Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators

BACKGROUND

Many anecdotes and several uncontrolled case series have suggested that emotionally stressful events, and more specifically, anger, immediately precede and appear to trigger the onset of acute myocardial infarction. However, controlled studies to determine the relative risk of myocardial infarction after episodes of anger have not been reported.

METHODS AND RESULTS

We interviewed 1623 patients (501 women) an average of 4 days after myocardial infarction. The interview identified the time, place, and quality of myocardial infarction pain and other symptoms, the estimated usual frequency of anger during the previous year, and the intensity and timing of anger and other potentially triggering factors during the 26 hours before the onset of myocardial infarction. Anger was assessed by the onset anger scale, a single-item, seven-level, self-report scale, and the state anger subscale of the State-Trait Personality Inventory. Occurrence of anger in the 2 hours preceding the onset of myocardial infarction was compared with its expected frequency using two types of self-matched control data based on the case-crossover study design. The onset anger scale identified 39 patients with episodes of anger in the 2 hours before the onset of myocardial infarction. The relative risk of myocardial infarction in the 2 hours after an episode of anger was 2.3 (95% confidence interval, 1.7 to 3.2). The state anger subscale corroborated these findings with a relative risk of 1.9 (95% confidence interval, 1.3 to 2.7). Regular users of aspirin had a significantly lower relative risk (1.4; 95% confidence interval, 0.8 to 2.6) than nonusers (2.9; 95% confidence interval, 2.0 to 4.1) (P < .05).

CONCLUSIONS

Episodes of anger are capable of triggering the onset of acute myocardial infarction, but aspirin may reduce this risk. A better understanding of the manner in which external events trigger the onset of acute cardiovascular events may lead to innovative preventive strategies aimed at severing the link between these external stressors and their pathological consequences.

Transdermal Drug Delivery: Penetration Enhancement Techniques

There is considerable interest in the skin as a site of drug application both for local and systemic effect. However, the skin, in particular the stratum corneum, poses a formidable barrier to drug penetration thereby limiting topical and transdermal bioavailability. Skin penetration enhancement techniques have been developed to improve bioavailability and increase the range of drugs for which topical and transdermal delivery is a viable option. This review describes enhancement techniques based on drug/vehicle optimisation such as drug selection, prodrugs and ion-pairs, supersaturated drug solutions, eutectic systems, complexation, liposomes, vesicles and particles. Enhancement via modification of the stratum corneum by hydration, chemical enhancers acting on the structure of the stratum corneum lipids and keratin, partitioning and solubility effects are also discussed. The mechanism of action of penetration enhancers and retarders and their potential for clinical application is described.

Academic stress, power motivation, and decrease in secretion rate of salivary secretory immunoglobulin A

The effect of academic stress on immune function, as measured by the rate of secretion of salivary secretory immunoglobulin A (s-IgA), was studied prospectively in 64 first-year dental school students. Perceived stress and s-IgA secretion rate were measured five times--during an initial low-stress period, three high-stress periods coinciding with major examinations, and a final low-stress period. The s-IgA secretion rate was significantly lower in high-stress than low-stress periods for the whole group. In addition, personality characteristics differentiated patterns of s-IgA secretion rates. Students characterised by a great need to establish and maintain warm personal relationships secreted more s-IgA at each point than did all other subjects. The s-IgA secretion rates of those with a high inhibited need for power continued to decline through the final low-stress period rather than recovering as in all other subjects.

In vivo evidence for a novel pathway of vitamin D₃ metabolism initiated by P450scc and modified by CYP27B1

We define previously unrecognized in vivo pathways of vitamin D(3) (D3) metabolism generating novel D3-hydroxyderivatives different from 25-hydroxyvitamin D(3) [25(OH)D3] and 1,25(OH)(2)D3. Their novel products include 20-hydroxyvitamin D(3) [20(OH)D3], 22(OH)D3, 20,23(OH)(2)D3, 20,22(OH)(2)D3, 1,20(OH)(2)D3, 1,20,23(OH)(3)D3, and 17,20,23(OH)(3)D3 and were produced by placenta, adrenal glands, and epidermal keratinocytes. We detected the predominant metabolite [20(OH)D3] in human serum with a relative concentration ∼20 times lower than 25(OH)D3. Use of inhibitors and studies performed with isolated mitochondria and purified enzymes demonstrated involvement of the steroidogenic enzyme cytochrome P450scc (CYP11A1) as well as CYP27B1 (1α-hydroxylase). In placenta and adrenal glands with high CYP11A1 expression, the predominant pathway was D3 → 20(OH)D3 → 20,23(OH)(2)D3 → 17,20,23(OH)(3)D3 with further 1α-hydroxylation, and minor pathways were D3 → 25(OH)D3 → 1,25(OH)(2)D3 and D3 → 22(OH)D3 → 20,22(OH)(2)D3. In epidermal keratinocytes, we observed higher proportions of 22(OH)D3 and 20,22(OH)(2)D3. We also detected endogenous production of 20(OH)D3, 22(OH) D3, 20,23(OH)(2)D3, 20,22(OH)(2)D3, and 17,20,23(OH)(3)D3 by immortalized human keratinocytes. Thus, we provide in vivo evidence for novel pathways of D3 metabolism initiated by CYP11A1, with the product profile showing organ/cell type specificity and being modified by CYP27B1 activity. These findings define the pathway intermediates as natural products/endogenous bioregulators and break the current dogma that vitamin D is solely activated through the sequence D3 → 25(OH)D3 → 1,25(OH)(2)D3.

Transfersomes for transdermal drug delivery

Transfersomes (Idea AG) are a form of elastic or deformable vesicle, which were first introduced in the early 1990s. Elasticity is generated by incorporation of an edge activator in the lipid bilayer structure. The original composition of these vesicles was soya phosphatidyl choline incorporating sodium cholate and a small concentration of ethanol. Transfersomes are applied in a non-occluded method to the skin and have been shown to permeate through the stratum corneum lipid lamellar regions as a result of the hydration or osmotic force in the skin. They have been used as drug carriers for a range of small molecules, peptides, proteins and vaccines, both in vitro and in vivo. It has been claimed by Idea AG that intact Transfersomes penetrate through the stratum corneum and the underlying viable skin into the blood circulation. However, this has not been substantiated by other research groups who have extensively probed the mechanism of penetration and interaction of elastic vesicles in the skin. Structural changes in the stratum corneum have been identified, and intact elastic vesicles visualised within the stratum corneum lipid lamellar regions, but no intact vesicles have been ascertained in the viable tissues. Using the principle of incorporating an edge-activator agent into a bilayer structure, a number of other elastic vesicle compositions have been evaluated. This review describes the research into the development and evaluation of Transfersomes and elastic vesicles as topical and transdermal delivery systems.

Exaggerated heart rate oscillations during two meditation techniques

We report extremely prominent heart rate oscillations associated with slow breathing during specific traditional forms of Chinese Chi and Kundalini Yoga meditation techniques in healthy young adults. We applied both spectral analysis and a novel analytic technique based on the Hilbert transform to quantify these heart rate dynamics. The amplitude of these oscillations during meditation was significantly greater than in the pre-meditation control state and also in three non-meditation control groups: i) elite athletes during sleep, ii) healthy young adults during metronomic breathing, and iii) healthy young adults during spontaneous nocturnal breathing. This finding, along with the marked variability of the beat-to-beat heart rate dynamics during such profound meditative states, challenges the notion of meditation as only an autonomically quiescent state.

The relaxation response: psychophysiologic aspects and clinical applications

It is hypothesized that situations requiring continous behavioral adjustment activate an integrated, hypothalamic response, the emergency reaction. The frequent elicitation of the physiologic changes associated with the emergency reaction has been implicated in the development of diseases such as hypertension. Prevention and treatment of these diseases may be through the use of the relaxation response, an integrated hypothalamic response whose physiologic changes appear to be the counterpart of the emergency reaction. This article describes the basic elements of techniques which elicit the relaxation response and discusses the results of clinical investigations which employ the relaxation response as a therapeutic intervention.

Topical and Transdermal Drug Delivery: From Simple Potions to Smart Technologies

This overview on skin delivery considers the evolution of the principles of percutaneous ab-sorption and skin products from ancient times to today. Over the ages, it has been recognised that products may be applied to the skin for either local or systemic effects. As our understanding of the anatomy and physiology of the skin has improved, this has facilitated the development of technologies to effectively and quantitatively deliver solutes across this barrier to specific target sites in the skin and beyond. We focus on these technologies and their role in skin delivery today and in the future.

Decreased systolic blood pressure through operant conditioning techniques in patients with essential hypertension

Operant conditioning-feedback techniques were employed to lower systolic blood pressure in seven patients with essential hypertension. In five of the patients, meaningful decreases of systolic blood pressure were obtained in the laboratory, ranging from 16 to 34 millimeters of mercury. The therapeutic value of such techniques remains to be established.

The mind/body program for infertility: a new behavioral treatment approach for women with infertility

There is increasing evidence that a behavioral treatment approach might be efficacious in the treatment of the emotional aspects of infertility and may lead to increased conception rates. The first 54 women to complete a behavioral treatment program based on the elicitation of the relaxation response showed statistically significant decreases in anxiety, depression, and fatigue as well as increases in vigor. In addition, 34% of these women became pregnant within 6 months of completing the program. These findings established a role for stress reduction in the long-term treatment of infertility. They further suggest that behavioral treatment should be considered for couples with infertility before or in conjunction with reproductive technologies such as intrauterine insemination and gamete intrafallopian transfer.

Reduced sympathetic nervous system responsivity associated with the relaxation response

Sympathetic nervous system activity was assessed in experimental and control subjects who were exposed to graded orthostatic and isometric stress during monthly hospital visits. After the first session, the experimental subjects practiced a technique that elicited the relaxation response. Their concentrations of plasma norepinephrine during subsequent graded stresses were significantly higher. No such changes were noted in the control group. These results were than replicated in the control group in a crossover experiment. The groups did not differ in their heart rate and blood pressure responses. These observations are consistent with reduced norepinephrine end-organ responsivity after regular elicitation of the relaxation response.

Liquid chromatographic assay for common sunscreen agents: application to in vivo assessment of skin penetration and systemic absorption in human volunteers

The purpose of the present study was to develop a reverse-phase high-performance liquid chromatographic (HPLC) assay for quantifying four common sunscreen agents, namely 2-hydroxy-4-methoxybenzophenone, 2-ethylhexyl-p-methoxycinnamate, 2-ethylhexylsalicylate (octylsalicylate) and salicylic acid 3,3,5-trimethcyclohexyl ester (homosalate) in a range of biological matrices. This assay was further applied to study the skin penetration and systemic absorption of sunscreen filters after topical application to human volunteers. Separation was achieved utilizing a Symmetry C(18) column with methanol-water as the mobile phase. The assay permits analysis of the sunscreen agents in biological fluids, including bovine serum albumin (BSA) solution, plasma and urine, and in human epidermis. The assay was linear (r2 > 0.99) with minimum detectable limits of 0.8 ng for oxybenzone, 0.3 ng for octylmethoxycinnamate, and 2 ng for homosalate and octylsalicylate. The inter- and intra-day variation for the four sunscreens was less than 3% at the upper end of the linear range and less than 6% at the lower end. Recoveries of sunscreens from plasma, 4% (w/v) BSA solution and epidermal membranes were within the range of 91-104%. Recoveries from urine of the four sunscreens, and oxybenzone with its metabolites were more than 86%. Up to approximately 1% of the applied dose of oxybenzone and its metabolites was detected in the urine. Appreciable amounts were also detected in the stratum corneum through tape stripping. The HPLC assay and extraction procedures developed are sensitive, simple, rapid, accurate and reproducible. Results from the preliminary clinical study demonstrate significant penetration of all sunscreen agents into the skin, and oxybenzone and metabolites across the skin.

A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints

This randomized, prospective study investigated the effectiveness of two group behavioral medicine interventions for primary care patients experiencing physical symptoms with a psychosocial component (eg, palpitations, gastrointestinal disturbances, headaches, malaise, sleep disorders). The subjects were 80 volunteers at a health maintenance organization (HMO) in the greater Boston area. Both interventions focused on the mind/body relationship and used didactic material, relaxation-response training, awareness training, and cognitive restructuring. The two behavioral medicine intervention groups were compared with a group that focused exclusively on information about stress management and its relation to illness. Measures of visits to the HMO and of distress from physical and psychological symptoms were obtained before the interventions and again 6 months afterward. At the 6-month follow-up, patients in the behavioral medicine groups showed significantly greater reductions in visits to the HMO and in discomfort from physical and psychological symptoms than did the patients in the information group. The results suggest that when the relationship among thoughts and behaviors and symptoms of patients with psychosomatic dysfunction is actively addressed, the patients' discomfort level and the cost of medical care can be reduced.

Drug delivery across the blood-brain barrier

The brain is protected and isolated from the general circulation by a highly efficient blood-brain barrier. This is characterised by relatively impermeable endothelial cells with tight junctions, enzymatic activity and active efflux transport systems. Consequently the blood-brain barrier is designed to permit selective transport of molecules that are essential for brain function. This creates a considerable challenge for the treatment of central nervous system diseases requiring therapeutic levels of drug to enter the brain. Some small lipophilic drugs diffuse across the blood-brain barrier- sufficiently well to be efficacious. However, many potentially useful drugs are excluded. This review provides an insight into the current research into technologies to target small molecules, peptides and proteins to the brain. A brief review of the nature of the blood-brain barrier and its transport mechanisms is provided. Strategies to target and improve transport across the blood-brain barrier include the prodrug-lipidisation approach, sequential metabolism chemical delivery systems, drug-vectors, liposomes and nanoparticles. Included is the discussion of techniques to minimise clearance from the circulation by the reticuloendothelial system in order to extend circulation residence time and optimise the opportunity for interaction between the drug delivery system and the blood-brain barrier.

Behavioral medicine, clinical health psychology, and cost offset

The use of medical services is a function of several interacting psychological and social variables as well as a function of physical malfunction. The clinical significance of addressing patients' psychosocial issues has only occasionally been considered. However, the shift in health care economics toward health care maintenance is responsible for the increased interest in interventions in the domain of behavioral medicine and health psychology. Evidence is reviewed for 6 mechanistic pathways by which behavioral interventions can maximize clinical care and result in significant economic benefits. The rationale for further integration of behavioral and biomedicine interventions is also reviewed.

Decreased clinic use by chronic pain patients: response to behavioral medicine intervention

The treatment of chronic pain is costly and frustrating for the patient, health care provider, and health care system. This is due, in part, to the complexity of pain symptoms which are influenced by behavior patterns, socioeconomic factors, belief systems, and family dynamics as well as by physiological and mechanical components. Assessment of treatment outcomes is often limited to the patient's subjective, multidimensional, self-reports. Outcome measures based on data about return to work or clinic use can provide more objective assessments of intervention benefits. In this study, a 36% reduction in clinic visits in the first year postintervention was found among the 109 patients who participated in an outpatient behavioral medicine program. Decreased clinic use continued in the first 50 patients followed 2 years postintervention. Decreased use projected to an estimated net savings of $12,000 for the first year of the study posttreatment and $23,000 for the second year.

Three case reports of the metabolic and electroencephalographic changes during advanced Buddhist meditation techniques

To examine the extent to which advanced meditative practices might alter body metabolism and the electroencephalogram (EEG), we investigated three Tibetan Buddhist monks living in the Rumtek monastery in Sikkim, India. In a study carried out in February 1988, we found that during the practice of several different meditative practices, resting metabolism (VO2) could be both raised (up to 61%) and lowered (down to 64%). The reduction from rest is the largest ever reported. On the EEG, marked asymmetry in alpha and beta activity between the hemispheres and increased beta activity were present. From these three case reports, we conclude that advanced meditative practices may yield different alterations in metabolism (there are also forms of meditation that increase metabolism) and that the decreases in metabolism can be striking.

An Inventory of Positive Psychological Attitudes with potential relevance to health outcomes: validation and preliminary testing

This article describes the validation of an Inventory of Positive Psychological Attitudes that has potential relevance to health outcomes and its preliminary testing with chronic pain patients. The inventory taps two attitudinal domains: (1) life purpose and satisfaction and (2) self-confidence during potentially stressful situations. It also provides a total score. The inventory scales, developed using factor analysis, were found to have a strong degree of internal reliability and concurrent validity. Preliminary testing suggested that positive change on these scales correlates with positive changes in the health status of chronic pain patients. Multiple regression analyses suggested that the interactions of these positive psychological attitudes with health status are not fully accounted for by the interactions of negative psychological attitudes with health status.