial factors failed to predict screening receipt among women randomized to the mobile mammography intervention. Results suggest that the importance of psychosocial predictors might be diminished when a major access barrier has been removed, and they highlight the importance of convenience.

CONCLUSION

Future interventions should focus on not only removing obvious concrete and psychosocial barriers but also on enhancing convenience.

Stages of change in readiness to adopt a self-management approach to chronic pain: the moderating role of early-treatment stage progression in predicting outcome

Relative readiness to assume a self-management approach to chronic pain can be conceptualised as a stage model. Although both initial stage (precontemplation, action) and changes in attitudes reflecting stage orientation have been shown to predict treatment outcome, the joint contributions of these factors need to be examined. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary pain program, completed the Pain Stages of Change Questionnaire (PSOCQ), subscales of the Multidimensional Pain Inventory, and the Beck Depression Inventory at pre-, mid- and post-treatment. Patients were assigned to stage group (precontemplation or action) based on whether their Precontemplation or Action subscale scores were highest. Results showed that: (a) stage group interacted with pre- to mid-treatment Precontemplation subscale changes to predict mid- to late-treatment pain severity and interference changes such that precontemplation attitude decreases were related to reduced pain and interference only among patients who were already action stage at pre-treatment; (b) stage group interacted with pre- to mid-treatment Action subscale changes to predict mid- to late-treatment interference and activity changes such that action attitude increases were related to reduced interference and increased activity only among patients at the action stage at pre-treatment; (c) pre- to mid-treatment decreases in depression did not account for these effects. Results suggest that any advantage enjoyed by patients with predominant action attitudes at pre-treatment may be enhanced by consolidating a pain self-management approach during treatment. In contrast, late-treatment gains of patients initially taking a predominant precontemplation stance were unaffected by their degree of early-treatment attitude changes.

S-Adenosylhomocysteine hydrolase deficiency: a second patient, the younger brother of the index patient, and outcomes during therapy

S-Adenosylhomocysteine (AdoHcy) hydrolase deficiency has been proven in a human only once, in a recently described Croatian boy. Here we report the clinical course and biochemical abnormalities of the younger brother of this proband. This younger brother has the same two mutations in the gene encoding AdoHcy hydrolase, and has been monitored since birth. We report, as well, outcomes during therapy for both patients. The information obtained suggests that the disease starts in utero and is characterized primarily by neuromuscular symptomatology (hypotonia, sluggishness, psychomotor delay, absent tendon reflexes, delayed myelination). The laboratory abnormalities are markedly increased creatine kinase and elevated aminotransferases, as well as specific amino acid aberrations that pinpoint the aetiology. The latter include, most importantly, markedly elevated plasma AdoHcy. Plasma S-adenosylmethionine (AdoMet) is also elevated, as is methionine (although the hypermethioninaemia may be absent or nonsignificant in the first weeks of life). The disease seems to be at least to some extent treatable, as shown by improved myelination and psychomotor development during dietary methionine restriction and supplementation with creatine and phosphatidylcholine.

Interventions to improve follow-up of abnormal findings in cancer screening

The potential reduction in morbidity and mortality through cancer screening cannot be realized without receipt of appropriate follow-up care for abnormalities identified via screening. In this paper, the authors critically examine the existing literature on correlates of receipt of appropriate follow-up care for screen-detected abnormalities, as well as the literature on interventions designed to increase rates of receipt of follow-up care. Lessons learned describe what is known and not known about factors that are related to or predict receipt of follow-up care. Similarly, effective interventions to increase follow-up are described and gaps identified. A conceptual model is developed that categorizes the health care system in the United States as comprising four levels: policy, practice, provider, and patient. Some patient-level factors that influence follow-up receipt are identified, but the lack of data severely limit the understanding of provider, practice, and policy-level correlates. The majority of intervention studies to increase follow-up receipt have focused on patient-level factors and have targeted follow-up of abnormal Papanicolaou smears. Insufficient information is available regarding the effectiveness of provider, practice, or policy-level interventions. Standard definitions of what constitutes appropriate follow-up are lacking, which severely limit comparability of findings across studies. The validity of various methods of obtaining outcome data has not been clearly established. More research is needed on interventions targeting provider, system, and policy-level factors, particularly interventions focusing on follow-up of colorectal and breast abnormalities. Standardization of definitions and measures is needed to facilitate comparisons across studies.

Pain self-management in the process and outcome of multidisciplinary treatment of chronic pain: evaluation of a stage of change model

For chronic pain patients, acceptance of a self-management approach for pain may influence success in treatment, and adopting such a perspective may be conceptualized as a stage of change model. For 65 chronic pain patients in multidisciplinary treatment programs, we examined whether pretreatment self-management stage, assessed with Pain Stage of Change Questionnaire subscales, affected improvements in outcomes, and whether changes in stage represented a therapeutic process factor. Results showed (a) low precontemplation, high contemplation, and high action attitudes at pretreatment predicted greater improvements in outcomes than the opposite pattern of attitudes; (b) pre- to midtreatment changes in precontemplation and contemplation attitudes predicted mid- to posttreatment changes in pain severity and interference, but not vice versa. Results support the usefulness of a stage model in conceptualizing patients' acquisition of a self-management approach to pain, and suggest that early-treatment progression across stages may lead to reductions in pain severity and lifestyle interference.

Cognitive factors influence outcome following multidisciplinary chronic pain treatment: a replication and extension of a cross-lagged panel analysis

Reducing maladaptive cognitions is hypothesized to constitute an active therapeutic process in multidisciplinary pain programs featuring cognitive-behavioral interventions. A cross-lagged panel design was used to determine whether: a) early-treatment cognitive changes predicted late-treatment pain, interference, activity and mood changes, but not vice versa; b) three cognitive factors made unique contributions to outcome; c) substantial cognitive changes preceded substantial improvements in outcome. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary program, completed measures of pain helplessness, catastrophizing, pain-related anxiety (process factors), pain severity, interference, activity level and depression (outcomes) at pre-, mid- and posttreatment. Results showed that early-treatment reductions in pain helplessness predicted late-treatment decreases in pain and interference, but not vice versa, and that early-treatment reductions in catastrophizing and pain-related anxiety predicted late-treatment improvements in pain severity, but not vice versa. Findings suggested that the three process factors predicted improvements mostly in common. However, little evidence was found that large early-treatment reductions in process variables preceded extensive improvements in pain. Findings replicate those of a recent report regarding cross-lagged effects, and offer support that cognitive changes may indeed influence late-treatment changes in outcomes.

Anxiolytic profile of GR 38032F in the potentiated startle paradigm

The potentiated startle paradigm has been demonstrated to be a model of anxiety sensitive to a range of established and putative anxiolytics. This study reports a preliminary investigation of the effects of the 5-HT(3) antagonist GR 38032F on potentiated startle. Doses of 0.01 and 0.1mg/kg each showed an anxiolytic profile in significantly reducing startle amplitude, with the lower dose having an effect comparable to chlordiazepoxide at 5.0mg/kg. 5-hydroxytryptophan at 25mg/kg significantly enhanced startle amplitude, and a mutual antagonism was found when 5-HTP was combined with GR 38032F. The results extend previous work with other models of anxiety suggesting anxiolytic potential for GR 38032F, and further demonstrate the possibility that the anxiolytic effect is mediated by serotonergic mechanisms.

Gender differences in associations between trauma history and adjustment among chronic pain patients

This study examines the relationship between a trauma history and emotional functioning in response to a chronic pain condition. We broadened the traditional study of trauma in chronic pain from sexual and physical abuse to include a variety of traumatic events and experiences that occurred not only during childhood, but during adulthood as well. Seventy-three (51% female, 60% lower back) chronic pain patients were administered the Trauma History Questionnaire (Green, B.L., Trauma History Questionnaire. In B.H. Stamm (Eds.), Measurement of Stress, Trauma and Adaptation, Sidran, Lutherville, MD, 1996, pp. 366-369), the Multidimensional Pain Inventory (Kerns, R.D., Turk, D.C. and Rudy, T.E., The West Haven-Yale Multidimensional Pain Inventory (WHYMPI), Pain, 23 (1985) 345-356), The Beck Depression Inventory (Beck, A.T., Ward, C.H., Mendelson, M., Mock, J. and Erbaugh, J., An inventory for measuring depression, Arch. Gen Psychiatry, 4 (1961) 561-571), and the Pain Anxiety Symptoms Scale (McCracken, L.M., Zayfert, C., Gross, R.T. The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain, Pain, 50 (1992) 67-73) prior to starting a multidisciplinary pain program. We hypothesized that high levels of emotional distress and anxiety would differentiate patients with a substantial history of trauma from those without, while levels of pain severity and disability would not. A MANOVA revealed a significant Trauma Group (low vs. high) by Gender interaction for the dependent variables, which included both measures of emotional distress and pain severity and disability. Univariate tests showed that the interaction was significant only for emotional distress variables and not for pain severity and disability. Further, the multivariate effect of Trauma Group and the univariate effects for emotional distress variables were significant only among men. Results indicate that a substantial history of trauma may detrimentally impact a chronic pain patient's ability to manage their pain effectively, particularly among men.

Transvenous embolization of a dural arteriovenous fistula of the cavernous sinus through the contralateral pterygoid plexus

We report a new transvenous endovascular route for treatment of dural arteriovenous fistulas of the cavernous sinus. The cavernous sinus was approached from the contralateral pterygoid plexus and embolization of a dural fistula was performed successfully with Guglielmi detachable coils.

Assessment of intraaxial and extraaxial brain lesions with digitized computed tomographic images versus film: ROC analysis

RATIONALE AND OBJECTIVES

The authors evaluated the diagnostic accuracy of viewing computed tomographic (CT) scans as film versus soft-copy images at a workstation.

METHODS

Receiver operating characteristic analysis of the interpretation of 202 CT scans (103 were normal, 99 were abnormal) by five neuroradiologists was performed. Abnormal images contained high- or low-attenuation intraaxial lesions or extraaxial fluid (subdural, subarachnoid, or epidural hemorrhage). Hard copies were read on a standard light box, and digital images were examined at a 1,024 x 1,250 workstation. Lesion location and type and confidence ratings were recorded on a worksheet.

RESULTS

There were no statistically significant differences in diagnostic accuracy between the two display modes. Reader performance was slightly better with the workstation in the assessment of low-attenuation lesions.

CONCLUSION

Diagnostic accuracy is similar for CT scans displayed at a workstation and those displayed as hard copy in the assessment of subtle intra- and extraaxial brain lesions.

Eye-head coordination during large gaze shifts

1. Three-dimensional (3D) eye and head rotations were measured with the use of the magnetic search coil technique in six healthy human subjects as they made large gaze shifts. The aims of this study were 1) to see whether the kinematic rules that constrain eye and head orientations to two degrees of freedom between saccades also hold during movements; 2) to chart the curvature and looping in eye and head trajectories; and 3) to assess whether the timing and paths of eye and head movements are more compatible with a single gaze error command driving both movements, or with two different feedback loops. 2. Static orientations of the eye and head relative to space are known to resemble the distribution that would be generated by a Fick gimbal (a horizontal axis moving on a fixed vertical axis). We show that gaze point trajectories during eye-head gaze shifts fit the Fick gimbal pattern, with horizontal movements following straight "line of latitude" paths and vertical movements curving like lines of longitude. However, horizontal (and to a lesser extent vertical) movements showed direction-dependent looping, with rightward and leftward (and up and down) saccades tracing slightly different paths. Plots of facing direction (the analogue of gaze direction for the head) also showed the latitude/longitude pattern, without looping. In radial saccades, the gaze point initially moved more vertically than the target direction and then curved; head trajectories were straight. 3. The eye and head components of randomly sequenced gaze shifts were not time locked to one another. The head could start moving at any time from slightly before the eye until 200 ms after, and the standard deviation of this interval could be as large as 80 ms. The head continued moving for a long (up to 400 ms) and highly variable time after the gaze error had fallen to zero. For repeated saccades between the same targets, peak eye and head velocities were directly, but very weakly, correlated; fast eye movements could accompany slow head movements and vice versa. Peak head acceleration and deceleration were also very weakly correlated with eye velocity. Further, the head rotated about an essentially fixed axis, with a smooth bell-shaped velocity profile, whereas the axis of eye rotation relative to the head varied throughout the movement and the velocity profiles were more ragged. 4. Plots of 3D eye orientation revealed strong and consistent looping in eye trajectories relative to space.(ABSTRACT TRUNCATED AT 400 WORDS)

Imidazo[1,2-b]pyridazines. XV. Synthesis and Anxiolytic Activity of Some 3-(Benzamidomethyl and fluorobenzamidomethyl)-6-(fluoro, chloro and methylthio)-2-(4-tolyl and 3,4-methylenedioxyphenyl)imidazo[1,2-b]pyridazines

Syntheses are reported for some 3-( benzamido-and fluorobenzamido -methyl)-6-( fluoro , chloro and methylthio )-2(4-methyl-, 4-t-butyl-, 4-cyclohexyl- and 3,4-methylenedioxy-phenyl) imidazo-[1,2-b] pyridazines from the relevant 3-unsubstituted imidazo [1,2-b] pyridazines and the N-( hydroxymethyl ) benzamides. In tests of the ability of these compounds to displace [3H]diazepam from rat brain membrane, 3-(3- or 4-fluorobenzamidomethyl)-2-(3,4-methylenedioxyphenyl)-6-methylthioimidazo[1,2-b]- pyridazine bound most strongly, with IC50 2nM; but in behavioural tests in rats the most active compounds were 6-chloro(and methylthio )-3-(2-fluorobenzamidomethyl)-2-(3,4-methylenedioxyphenyl) imidazo [1,2-b] pyridazines which showed a significant anxiolytic activity at 2.5 mg/kg.

Violations of Listing's law after large eye and head gaze shifts

1. Kinematic constraints were examined in static eye and head positions after large gaze shifts to visual targets. Three-dimensional eye and head rotations were measured in six adult human subjects by the use of the magnetic field search coil technique. 2. Eye positions in space were found to obey Donder's law; i.e., for any given gaze direction there was a unique three-dimensional orientation. In other words, angular eye positions in space (expressed as quaternions) were constrained to a two-dimensional surface. 3. When only the eye moved (head stationary), the shape of this surface resembled a plane and thus the eye position in space obeyed Listing's law. However, after gaze shifts involving both the eye and the head, the eye in space surface became twisted and thus nonplanar. This twist was similar to that achieved by a Fick gimbal model of rotations in which the horizontal axis is nested within a fixed vertical axis. During oblique gaze shifts, the head made predominantly horizontal movements whereas the eye made predominantly vertical movements. This, combined with the fact that the eye is mounted within the head, causes the eye in space surface to resemble that of a Fick gimbal. 4. The angular position of the head in space was also constrained to a two-dimensional surface. This surface was also not planar (Listinglike) and twisted in a manner similar to that of the eye in space. 5. Whereas the angular position of the eye in head was found to obey Listing's law after head-fixed gaze shifts, violations of Listing's law occurred after head-free gaze shifts. These violations showed significant intersubject variation in their magnitude and character. 6. Given that the eye in space violates Listing's law after head movements, the supposition that Listing's law serves the perceptual purpose of maintaining radial constancy is untenable. The Fick gimballike behavior of the head in space and eye in space may hold several advantages over a Listing's system. When the head in space behaves like a Fick gimbal, a horizontal line through the eyes remains parallel to the horizon. By having the eye in space behave like a Fick gimbal, the work done against gravity may be minimized by having the eye contribute more to vertical gaze shifts than does the head.

Behavioural effects of selective tachykinin agonists in midbrain dopamine regions

The effects of selective NK-1, NK-2 and NK-3 tachykinin agonists in midbrain dopamine cell containing regions were investigated in the rat. The NK-3 agonist senktide induced locomotion, rearing and sniffing following infusion into the substantia nigra pars compacta, and to a lesser extent in the ventral tegmental area. These behavioural responses were not seen following infusion of the selective NK-1 agonist [Sar9,Met (O2)11]SP or the NK-2 agonist [N1e10]NKA4-10. In contrast, grooming was induced only by the NK-1 agonist administered into the substantia nigra. Yawning, chewing mouth movements and wet dog shakes were all seen following infusion of senktide into the ventral tegmental area. These findings suggest that (i) dopamine-mediated behavioural responses seen following tachykinin administration into the midbrain are dependent upon stimulation of NK-3 tachykinin receptors, (ii) tachykinin-induced grooming is mediated by stimulation of NK-1 receptors and (iii) some of the previously described 5-HT mediated behaviours seen following administration of NK-3 tachykinin agonists are probably generated by stimulation of 5-HT cell bodies in the ventral tegmental area.

Evidence that the amygdala is involved in benzodiazepine and serotonergic effects on punished responding but not on discrimination

Interactions between the benzodiazepines (BZs) chlordiazepoxide (CDP) and midazolam (MDZ), the BZ antagonist R0 15-1788, the inverse BZ receptor agonists CGS 8216 and FG 7142, gamma-aminobutyrate (GABA), serotonin (5-HT), the 5-HT2 antagonist methysergide and the putative 5-HT agonist 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT) were investigated using peripheral and intra-amygdaloid treatments. A multiple schedule consisting of rewarded, nonrewarded (Time out: TO) and conflict periods was used to compare in parallel effects on successive discrimination between rewarded and nonrewarded periods and punished responding. The three components were presented in both a fixed order (Experiment 1) and a random order (Experiments 2 and 3). Intra-amygdaloid treatments with GABA and the BZs selectively increased rates of punished responding. CDP given systemically, on the other hand, increased both TO and conflict rates, suggesting an additional impairment of discrimination, which was more marked in the random than the fixed order condition. R0 15-1788, CGS 8216 and FG 7142 given by both routes counteracted the anti-conflict effects of CDP given centrally or systemically. However increases in TO rates induced by IP CDP were antagonized only by IP treatments with these compounds. The two inverse agonists, but not R0 15-1788, also counteracted increases in punished responding which were found after intra-amygdaloid GABA infusions. In Experiments 2 and 3 where baseline rates of pressing in Conflict periods were sufficiently high to detect decreases, CGS 8216 and FG 7142 reduced responding below control level, suggesting a specific anxiogenic activity. Evidence for effects of R0 15-1788 by itself was inconclusive. 5-HT injected into the amygdala also reduced punished responding below control level, whereas methysergide increased it with both central and peripheral treatment. Effects of 8-OH-DPAT varied according to route of administration. With IP treatment Conflict rates were increased, but after amygdaloid infusion both TO and Conflict rates were marginally reduced below control level, with a more consistent depression of punished responding. These results provide evidence that effects of BZs on punished responding are mediated by a GABAergic system which includes the lateral/basolateral amygdala, but which does not participate in BZ-induced disruption of discrimination. They also indicate that the antagonistic effects of CGS 8216 and FG 7142 involve a decrease in GABA transmission, and that these compounds may also be anxiogenic.(ABSTRACT TRUNCATED AT 400 WORDS)

Kinetics of single doses of fenbufen in patients with renal insufficiency

Fenbufen (gamma-oxo[1,1'-biphenyl]-4-butanoic acid) is a nonsteroidal anti-inflammatory analgesic that is metabolized to four major metabolites: gamma-hydroxy [1,1'-biphenyl]-4-butanoic acid (II), [1,1'-biphenyl]-4-acetic acid (III), 4'hydroxy [1,1'-biphenyl]-4-acetic acid (IV), and gamma, 4'-dihydroxy [1, 1'-biphenyl]-4-butanoic acid (V). Fenbufen and metabolites II and III circulate to plasma and are pharmacologically active; metabolites IV and V are normally excreted in urine. Single 800-mg doses of fenbufen were safely administered to 10 healthy subjects and to 16 patients with varying degrees of renal insufficiency. Drug and metabolite concentrations in serum and urine were determined at intervals for 3 days. It was found that renal impairment altered the metabolic pattern of fenbufen. Although t1/2 beta was the same for fenbufen and II, their plasma levels fell. No change was found in the plasma levels of III. There was evidence of moderate cumulation in plasma of the two more polar urinary metabolites (IV, V) corresponding to the degree of renal insufficiency. The total of all five compounds excreted into the urine was diminished. To account for this, either biliary and gastrointestinal excretion increased or there may have been further hepatic biotransformation of the metabolites.