Stress can lead to an increase in smartphone use in the context of texting while walking

Texting while walking (TWW) is a dangerous behavior that can lead to injury and even death. While several studies have examined the relationship between smartphone use and stress, to our knowledge no studies have yet investigated the relationship between stress and TWW. The objective of the present study was to investigate this relationship by examining the effects of stress on TWW, the effects of TWW on subsequent stress, and the effect of stress on multitasking performance. A total of 80 participants completed two sequential tasks in a laboratory while they walked on a treadmill and responded to a biological motion stimulus imitating the movement of another pedestrian. In the unrestricted task, participants were given the choice to use their personal phones. In the controlled task, they carried a text conversation with a research assistant while they walked and responded to the stimulus. Stress was measured via questionnaire and saliva collection for measure of cortisol (a stress hormone) before and after each task. Results show that greater psychological stress and cortisol variations were associated with a greater number of phone uses during the unrestricted task. Greater phone use during the unrestricted task was associated with lower subsequent psychological stress in women and total time of phone use was correlated with subsequent cortisol levels. Stress measured before the controlled task had no effect on multitasking performance, but participants with moderate performance were those with the highest cortisol levels. Our results suggest that stress could be a precursor to TWW and that it could affect a pedestrian’s ability to stay safe when using their smartphone.

Measuring the Switch Cost of Smartphone Use While Walking

This paper presents a study protocol to measure the task-switching cost of using a smartphone while walking. This method involves having participants walk on a treadmill under two experimental conditions: a control condition (i.e., simply walking) and a multitasking condition (i.e., texting while walking). During these conditions, the participants must switch between the tasks related to the experimental condition and a direction determining task. This direction task is done with a point-light walker figure, seemingly walking towards the left or the right of the participant. Performance on the direction task represents the participant's task-switching costs. There were two performance measures: 1) correct identification of the direction and 2) response time. EEG data are recorded in order to measure the alpha oscillations and cognitive engagement occurring during the task switch. This method is limited in its ecological validity: pedestrian environments have many stimuli occurring simultaneously and competing for attention. Nonetheless, this method is appropriate for pinpointing task-switching costs. The EEG data allow the study of the underlying mechanisms in the brain that are related to differing task-switching costs. This design allows the comparison between task switching when doing one task at a time, as compared to task switching when multitasking, prior to the stimulus presentation. This allows understanding and pinpointing both the behavioral and neurophysiological impact of these two different task-switching conditions. Furthermore, by correlating the task-switching costs with the brain activity, we can learn more about what causes these behavioral effects. This protocol is an appropriate base for studying the switching cost of different smartphone uses. Different tasks, questionnaires, and other measures can be added to it in order to understand the different factors involved in the task-switching cost of smartphone use while walking.

Regulatory focus, time perspective, locus of control and sensation seeking as predictors of risky driving behaviors

Empirical evidence shows that most of the road safety efforts fail to reach the most risk-prone drivers. In light of this issue, we have developed this study in order to distinguish between high-risk drivers and low-risk drivers based on variables that have already been shown to affect the effectiveness of preventive messages: regulatory focus orientation, time perspective, locus of control and sensation seeking. We sent paper and pencil questionnaires to five thousand low-risk drivers and five thousand high-risk drivers randomly selected based on their driving records. A driver who has been convicted of two or more traffic infractions with demerit points (e.g., exceeding speed limits, red light violation, no seatbelt, etc.) in the last two years was considered a high-risk driver whereas a low-risk driver had no traffic offense registered in his driving record in the last four years. We received two thousand and sixty-four completed questionnaires for a response rate of 20.6%. Seven hundred and ninety-eight belonged to the group of high-risk drivers and one thousand two hundred and sixty-six to the group of low-risk drivers. The results show that a promotion focused orientation, a present hedonistic perspective, an internal locus of control, and sensation seeking are associated with more risky driving behaviors and could therefore distinguish between high-risk and low-risk drivers. These results increase the understanding of risky drivers' personalities and motivations. The literature review provides insight into how these findings might be considered in developing more effective road safety programs and campaigns, and the conclusion encourages researchers to explore these new avenues in future research.

L₁ splitting rules in survival forests

The log-rank test is used as the split function in many commonly used survival trees and forests algorithms. However, the log-rank test may have a significant loss of power in some circumstances, especially when the hazard functions or when the survival functions cross each other in the two compared groups. We investigate the use of the integrated absolute difference between the two children nodes survival functions as the splitting rule. Simulations studies and applications to real data sets show that forests built with this rule produce very good results in general, and that they are often better compared to forests built with the log-rank splitting rule.

Survival forests for data with dependent censoring

Tree-based methods are very powerful and popular tools for analysing survival data with right-censoring. The existing methods assume that the true time-to-event and the censoring times are independent given the covariates. We propose different ways to build survival forests when dependent censoring is suspected, by using an appropriate estimator of the survival function when aggregating the individual trees and/or by modifying the splitting rule. The appropriate estimator used in this paper is the copula-graphic estimator. We also propose a new method for building survival forests, called p-forest, that may be used not only when dependent censoring is suspected, but also as a new survival forest method in general. The results from a simulation study indicate that these modifications improve greatly the estimation of the survival function in situations of dependent censoring. A real data example illustrates how the proposed methods can be used to perform a sensitivity analysis.

Effects of introducing an administrative .05% blood alcohol concentration limit on law enforcement patterns and alcohol-related collisions in Canada

Except for Quebec, all Canadian provinces have introduced administrative laws to lower the permitted blood alcohol concentration (BAC) to .05% or .04% for driving-or having the care of-a motor vehicle. Using linear mixed effects models for longitudinal data, this study evaluates the effect of administrative BAC laws on fatal alcohol related crashes and law enforcement patterns in Canada from 1987 to 2010. Results reveal a significant decrease of 3.7% (95% C.I.: 0.9-6.5%) in fatally injured drivers with a BAC level equal or greater than .05% following the introduction of these laws. Reductions were also observed for fatally injured drivers with BAC levels greater that .08% and .15%. The introduction of administrative BAC laws led neither to significant changes in the rate of driving while impaired (DWI) incidents reported by police officers nor in the probability of being charged for DWI under the Criminal Code.

Occupant injury severity from lateral collisions: a literature review

PROBLEM

Side impacts are a serious automotive injury problem; they represent about 30% of all fatalities for passenger vehicle occupants. This literature review focuses on occupant injuries resulting from real lateral collisions. It emphasizes the interaction between injury patterns and crash factors, taking into account type of injuries and their severity. It highlights what is known on the subject and suggests further studies.

METHOD

We reviewed papers identified by searches in two electronic databases for the 1996-2009 publication period, and in specific journals and conference proceedings.

RESULTS

Studies on the Primary Direction of Force (PDOF) have revealed that fatal crashes occur most frequently when the PDOF is at 3 or 9 o'clock. The risk of serious injury is two to three times higher for the near-side occupant than for the far-side occupant. Head injuries predominate in oblique impacts and thoracic injuries in perpendicular ones. A few results are also reported on side airbag protection.

CONCLUSIONS

This literature review presents an overall picture of the injuries caused by lateral collisions, though each of the papers or articles examined focuses mostly on some particular aspect of the problem. The incidence of specific injuries depends on the data source used. Very few population-based analyses of lateral collision injuries were found.

IMPACT ON INDUSTRY

New studies are needed to evaluate new protective devices (e.g., lateral airbags, inflatable curtains). Without interfering with their care duties, Emergency Medical Technicians could be systematically trained to observe the collision's specific characteristics and to report all their relevant observations to the emergency physicians to increase the likelihood of prompt diagnosis and proper care.

The value of a statistical life: a meta-analysis with a mixed effects regression model

The value of a statistical life (VSL) is a very controversial topic, but one which is essential to the optimization of governmental decisions. We see a great variability in the values obtained from different studies. The source of this variability needs to be understood, in order to offer public decision-makers better guidance in choosing a value and to set clearer guidelines for future research on the topic. This article presents a meta-analysis based on 39 observations obtained from 37 studies (from nine different countries) which all use a hedonic wage method to calculate the VSL. Our meta-analysis is innovative in that it is the first to use the mixed effects regression model [Raudenbush, S.W., 1994. Random effects models. In: Cooper, H., Hedges, L.V. (Eds.), The Handbook of Research Synthesis. Russel Sage Foundation, New York] to analyze studies on the value of a statistical life. We conclude that the variability found in the values studied stems in large part from differences in methodologies.

Safety impacts due to the incompatibility of SUVs, minivans, and pickup trucks in two-vehicle collisions

This research sets out to estimate the effects of vehicle incompatibility on the risk of death or major injury to drivers involved in two-vehicle collisions. Based on data for 2,999,395 drivers, logistic regression was used to model the risk of driver death or major injury (defined has being hospitalized). Our analyses show that pickup trucks, minivans and sport utility vehicles (SUVs) are more aggressive than cars for the driver of the other vehicle and more protective for their own drivers. The effect of the pickups is more pronounced in terms of aggressivity. The point estimates are comparable to those in the Toy and Hammitt study [Toy, E.L., Hammitt, J.K., 2003. Safety impacts of SUVs, minivans, and pickup trucks in two-vehicle crashes. Risk Analysis 23, 641-650], but, in contrast to that study, we are now able to establish that a greater number of these effects are statistically significant with a larger sample size. Like vehicle mass and type, other characteristics of drivers and the circumstances of the collision influence the driver's condition after impact. Male drivers, older drivers, drivers who are not wearing safety belts, collisions occurring in a higher speed zone and head-on collisions significantly increase the risk of death. Except for the driver's sex, all of these categories are also associated with an increased risk of death or of being hospitalized after being involved in a two-vehicle collision. For this risk, a significant increase is associated with female drivers.

Sex and cultural differences in the acceptance of functional foods: a comparison of American, Canadian, and French college students

OBJECTIVE

Functional foods (FF)--foods containing nutritional supplements in addition to natural nutrients--have an increasing presence in the marketplace. Expanding on previous research, the authors investigated college students' acceptance of FF.

PARTICIPANTS

In September--March 2004, 811 undergraduates in Canada, the United States, and France participated in the study.

METHODS

A self-administered questionnaire measured students' general food attitudes and beliefs as well as FF-related knowledge, attitudes, beliefs, and purchase intention.

RESULTS

Overall, participants slightly favored FF over traditional foods. However, although most respondents associated FF with positive health benefits, many remained dubious of currently available FF information. In terms of culture and sex, the authors found small but significant divergences in FF knowledge, attitudes, and behaviors.

CONCLUSIONS

Stronger labeling and education efforts may increase cross-cultural acceptance of FF by college students.

Comparing the Validity of Different Sources of Information on Emergency Department Visits

BACKGROUND

Emergency department (ED) use in Quebec may be measured from varied sources, eg, patient's self-reports, hospital medical charts, and provincial health insurance claims databases. Determining the relative validity of each source is complicated because none is a gold standard.

OBJECTIVE

We sought to compare the validity of different measures of ED use without arbitrarily assuming one is perfect.

SUBJECTS

Data were obtained from a nursing liaison intervention study for frail seniors visiting EDs at 4 university-affiliated hospitals in Montreal.

MEASURES

The number of ED visits during 2 consecutive follow-up periods of 1 and 4 months after baseline was obtained from patient interviews, from medical charts of participating hospitals, and from the provincial health insurance claims database.

METHODS

Latent class analysis was used to estimate the validity of each source. The impact of the following covariates on validity was evaluated: hospital visited, patient's demographic/clinical characteristics, risk of functional decline, nursing liaison intervention, duration of recall, previous ED use, and previous hospitalization.

RESULTS

The patient's self-report was found to be the least accurate (sensitivity: 70%, specificity: 88%). Claims databases had the greatest validity, especially after defining claims made on consecutive days as part of the same ED visit (sensitivity: 98%, specificity: 98%). The validity of the medical chart was intermediate. Lower sensitivity (or under-reporting) on the self-report appeared to be associated with higher age, low comorbidity and shorter length of recall.

CONCLUSION

The claims database is the most valid method of measuring ED use among seniors in Quebec compared with hospital medical charts and patient-reported use.

Pulmonary and systemic nitric oxide measurements during CCK-5-induced panic attacks

Nitric oxide (NO) plays a major role in cardiopulmonary regulation as illustrated by the alterations of the NO system described in cardiopulmonary illnesses. Recent studies have found an association between panic disorder and cardiovascular death and illness, as well as pulmonary diseases. Our objective was to investigate whether pulmonary or systemic NO production was altered during induced panic attacks (PAs). We used a double-blind placebo-controlled crossover design with randomization of the order of an injection of placebo and pentagastrin, a cholecystokinin-B receptor agonist that induces PAs in healthy volunteers (HVs). A total of 17 HVs experienced a PA after pentagastrin challenge. Exhaled NO and NO metabolites were measured by chemiluminescence. During pentagastrin-induced PAs, HVs displayed significant decreases in plateau concentrations of NO exhaled, which were associated with proportional increases in minute ventilation. There were no significant changes in pulmonary or systemic NO production. These results suggest that the decrease in exhaled NO concentration observed during pentagastrin-induced PAs is related to the associated hyperventilation, rather than to any change in lung NO production. This study is the first to evaluate changes in NO measurements during acute anxiety.

Wireless telephones and the risk of road crashes

In light of the rapidly increasing development of the cell phone market, the use of such equipment while driving raises the question of whether it is associated with an increased accident risk; and if so, what is its magnitude. This research is an epidemiological study on two large cohorts, namely users and non-users of cell phones, with the objective of verifying whether an association exists between cell phone use and road crashes, separating those with injuries. The Société de l'Assurance Automobile du Québec (SAAQ) mailed a questionnaire and letter of consent to 175000 licence holders for passenger vehicles. The questionnaire asked about exposure to risk, driving habits, opinions about activities likely to be detrimental to driving and accidents within the last 24 months. For cell phone users, questions pertaining to the use of the telephone were added. We received 36078 completed questionnaires, with a signed letter of consent. Four wireless phone companies provided the files on cell phone activity, and the SAAQ the files for 4 years of drivers' records and police reports. The three data sources were merged using an anonymized identification number. The statistical methods include logistic-normal regression models to estimate the strength of the links between the explanatory variables and crashes. The relative risk of all accidents and of accidents with injuries is higher for users of cell phones than for non-users. The relative risks (RR) for injury collisions and also for all collisions is 38% higher for men and women cell phone users. These risks diminish to 1.1 for men and 1.2 for women if other variables, such as the kilometres driven and driving habits are incorporated into the models. Similar results hold for several sub-groups. The most significant finding is a dose-response relationship between the frequency of cell phone use, and crash risks. The adjusted relative risks for heavy users are at least two compared to those making minimal use of cell phones; the latter show similar collision rates as do the non-users.

Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial

BACKGROUND

Delirium is common and often goes undetected in older patients admitted to medical services. It is associated with poor outcomes. We conducted a randomized clinical trial to determine whether systematic detection and multidisciplinary care of delirium in older patients admitted to a general medical service could reduce time to improvement in cognitive status.

METHODS

Consecutive patients aged 65 or more who were newly admitted to 5 general medical units between Mar. 15, 1996, and Jan. 31, 1999, were screened with the Confusion Assessment Method within 24 hours after admission to detect prevalent delirium and rescreened within a week to detect incident cases. Patients with delirium were randomly allocated to receive the intervention or usual care. Subjects in the intervention group were seen by a geriatric specialist consultant and followed in hospital for up to 8 weeks by an intervention nurse who liaised with the consultant, attending physicians, family and the primary care nurses. Subjects in the usual care group received standard hospital services but could consult geriatric specialists as needed. A research assistant, blinded as to treatment allocation, administered within 24 hours after enrolment the MiniMental Status Exam (MMSE), Delirium Index (measuring the severity of the delirium) and Barthel Index (measuring independence of personal care). Improvement was defined as an increase in the MMSE score of 2 or more points, with no decrease below baseline plus 2 points, or no decrease below a baseline MMSE score of 27. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly was completed to identify patients with possible dementia. Subjects were assessed 3 times during the first week and weekly thereafter for up to 8 weeks in hospital or until discharge. Data on clinical severity of illness, length of stay and living arrangements after discharge were also collected. The primary outcome measure was time to improvement in MMSE score.

RESULTS

Of the 1925 patients who met the inclusion criteria and were screened, 227 had prevalent or incident delirium and consented to participate (113 in intervention group and 114 in usual care group). There were no clinically significant differences between the intervention and usual care groups except for sex (female 58.4% v. 50.0%) and marital status (married 34.8% v. 41.2%). Overall, 48% of the patients in the intervention group and 45% of those in the usual care group met the predetermined criteria for improvement. The Cox proportional hazards ratio (HR) for a shorter time to improvement with the intervention versus usual care, adjusted for age, sex and marital status, was 1.10 (95% confidence interval [CI] 0.74-1.63). There were no significant differences within 8 weeks after enrolment between the 2 groups in time to and rate of improvement of the Delirium Index, the Barthel Index, length of stay, rate of discharge to the community, living arrangements after discharge or survival. Outcomes between the 2 groups did not differ statistically significantly for patients without dementia (HR 1.54, 95% CI 0.80-2.97), for those who had less co-morbidity (HR 1.36, 95% CI 0.75-2.46) or for those with prevalent delirium (HR 1.15, 95% CI 0.48-2.79).

INTERPRETATION

Systematic detection and multidisciplinary care of delirium does not appear to be more beneficial than usual care for older patients admitted to medical services.

Infant sucking ability, non-organic failure to thrive, maternal characteristics, and feeding practices: a prospective cohort study

This prospective study examined the relation of neonatal sucking to later feeding, postnatal growth, maternal postpartum depression, and feeding practices. Healthy infants of at least 37 weeks gestational age were recruited. At 1 week of age, a strain-gage device was attached to the infant's cheeks during sucking to identify sucking efficiency. Two-hundred and two infants (100 males, 102 females; mean age 39.6 weeks, SD 1.1 weeks) with efficient sucking and 207 (101 males, 106 females; mean gestational age 39.4 weeks, SD 1.2 weeks) with inefficient sucking were identified. Growth was measured at 2, 6, 10, and 14 months. Mothers completed a feeding questionnaire and the Edinburgh Postnatal Depression Scale at the same testing points. While 18 infants (5%) showed a downward shift in growth, their clinical picture did not present as non-organic failure to thrive (NFTT). Inefficient neonatal sucking did not predict postnatal growth, later feeding difficulties, nor maternal feeding practices, but concurrent inefficient feeding did. Maternal depression did not affect feeding practices, infant feeding abilities, nor growth, suggesting that the importance of maternal postpartum depression in association with feeding may be less than previously assumed. The term NFTT, therefore, merits reexamination and a more focused definition.

Effect of artificial tooth material on mandibular residual ridge resorption

PURPOSE

In this 10-year longitudinal study we evaluated the amount of mandibular residual ridge resorption for 2 groups of subjects with complete dentures, one group with porcelain artificial teeth and the other with acrylic resin teeth.

METHODS

One hundred and nine patients who had undergone ridge extension procedures with skin graft and prosthetic rehabilitation with porcelain or acrylic resin teeth were investigated for mandibular bone loss. Measurements were made on serial cephalograms.

RESULTS

There were no significant differences between the groups in terms of their baseline characteristics (age, period of edentulousness, period of observation, vertical facial morphology, sex, severity of atrophy or presence of bruxism). Similarly, there were no statistically significant differences in amount of bone loss in relation to baseline characteristics.

CONCLUSION

The view that acrylic resin teeth should be preferred to prevent bone resorption of the mandibular residual ridge is not supported by these data. Further research concerning soft denture-lining material should be undertaken to elucidate the potential role of denture pressure in ridge resorption.

St John's wort or sertraline? Randomized controlled trial in primary care

OBJECTIVE

To compare the change in severity of depressive symptoms and occurrence of side effects in primary care patients treated with St John's wort (SJW) and sertraline.

DESIGN

Double-blind, randomized 12-week trial.

SETTING

Community-based offices of 12 family physicians practising in greater Montreal, Que.

PARTICIPANTS

Eighty-seven men and women with major depression and an initial score of > or = 16 on the Hamilton Rating Scale for Depression (Ham-D).

INTERVENTIONS

Patients were randomized to treatment with either sertraline (50 to 100 mg/d) or SJW (900 to 1800 mg/d) in a double-blind fashion. Assessment of depression was done at entry and at 2, 4, 8, and 12 weeks using the Ham-D, the Beck Depression Inventory (BDI), and a questionnaire asking about compliance and side effects.

MAIN OUTCOME MEASURES

Changes from baseline in Ham-D and BDI scores and self-reported side effects.

RESULTS

There were no important differences in changes in mean Ham-D and BDI scores (using intention-to-treat analysis), with and without adjustment for baseline demographic characteristics, between the two groups at 12 weeks. Significantly more side effects were reported in the sertraline group than in the SJW group at 2 and 4 weeks' follow up.

CONCLUSION

The more benign side effects of SJW make it a good first choice for this patient population.

Neuroactive steroid changes in response to challenge with the panicogenic agent pentagastrin

BACKGROUND

Female hormones and female hormone derivatives, including neuroactive steroids (NASs) have been suspected to play a role in the pathophysiology of panic disorder (PD). The panicogenic agent CO(2) has been shown to induce a delayed release of NASs in both brain and plasma of rats. In the present study, we measured NASs plasma levels in response to challenge with another panicogenic agent, pentagastrin, and assessed the effect of ethynil estradiol (EE) pretreatment.

METHODS

A double-blind cross-over placebo-controlled design with randomization of the order of a three day pretreatment of EE (50 microg/day) or placebo was used to assess the effect of a 30 microg iv bolus injection of pentagastrin on the release of allopregnanolone (ALLO) and dehydroepiandrosterone (DHEA) into plasma in 15 male PD patients and 10 male healthy volunteers (HV).

RESULTS

After pentagastrin challenge there was a significant release of DHEA and a trend for the release of ALLO. EE pretreatment did not affect the pentagastrin-induced panic response or NAS release.

CONCLUSIONS

Pentagastrin induced release of NASs into plasma, the purpose of which remains to be determined.

No evidence for short or long term morbidity after increased titer measles vaccination in Sudan

BACKGROUND

Increased mortality rates have been reported after high titer measles [>10(5.0) plaque-forming units (PFU)] vaccination in several large studies in the developing world. An increased titer measles vaccine study conducted in Sudan included a prolonged prospective evaluation of childhood morbidity after vaccination.

METHODS

Five hundred ten children (170 per group) were randomized to receive 1 of 3 regimens at 5 and 9 months of age: (1) meningococcal vaccine, then standard titer (50% tissue culture-infective dose, 103.8) Schwarz measles vaccine; (2) increased titer (10(4.7) PFU) Edmonston-Zagreb measles vaccine followed by meningococcal vaccine; and (3) increased titer (10(4.7) PFU) Connaught vaccine followed by standard titer Schwarz measles vaccine.

RESULTS

Health workers collected information at 31,582 semi-monthly and monthly visits during 5 years. No increase in infant mortality was observed, but the statistical power was limited. There were 13, 13 and 10 deaths in the Schwarz, Edmonston-Zagreb and Connaught groups, respectively. There were no differences in duration or incidence of illness between groups at any time during the 5-year follow-up, with comparisons stratified by age and sex. Statistical power for each pairwise comparison was good, with at least 80% power to detect a difference of 1 day per month of illness and a 12% difference in the proportion of visits with an illness recorded.

CONCLUSIONS

We were unable to document increased morbidity in recipients of the increased titer measles vaccines used in this study. These data do not support the hypothesis that increased mortality after increased titer vaccine exposure is the result of increased and cumulative morbidity.

Pharmacokinetics of morphine and its glucuronidated metabolites in burn injuries

OBJECTIVE

To investigate the effects of major thermal burn injury and continuous intravenous morphine infusion on the disposition of morphine and its glucuronidated metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) once a week for three weeks.

CASE SUMMARIES

Five patients with major first-, second-, or third-degree burn injuries received long-term intravenous morphine infusion. The required dose varied greatly (from 4 to 39.5 mg/h). The steady-state concentrations of morphine, M3G, and M6G ranged from 20 to 452, 29 to 3436, and 20 to 1240 mumol/L, respectively. The systemic clearance (Cls) of morphine ranged from 14.8 to 40.3 mL/min/kg and did not change over time. The ratios of M6G and M3G to morphine were not affected by dose, even with the wide variation of intravenous dosage. Morphine kinetics appeared to be first-order. Mean recovery of morphine, M3G, and M6G in urine was 1.7 +/- 1.0%, 42.0 +/- 16.8%, and 11.8 +/- 3.2%, respectively, and renal clearance ranged from 8 to 64, 26 to 325, and 59 to 589 mL/min, respectively. Mean pain intensity ratings at rest remained low and stable (0.7 +/- 0.9 on day 7, 0.4 +/- 0.3 on day 14, 0 +/- 0 on day 21).

DISCUSSION

To our knowledge, this is the first published report describing morphine, M3G, and M6G disposition in patients with major thermal burn injury. The Cls of morphine is similar to that observed in other patient populations and healthy subjects, suggesting that the presence of major burn injuries or a continuous morphine infusion over a three-week period may not contribute significantly to the variability among individuals. In these cases, the renal clearance of morphine and its glucuronides was within the range of values reported for other populations of patients and healthy subjects. Recovery of morphine and its glucuronides in urine was also similar to that in healthy individuals.

CONCLUSIONS

These cases suggest that the effects of major burn injuries and of long-term intravenous infusion of morphine did not seem to modify morphine, M3G, and M6G disposition. Among patients with burn injuries, the severity of burns of duration of administration are not a cause of nonlinear kinetic of morphine or of morphine resistance. The morphine infusion rate was substantially variable and not directly related to its clearance, suggesting that monitoring of morphine should be focused on the clinical response.

Effect of ethinyl estradiol on the panic response to the panicogenic agent pentagastrin

BACKGROUND

Panic disorder (PD) symptomatology has been reported to be altered by hormonal events or treatments which affect estrogen levels. Coryell et al. [Arch. Gen. Psychiatry, 39 (1982) 701-703; Am. J. Psychiatry, 143 (1986) 508-510] have suggested that the increased cardiovascular risk associated with PD is significantly greater in males, alluding to a potential cardioprotective effect of female hormones in the context of panic attacks. In the present study, we were, therefore, interested in elucidating the role of estrogen in modulating the behavioural and cardiovascular responses induced by the panicogenic agent pentagastrin, a cholecystokinin-B (CCK(B)) receptor agonist.

METHODS

A double-blind cross-over placebo-controlled design with randomization of the order of a 3-day pretreatment of ethinyl estradiol (EE) (50 microg/day) or placebo was used to assess the effect of a 30-microg i.v. bolus injection of pentagastrin on panic symptom intensity and on increases in heart rate (DeltaHR), systolic (DeltaSBP) and diastolic (DeltaDBP) blood pressure following each pretreatment. Subjects were 9 male healthy controls and 11 male PD patients.

RESULTS

EE pretreatment did not significantly reduce the pentagastrin-induced panic symptom scale (PSS) scores and had no effect on DeltaDBP or DeltaSBP. EE did, however, attenuate the pentagastrin-induced increase in HR in both PD patients and healthy controls.

LIMITATIONS

Only male subjects were included in the present study; however, we are currently investigating the influence of female gonadal hormones on the panic response to pentagastrin in female PD patients and healthy controls.

CONCLUSION

Our results suggest that estrogens may display cardioprotective effects in the context of panic attacks.

The influence of Type A behavior pattern on the response to the panicogenic agent CCK-4

OBJECTIVES

Review of the literature equivocally suggests that subjects with Type A behavioral pattern (TABP) compared to subjects with Type B behavioral pattern display an increased sympathetic activity, a condition associated with sudden cardiac death. The objective of this study was to determine whether healthy subjects classified as Type A or Type B differed in their reactivity to the beta 1 and beta 2 receptor agonist isoproterenol and to the panicogenic agent cholecystokinin-tetrapeptide (CCK-4). By comparing reactivity to CCK-4 after pretreatment with placebo or propranolol, a beta 1 and beta 2 receptor antagonist, the role of the beta adrenergic system in the hypothesized increased response of Type A subjects to CCK-4 was also assessed.

METHODS

The study used a randomized, double-blind, placebo-controlled design. Twenty-seven Type A or B subjects were included in the study. The reactivity to isoproterenol was assessed with the CD25 of isoproterenol (i.e., the intravenous dose of isoproterenol necessary to increase the heart rate of 25 bpm). The panic symptom response and the cardiovascular response to bolus injection of 50 microg of CCK-4 was assessed in subjects pretreated with either propranolol or placebo infusions prior to the CCK-4 challenge. An additional group of subjects was recruited and these subjects received a placebo infusion pretreatment before an injection of placebo.

RESULTS

The CD25 was significantly greater in Type A subjects than in Type B subjects. No difference was found among the groups on behavioral sensitivity to the CCK-4 challenge. However, CCK-4-induced maximum increase in heart rate was greater in Type A subjects.

CONCLUSION

Our finding that Type A subjects exhibited greater CD25 of isoproterenol and greater increases in heart rate following CCK-4 administration compared to Type B subjects suggests that peripheral beta-receptor sensitivity may be increased in individuals with TABP.

Arginine-vasopressin and oxytocin response to cholecystokinin-tetrapeptide

This study examined the effects of i.v. administration of cholecystokinin-tetrapeptide (CCK-4) on plasma release of arginine vasopressin (AVP) and oxytocin (OT) in women with premenstrual dysphoric disorder (PMDD) and control women, during both the follicular phase and the luteal phase of their menstrual cycle. Plasma AVP and OT concentrations increased following CCK-4 administration. AVP and OT response to CCK-4 was similar for PMDD and control women and unaffected by menstrual cycle phase. AVP and OT may play a role in the hypothalamo-pituitary adrenal (HPA) axis activity associated with the panic response induced by CCK-4.

Feasibility and effectiveness of treatments for post-stroke depression in elderly inpatients: systematic review

To determine the feasibility and effectiveness of antidepressive treatments for post-stroke depression in elderly medical inpatients, MEDLINE was searched for potentially relevant articles published from January 1987 to August 1997 using the keywords "depression or depressive disorder" (exploded) and "aged." Thirteen reports met the following inclusion criteria: (1) published in English or French; (2) minimum age criterion of 55 and over or mean age 65 and over; (3) post-stroke subjects admitted to a medical, geriatric, or rehabilitation service; (4) used accepted criteria for depression; (5) examined treatment(s) for depression; and (6) reported outcomes as a depression diagnosis and/or symptom level. Data were abstracted independently from each article by two reviewers. The limited evidence suggests contraindications to treatment of 83% of a group to receive a heterocyclic antidepressant compared with 11% of a group to receive a selective serotonin reuptake inhibitor (SSRI); rates of discontinuation and study completion are similar for heterocyclics, SSRIs and psychostimulants. All of the treatments appear to be at least modestly effective in the short term.

Power comparison of robust approximate and non-parametric tests for the analysis of cross-over trials

The main advantage of cross-over designs in practice is the use of a smaller number of subjects to produce treatment comparisons with sufficient precision. Bellavance and Tardif proposed a non-parametric approach to test the hypotheses of direct treatment and carry-over effects for the three-treatment three-period and six sequences cross-over design and showed the high asymptotic efficiency of their approach relative to the classical F-test based on ordinary least squares (OLS). In a more recent paper, Ohrvik suggested another non-parametric method for the analysis of cross-over trials. The power of these two non-parametric approaches is evaluated for small sample sizes via simulations, and compared to the power of the usual analysis of variance model based on OLS and a modified F-test approximation that take into account the correlation structure of the repeated measurements within subjects. Different covariance structures, sample sizes, and probability distributions for the responses, namely normal and gamma, are used in the simulations to evaluate the power and robustness of these different methods of analysis.

Feasibility and effectiveness of treatments for depression in elderly medical inpatients: a systematic review

To determine the feasibility and effectiveness of treatments for depressed elderly medical inpatients, MEDLINE was searched for potentially relevant articles published from January 1987 to August 1997, using the keywords "depression or depressive disorder" (exploded) and "aged." The bibliographies of relevant articles were searched for additional references. Fifteen reports met the following inclusion criteria: (a) published in English or French; (b) minimum age criterion of 55 and over or mean age 65 and over; (c) subjects admitted to the medical service of an acute care hospital; (d) used accepted criteria for depression; (e) examined treatment(s) for depression; and (f) reported outcomes as a depression diagnosis and/or symptom level. Information was abstracted independently from each article by two reviewers, tabulated, and compared. The limited evidence suggests contraindications to treatment in 38% to 87% of subjects who received a heterocyclic antidepressant compared to 4% of subjects who received the selective serotonin reuptake inhibitor (SSRI) fluoxetine; rates of discontinuation and study completion were similar for heterocyclics, the SSRIs, and psychostimulants. All of the treatments (including social support/psychotherapy) appeared to be at least modestly effective in the short term.

Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit

STUDY OBJECTIVE

A simple screening tool, Identification of Seniors at Risk (ISAR), developed for administration in the emergency department for patients 65 years and older, predicts adverse health outcomes during the 6 months after the ED visit. In this study, we investigated whether the ISAR tool can also predict acute care hospital utilization in the same population.

METHODS

Patients 65 years and older who visited the EDs of 4 acute care Montreal hospitals during the weekday shift over a 3-month period were enrolled. At the initial (index) ED visit, 27 self-report screening questions (including the 6 ISAR items) were administered. The number of acute care hospital days during the 6 months after the index visit were abstracted from the provincial hospital discharge database. High utilization was defined as the top decile of the distribution of acute care hospital days.

RESULTS

Among 1,620 patients with linked data, a score of 2+ on the ISAR tool predicted high hospital utilization with a sensitivity of 73% and a specificity of 51%; the area under the receiver operating characteristic curve was 0.68. The ISAR tool also performed well in subgroups defined by disposition (admitted versus discharged) and by age (65 to 74 years versus 75 years and older).

CONCLUSION

The ISAR tool, a 6-item self-report questionnaire, can be used in the ED to identify elderly patients who will experience high acute care hospital utilization as well as adverse health outcomes.

Prevalence and detection of delirium in elderly emergency department patients

BACKGROUND

Delirium is a complex medical disorder associated with high morbidity and mortality among elderly patients. The goals of our study were to determine the prevalence of delirium in emergency department (ED) patients aged 65 years and over and to determine the sensitivity and specificity of a conventional clinical assessment by an ED physician for the detection of delirium in the same population.

METHODS

All elderly patients presenting to the ED in a primary acute care, university-affiliated hospital who were triaged to the observation room on a stretcher because of the severity of their illness were screened for delirium by a research psychiatrist using the Mini-Mental State Examination and the Confusion Assessment Method. The diagnosis of "delirium" or an equivalent term by the ED physician was determined by 2 methods: completion of a mental status checklist by the ED physician and chart review. The prevalence of delirium and the sensitivity and specificity of the ED physician's clinical assessment were calculated with their 95% confidence intervals. The demographic and clinical characteristics of patients with detected delirium and those with undetected delirium were compared.

RESULTS

A sample of 447 patients was screened. The prevalence of delirium was 9.6% (95% confidence interval 6.9%-12.4%). The sensitivity of the detection of delirium by the ED physician was 35.3% and the specificity, 98.5%. Most patients with delirium had neurologic or pulmonary diseases, and most patients with detected delirium had neurologic diseases.

INTERPRETATION

Despite the relatively high prevalence of delirium in elderly ED patients, the sensitivity of a conventional clinical assessment for this condition is low. There is a need to improve the detection of delirium by ED physicians.

Tracking cognitive decline in Alzheimer's disease using the mini-mental state examination: a meta-analysis

OBJECTIVES

To estimate the annual rate of change scores (ARC) on the Mini-Mental State Examination (MMSE) in Alzheimer's disease (AD) and to identify study or population characteristics that may affect the ARC estimation.

METHODS

MEDLINE was searched for articles published from January 1981 to November 1997 using the following keywords: AD and longitudinal study or prognosis or cognitive decline. The bibliographies of review articles and relevant papers were searched for additional references. All retrieved articles were screened to meet the following inclusion criteria: (a) original study; (b) addressed cognitive decline or prognosis or course of AD; (c) published in English; (d) study population included AD patients with ascertainable sample size; (e) used either clinical or pathological diagnostic criteria; (f) longitudinal study design; and (g) used the MMSE as one of the outcome measures. Data were systematically abstracted from the included studies, and a random effects regression model was employed to synthesize relevant data across studies and to evaluate the effects of study methodology on ARC estimation and its effect size.

RESULTS

Of the 439 studies screened, 43 met all the inclusion criteria. After 6 studies with inadequate or overlapping data were excluded, 37 studies involving 3,492 AD patients followed over an average of 2 years were included in the meta-analysis. The pooled estimate of ARC was 3.3 (95% confidence interval [CI]: 2.9-3.7). The observed variability in ARC across studies could not be explained with the covariates we studied, whereas part of the variability in the effect size of ARC could be explained by the minimum MMSE score at entry and number of assessments.

CONCLUSIONS

A pooled average estimate of ARC in AD patients was 3.3 points (95% CI: 2.9-3.7) on the MMSE. Significant heterogeneity of ARC estimates existed across the studies and cannot be explained by the study or population characteristics investigated. Effect size of ARC was related to the initial MMSE score of the study population and the number of assessments.

First lifetime back pain and psychiatry treatment: psychological factors and recovery in compensated workers

The role of psychological factors in recovery from first lifetime low back pain (LBP) was explored in this study. Consecutive clients from one physiatry clinic in Montreal who had LBP of less than 3 months' duration, were on sick leave and receiving workers' compensation benefits, and reported the current event as first lifetime LBP were enrolled. Psychological factors that fluctuate with current events (Psychiatric Symptom Index) and remain stable over time (General Well Being Scale) were assessed. Outcomes were late return to work (> 31 days) and 1 year incidence of compensated recurrence. Results from two multivariate models indicated lower psychological distress predicted late return to work, and higher well being, higher aggressiveness, and lower anxiety predicted compensated recurrence. Researchers concluded psychological factors do not impact clients with all types of LBP in the same way. For individuals lacking prior LBP experience, better psychological functioning increased lengthy work absence. Thus, awareness of the clients' psychological profiles and previous LBP experiences may benefit recovery.

Return to the emergency department among elders: patterns and predictors

OBJECTIVES

1) To describe the pattern of return visits to the emergency department (ED) among elders over the six months following an index visit; 2) to identify the predictors of early return (within 30 days) and frequent return (three or more return visits in six months); and 3) to evaluate a newly developed screening tool for functional decline, Identification of Seniors At Risk (ISAR), with regard to its ability to predict return visits.

METHODS

Subjects were patients aged 65 years or more who visited the EDs of four Canadian hospitals during the weekday shift over a three-month recruitment period. Excluded were patients who: could not be interviewed, due either to their medical conditions or to cognitive impairment, and no other informant was available; refused linkage of study data; or were admitted to hospital at the initial (index) visit. Measures made at the index ED visit included: 27 self-report screening questions on social, physical, and mental risk factors, medical history, use of hospital services, medications, and alcohol. Six of these questions comprised the ISAR scale. Return visits and diagnoses during the six months after the index visit were abstracted from the utilization database.

RESULTS

Among 1,122 patients released from the ED, 492 (43.9%) made one or more return visits; 216 (19.3%) returned early and 84 (7.5%) returned frequently. Earlier returns were more likely than later returns to be for the same diagnosis (p = 0.003). Using logistic regression, hospitalization during the previous six months, feeling depressed, and certain diagnoses predicted both early and frequent returns. Also, a history of heart disease, having ever been married, and not drinking alcohol daily predicted early return; a history of diabetes, a recent ED visit, and lack of support predicted frequent use.

CONCLUSIONS

In the first month after an ED visit, return rates are highest and are more likely to be for the same diagnosis. Both medical and social factors predict early and frequent returns to the ED; patients at increased risk of return can be quickly identified with a short, self-report questionnaire. The ISAR screening tool, developed to identify patients at increased risk of functional decline, can also identify patients who are more likely to return to the ED.

Outcomes in a referral cohort of patients with anxiety disorders

This study describes 6- and 12-month outcomes in a referral cohort with anxiety disorders and identifies treatment and prognostic factors related to these outcomes. Patients were recruited at three general hospital clinics, two psychologist-run clinics, and one psychiatric hospital clinic. Outcomes included severity of symptoms, physical and mental health status, and subjective global change in problem severity. Of 254 patients eligible for follow-up, 165 (65.0%) completed a follow-up questionnaire. Methods of treatment included consultation with return to the primary care physician (38.2%); or continued treatment at the clinic, with medications (16.4%), psychotherapy (22.4%), or both (23.0%). Both severity of symptoms and mental health status improved but remained abnormal at follow-up. In multiple logistic regression, subjective global improvement was related to a diagnosis of panic disorder only, treatment with psychotherapy, and type of referral. Change over time in symptom severity was related to clinic type, and change over time in mental health was related to clinic type and duration of previous treatment.

Characteristics and treatment of women with antenatal and postpartum depression

OBJECTIVE

Investigations of the efficacy of treatment for non-psychotic pregnancy-related mood disorders are scarce. Thus, a prospective, longitudinal study of six months duration, involving ninety-six index cases and forty-five healthy women as a reference group, was implemented to determine the response of mood, parenting stress and dyadic adjustment to an eclectic management.

METHOD

In this naturalistic study, the index cases were offered treatment consistent with their symptoms, context, and level of compliance. All women received individual psychotherapy combining strategies from Interpersonal and Cognitive Behavioral Psychotherapy and/or Marital Interventions and Pharmacology. Rating scales (Dyadic Adjustment Scale, Hamilton Rating Scale for Depression, Edinburgh Postnatal Depression Scale, Child Stress Inventory) scored monthly, were used to measure the response to treatment over time.

RESULTS

Depressive symptoms are generally alleviated by the second to third month of treatment. Dyadic discord accentuated by traditional sex role expectations and child care stress exacerbated by low self-esteem persisted throughout the trial at levels significantly different from the untreated reference group.

CONCLUSIONS

Short-term interventions are cost-effective for the relief of mood disorders. However, creative solutions, during an era of economic restraints, are required to extend treatment sufficiently to address couple conflicts and facilitate the transition to parenthood for index cases.

Validity of an activities of daily living questionnaire among older patients in the emergency department

The objective of this study was to determine the validity of French and English versions of the Older American Resources and Services (OARS) activities of daily living (ADL) questionnaire using a premorbid reference period among older emergency department (ED) patients. A sample of 404 ED patients aged 65 and over participating in a study of functional decline was invited to participate in a clinical assessment shortly after their ED visit. The OARS ADL questionnaire was administered either to the patient or a proxy informant at the ED visit. The clinical assessment was conducted by a nurse, blind to the OARS score, using the Functional Autonomy Measurement System (SMAF). Disability scores for the OARS and SMAF were computed, based on the patient's premorbid status. Assessments were conducted in 213 patients (52.7%). The OARS summary scores, a total and an ordinal score, were highly correlated with the SMAF total disability score (Spearman's r of 0.80 and 0.79, respectively). Similar correlations were found for French and English versions. The OARS ADL questionnaire with a premorbid reference period appears to be valid when administered in the ED, both in French and English.

Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool

OBJECTIVES

To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status.

DESIGN

Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older.

SETTING

The EDs of four acute-care hospitals in Montreal, Quebec, Canada.

PARTICIPANTS

Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available.

MEASUREMENTS

Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained.

RESULTS

Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics.

CONCLUSIONS

The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.

Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis

OBJECTIVE

The purpose of this study was to determine the prognosis of depression in elderly community and primary care populations.

METHOD

MEDLINE and PsycINFO were searched for potentially relevant articles published from January 1981 to November 1996 and from January 1984 to November 1996, respectively. The bibliographies of relevant articles were searched for additional references. Twelve studies met the following five inclusion criteria: original research, published in English or French, study population of community residents or primary care patients, subjects' mean age 60 years and over, and reported affective state as an outcome. The validity of the studies was assessed according to the criteria for prognostic studies described by the Evidence-Based Medicine Working Group. Information about the population, proportion of depressed subjects detected and treated by primary care physicians, length of follow-up, outcomes, and prognostic factors was systematically abstracted from each report.

RESULTS

All of the studies had some methodologic limitations. A meta-analysis of outcomes at 24 months estimated that 33% of subjects were well, 33% were depressed, and 21% had died. There was statistically significant heterogeneity in the outcomes across studies. The length of follow-up and lower age limit for enrollment explained part of the heterogeneity for the percent well but not for the other outcomes. Physical illness, disability, cognitive impairment, and more severe depression were associated with worse outcomes but inconsistently so.

CONCLUSIONS

Depression in elderly community and primary care populations has a poor prognosis, is perhaps chronic or relapsing or both, and is probably undertreated. Despite the methodologic limitations of the studies and this meta-analysis, these findings seem to support efforts to develop detection and treatment programs for depression in these populations.

Low incidence of severe adverse effects after mandibular ridge reconstruction using hydroxylapatite

The short and long term adverse effects after ridge reconstruction using hydroxylapatite (HA) are presented in this study. The HA was inserted using a modified tunnelling technique, followed by a lowering of the floor of the mouth and a vestibuloplasty using split thickness skin graft, 4-6 weeks later. The study comprised 637 patients followed for a period of 1 to 10 years (mean 6.0+/-2.6 years). Major loss of HA was seen in 17 patients (2.7%). Donor site visibility (skin graft) appeared to improve greatly over the years from 29.2% to 8.8% at the latest follow-up. Neurosurgery deficits also improved from 11.6% (paraesthesia and dysaesthesia) to 4.6%. Long term follow-up revealed a high percentage of patient satisfaction (97%), indicating that the low incidence of severe adverse effects of the procedure does play a significant role in the appreciation of the procedure and prosthetic care.

Sensitivity to CCK-4 in women with and without premenstrual dysphoric disorder (PMDD) during their follicular and luteal phases

The authors determined whether women with premenstrual dysphoric disorder (PMDD) exhibit a heightened sensitivity to the panicogenic effects of CCK-4 administration and whether this enhanced sensitivity to CCK-4 would vary with the phase of the menstrual cycle at the time of CCK-4 injection. Twenty-one normal controls and 18 PMDD women were randomly assigned to receive the first and second CCK-4 injection during the follicular phase and the luteal phase or vice versa. PMDD women showed a greater anxiety and panic response to CCK-4. These preliminary results suggest that the CCK-B system may play a role in the pathophysiology of PMDD.

Reliability and validity of a new measure of severity of delirium

The objective of this study was to assess the psychometric properties of a new instrument, the Delirium Index (DI), to measure changes in the severity of the symptoms of delirium among patients previously diagnosed with delirium. Subjects were medical inpatients aged 65 and over diagnosed with delirium by the Confusion Assessment Method. Interrater reliability of the DI was .78 between research assistants (concordance coefficient) and was .88 between research assistants and geriatric psychiatrists. Criterion validity, assessed by the correlation between DI and Delirium Rating Scale scores (Spearman's correlation coefficient, r), was .84. Construct validity was assessed using correlations of the DI with two measures of current function for convergent validity (r = -.60, -.70) and two measures of function before admission for discriminant validity (r = .26,-.42). We conclude that the DI has acceptable levels of interrater reliability, criterion validity, and construct validity.

The role of the beta-noradrenergic system in cholecystokinin-tetrapeptide-induced panic symptoms

BACKGROUND

The authors determined whether effective beta-adrenergic blockade could attenuate the panicogenic effects of cholecystokinin-tetrapeptide (CCK-4) in healthy volunteers.

METHODS

Subjects were randomly assigned to either a propranolol (n = 14) or placebo (n = 16) infusion. Ten minutes after completion of the infusion subjects received a bolus injection of CCK-4 (50 micrograms).

RESULTS

Acute pretreatment with propranolol was more effective than placebo in decreasing behavioral and cardiovascular sensitivity.

CONCLUSIONS

These preliminary results suggest that the panicogenic effects of CCK-4 are mediated, in part, through the beta-adrenergic system.

Detection and diagnosis of delirium in the elderly: psychiatrist diagnosis, confusion assessment method, or consensus diagnosis?

The clinical diagnosis of delirium has traditionally been based on an assessment by one or more physicians. Because of the transient, ubiquitous, and fluctuating nature of the symptoms of delirium, however, this approach may be flawed. Therefore, we decided to compare diagnosis based on one assessment by a psychiatrist, diagnosis by a nurse clinician (using the Confusion Assessment Method [CAM] and multiple observation points), and diagnosis by consensus. The study subjects were 87 patients aged 65 and over who were admitted consecutively from the emergency department to the medical wards, and who scored 3 or more on the Short Portable Mental Status Questionnaire. All subjects were assessed independently by one of three psychiatrists (a chart review and clinical examination) and a nurse clinician (using the CAM and multiple observation points). A consensus conference, attended by the three psychiatrists and the nurse clinician, used all available information to reach a consensus diagnosis. Compared to the consensus diagnosis, the clinical diagnosis by a psychiatrist had a sensitivity of .73 (95% confidence interval [CI]: .61-.85), a specificity of .93 (95% CI: .79-1.0), and an agreement kappa coefficient of .58 (95% CI: .41-.74). The nurse clinician diagnosis had a sensitivity of .89 (95% CI: .81-.97), a specificity of 1.00, and an agreement kappa coefficient of .86 (95% CI: .75-.97). These results suggest that one clinical assessment by a psychiatrist may not be the best method for detecting and diagnosing delirium in the elderly. A consensus diagnosis or diagnosis by a trained rater (using the CAM and multiple observation points) may be more sensitive approaches.