Epidemiology of the Systemic Inflammatory Response Syndrome (SIRS) in the emergency department

Introduction: Consensus guidelines recommend sepsis screening for adults with systemic inflammatory response syndrome (SIRS), but the epidemiology of SIRS among adult emergency department (ED) patients is poorly understood. Recent emphasis on cost-effective, outcomes-based healthcare prompts the evaluation of the performance of large-scale efforts such as sepsis screening. We studied a nationally representative sample to clarify the epidemiology of SIRS in the ED and subsequent category of illness.

Methods: This was a retrospective analysis of ED visits by adults from 2007 to 2010 in the National Hospital Ambulatory Medical Care Survey (NHAMCS). We estimated the incidence of SIRS using initial ED vital signs and a Bayesian construct to estimate white blood cell count based on test ordering. We report estimates with Bayesian modified credible intervals (mCIs).

Results: We used 103,701 raw patient encounters in NHAMCS to estimate 372,844,465 ED visits over the 4-year period. The moderate estimate of SIRS in the ED was 17.8% (95% mCI: 9.7 to 26%). This yields a national moderate estimate of approximately 16.6 million adult ED visits with SIRS per year. Adults with and without SIRS had similar demographic characteristics, but those with SIRS were more likely to be categorized as emergent in triage (17.7% versus 9.9%, p<0.001), stay longer in the ED (210 minutes versus 153 minutes, p<0.0001), and were more likely to be admitted (31.5% versus 12.5%, p<0.0001). Infection accounted for only 26% of SIRS patients. Traumatic causes of SIRS comprised 10% of presentations; other traditional categories of SIRS were rare.

Conclusion: SIRS is very common in the ED. Infectious etiologies make up only a quarter of adult SIRS cases. SIRS may be more useful if modified by clinician judgment when used as a screening test in the rapid identification and assessment of patients with the potential for sepsis. [West J Emerg Med. 2014;15(3):329–336.]

From vital signs to clinical outcomes for patients with sepsis: a machine learning basis for a clinical decision support system

OBJECTIVE

To develop a decision support system to identify patients at high risk for hyperlactatemia based upon routinely measured vital signs and laboratory studies.

MATERIALS AND METHODS

Electronic health records of 741 adult patients at the University of California Davis Health System who met at least two systemic inflammatory response syndrome criteria were used to associate patients' vital signs, white blood cell count (WBC), with sepsis occurrence and mortality. Generative and discriminative classification (naïve Bayes, support vector machines, Gaussian mixture models, hidden Markov models) were used to integrate heterogeneous patient data and form a predictive tool for the inference of lactate level and mortality risk.

RESULTS

An accuracy of 0.99 and discriminability of 1.00 area under the receiver operating characteristic curve (AUC) for lactate level prediction was obtained when the vital signs and WBC measurements were analysed in a 24 h time bin. An accuracy of 0.73 and discriminability of 0.73 AUC for mortality prediction in patients with sepsis was achieved with only three features: median of lactate levels, mean arterial pressure, and median absolute deviation of the respiratory rate.

DISCUSSION

This study introduces a new scheme for the prediction of lactate levels and mortality risk from patient vital signs and WBC. Accurate prediction of both these variables can drive the appropriate response by clinical staff and thus may have important implications for patient health and treatment outcome.

CONCLUSIONS

Effective predictions of lactate levels and mortality risk can be provided with a few clinical variables when the temporal aspect and variability of patient data are considered.

Hyperlactatemia affects the association of hyperglycemia with mortality in nondiabetic adults with sepsis

BACKGROUND

Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia's known association with hyperlactatemia was not addressed in these analyses.

OBJECTIVES

The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia.

METHODS

This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their emergency department (ED) encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia's association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction.

RESULTS

A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57).

CONCLUSIONS

In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.

Impact of metformin use on the prognostic value of lactate in sepsis

OBJECTIVE

The objective of this study is to determine if metformin use affects the prevalence and prognostic value of hyperlactatemia to predict mortality in septic adult emergency department (ED) patients.

METHODS

This is a single-center retrospective cohort study. Emergency department providers identified study subjects; data were collected from the medical record.

PATIENTS

Adult ED patients with suspected infection and 2 or more systemic inflammatory response syndrome criteria were included. The outcome was 28-day mortality. The primary risk variable was serum lactate (<2.0, 2.0-3.9, ≥ 4.0 mmol/L) categorized by metformin use; covariates: demographics, Predisposition, Infection, Response, Organ Dysfunction score and metformin use contraindications.

SETTING

The study was conducted at an urban teaching hospital; February 1, 2007 to October 31, 2008.

RESULTS

A total of 1947 ED patients were enrolled; 192 (10%) were taking metformin; 305 (16%) died within 28 days. Metformin users had higher median lactate levels than nonusers (2.2 mmol/L [interquartile range, 1.6-3.2] vs 1.9 mmol/L [interquartile range, 1.3-2.8]) and a higher, although nonsignificant, prevalence of hyperlactatemia (lactate ≥ 4.0 mmol/L) (17% vs 13%) (P = .17). In multivariate analysis (reference group nonmetformin users, lactate <2.0 mmol/L), hyperlactatemia was associated with an increased adjusted 28-day mortality risk among nonmetformin users (odds ratio [OR], 3.18; P < .01) but not among metformin users (OR, 0.54; P = .33). In addition, nonmetformin users had a higher adjusted mortality risk than metformin users (OR, 2.49; P < .01). These differences remained significant when only diabetic patients were analyzed.

CONCLUSIONS

In this study of adult ED patients with suspected sepsis, metformin users had slightly higher median lactate levels and prevalence of hyperlactatemia. However, hyperlactatemia did not predict an increased mortality risk in patients taking metformin.

Serum lactate is a better predictor of short-term mortality when stratified by C-reactive protein in adult emergency department patients hospitalized for a suspected infection

STUDY OBJECTIVE

We determine whether C-reactive protein (CRP) adds prognostic value to serum lactate levels when assessing mortality risk in emergency department (ED) patients admitted for a suspected infection.

METHODS

This was an observational cohort of unique adult patients (≥ 21 years of age) who had lactate and CRP testing in the ED and were admitted for a suspected infection during a 1-year period. All data were collected through retrospective chart review. The study site is an urban teaching hospital with an approximate annual census of 95,000 patients. The endpoint was 28-day inpatient mortality.

RESULTS

One thousand one hundred forty-three patients had lactate and CRP testing in the ED, an admitting diagnosis of infection, and complete records. Twenty-eight-day inpatient mortality for patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL was 44.0% (95% confidence interval [CI] 32.5% to 55.5%), for lactate greater than or equal to 4.0 mmol/L and CRP less than or equal to 10.0 mg/dL, it was 9.7% (95% CI 2.7% to 16.7%), and for lactate level less than 4.0 mmol/L, it was 9.1% (95% CI 7.3% to 10.9%). In a logistic regression model that included patient demographics and Charlson score, as well as 4 separate dichotomous variables that were positive only in subjects with (1) serum lactate greater than or equal to 4.0 mmol/L and CRP level greater than 10.0 mg/dL, (2) lactate level greater than or equal to 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL, (3) lactate level less than 4.0 mmol/L and CRP level greater than 10.0 mg/dL, and (4) lactate level less than 4.0 mmol/L and CRP level less than or equal to 10.0 mg/dL (as reference), patients with both a lactate level greater than or equal to 4.0 mmol/L and CRP greater than 10 mg/dL had an increased risk of 28-day inpatient mortality (odds ratio 12.3; 95% CI 6.8 to 22.3).

CONCLUSION

In this cohort, patients with both an increased CRP level and hyperlactatemia had a higher mortality rate than patients with abnormalities of either laboratory test in isolation.

Disposition of [s]-heparin in the rat

[(35)S]-Heparin is rapidly taken up by tissues after intraperitoneal injection andrapidly degraded. Skin, aorta and lung showed an especially high affinity for[(35)S]-heparin. In these organs, as well as in adrenal gland, stomach, heart and brain,the isotope was found preponderantly as dialysable metabolite(s) of heparin. Another group of tissues (large intestine, fat, kidney and liver) was characterized by a smaller proportion of dialysable material. Tissues that showed a high affinity for exogenous heparin appeared to catabolize it rapidly. It is also noted that some of the radioactive material present in tissues after the injection of [(35)S]-heparin could come from the uptake of [(35)S]-sulphate resulting from the degradation of [(35)S]-heparin. The incorporation of [(35)S]-sulphate into the sulphomucopolysaccharides of some tissues is recorded.

Primary placement of a titanium motility post in a porous polyethylene orbital implant: animal model with quantitative assessment of fibrovascular ingrowth and vascular density

PURPOSE

To determine whether a Medpor porous polyethylene orbital implant, at the time of initial orbital implant surgery, will tolerate the insertion of a titanium screw on the anterior surface of the implant.

METHODS

Twelve New Zealand white rabbits were enucleated and implanted with a porous polyethylene orbital implant. At the time of enucleation, the porous polyethylene orbital implants were drilled, and titanium motility coupling posts were inserted. The motility coupling posts were inserted at two projection heights (2 or 4 mm) and either covered within Tenon capsule/conjunctiva (eight implants) or left exposed (four implants). Rabbits were killed at 6 or 12 weeks. Clinical tissue tolerance, histologic response to the motility coupling post, and vascular density of the porous polyethylene orbital implant were evaluated.

RESULTS

The motility coupling posts were well tolerated, and extrusion or migration of the motility coupling post did not occur. The average percentage cross-sectional area of the implant occupied by fibrovascular tissue at 6 and 12 weeks was 76.3% and 97.5%, respectively. In comparing the vascular density (number of vessels per square millimeter) in the porous polyethylene orbital implant within a 1-mm zone immediately surrounding the motility coupling post, no significant difference between this zone and the vascular density found within its entire corresponding annulus was found at either 6 or 12 weeks.

CONCLUSIONS

During the 6- and 12-week observation periods, all implanted motility coupling posts demonstrated favorable tissue tolerance and stable interfaces with surrounding tissues. The extent of fibrovascular tissue ingrowth and vascular density verify that initial screw insertion does not adversely affect the healing process after porous polyethylene orbital implant implantation. Thus, primary placement of the motility coupling post may obviate the need for a secondary surgical procedure.

Hypnosis and suggestion-based approaches to smoking cessation: an examination of the evidence

This article reviews 59 studies of hypnosis and smoking cessation as to whether the research empirically supports hypnosis as a treatment. Whereas hypnotic procedures generally yield higher rates of abstinence relative to wait-list and no-treatment conditions, hypnotic interventions are generally comparable to a variety of nonhypnotic treatments. The evidence for whether hypnosis yields outcomes superior to placebos is mixed. In short, hypnosis cannot be considered a specific and efficacious treatment for smoking cessation. Furthermore, in many cases, it is impossible to rule out cognitive/behavioral and educational interventions as the source of positive treatment gains associated with hypnotic treatments. Hypnosis cannot, as yet, be regarded as a well-established treatment for smoking cessation. Nevertheless, it seems justified to classify hypnosis as a "possibly efficacious" treatment for smoking cessation.

Hypnosis, context effects, and the recall of early autobiographical memories

This study found that attempts to recall earliest memories were strongly influenced by the testing context. It showed that a brief 3-minute self-hypnosis experience, coupled with the insinuation that hypnosis improves memory, resulted in earlier autobiographical memory reports (M = 29.5 months) than instructions for relaxation (M = 37.9 months) or counting/visualization (M = 48.9 months). Inquiries about earliest memories across 5 age ranges showed that the hypnotic context resulted in a higher proportion of participants reporting a memory at or before 12, 24, 36, 48, and 60 months of age. Nearly 40% of the "hypnotized" participants reported a memory for an event that reportedly occurred at or before 12 months of age. A brief discussion of context effects and demand characteristics associated with hypnosis and memory follows.

Removal of an infected silicone rod frontalis sling without recurrence of ptosis

We examined a child with congenital ptosis. She underwent a bilateral silicone rod frontalis sling operation. One of the slings became infected and necessitated removal. We noticed no recurrence of her ptosis after sling removal. Removal of a frontalis sling does not invariably lead to recurrence of ptosis. We hypothesize that a scar tract formed in the plane of tissue from which the sling was removed. This band of scar tissue can act as a frontalis sling to elevate the eyelid.

Hypnotizability, the dissociative experiences scale, HGSHS: A amnesia, and automatic writing: is there an association?

The present study examined whether participants (N = 112) selected on the basis of high and low dissociative ability (Dissociative Experiences Scale [DES]; Bernstein & Putnam, 1986), high and low/simulating hypnotizability (Harvard Group Scale of Hypnotic Susceptibility, Form A [HGSHS:A]; Shor & Orne, 1962), and past performance on the HGSHS:A amnesia item differentially passed an automatic writing suggestion administered during a follow-up experiment. Results from a loglinear analysis supported a single main effect for hypnotizability. Low hypnotizable, simulating participants were more than six times as likely to pass the automatic writing suggestion than high hypnotizable participants. Results found dissociation status and past performance on an ostensibly dissociative suggestion (i.e., amnesia) to be independent of passing the automatic writing suggestion. Findings are discussed in light of other research regarding the relation between the DES and hypnotizability.

"Normal pressure" pseudotumor cerebri

We present a case report of a patient with clinical features suggestive of pseudotumor cerebri (PTC), without a documented elevated measurement of intracranial pressure (ICP). Chart review was done of one patient's clinical course over a 28-month period. The patient was treated for PTC even though she never had a documented elevated ICP. Her signs and symptoms, including headache, disc edema, and visual field loss, all showed improvement with standard PTC therapy, which ultimately included optic nerve sheath fenestration (ONSF). Her presenting symptoms of clinical depression were also relieved with this treatment. PTC may present without an elevated ICP as defined by current standards. Some patients may be more susceptible to lower levels of ICP and develop this syndrome, and it may be responsive to standard PTC therapy. Further investigation may warrant that clinical depression be included as another minor symptom of PTC.

Lack of a precursor-product relationship between histamine and its metabolites in brain after histidine loading

Levels of histamine and its major metabolites in brain, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), were measured in rat brains up to 12 h after intraperitoneal administration of L-histidine (His), the precursor of histamine. Compared with saline-treated controls, mean levels of histamine were elevated at 1 h (+102%) after a 500 mg/kg dose; levels of t-MH did not increase. Following a 1,000 mg/kg dose, mean histamine levels were increased for up to 7 h, peaked at 3 h, and returned to control levels within 12 h. In contrast, levels of t-MH showed a small increase only after 3 h; levels of t-MIAA remained unchanged after either dose. Failure of most newly formed histamine to undergo methylation, its major route of metabolism in brain, suggested that histamine was metabolized by another mechanism possibly following nonspecific decarboxylation. To test this hypothesis, other rats were injected with alpha-fluoromethylhistidine (alpha-FMHis; 75 mg/kg, i.p.), an irreversible inhibitor of specific histidine decarboxylase. Six hours after rats received alpha-FMHis, the mean brain histamine level was reduced 30% compared with saline-treated controls. Rats given His (1,000 mg/kg) 3 h after alpha-FMHis (75 mg/kg) and examined 3 h later had a higher (+112%) mean level of histamine than rats given alpha-FMHis, followed by saline. Levels of t-MH and t-MIAA did not increase. These results imply that high doses of His distort the simple precursor-product relationship between histamine and its methylated metabolites in brain. The possibility that some His may undergo nonspecific decarboxylation in brain after His loading is discussed. These findings, and other actions of His independent of histamine, raise questions about the validity of using His loading as a specific probe of brain histaminergic function.

pros-Methylimidazoleacetic acid in cerebrospinal fluid of patients with chronic schizophrenia: relationships to ratings of symptoms, ventricular brain ratios, and rates of urine excretion

Concentrations of pros-methylimidazoleacetic acid (p-MIAA) were measured in cerebrospinal fluid of 30 patients with chronic schizophrenia. Levels of p-MIAA correlated negatively with mean scores of the Psychiatric Symptom Assessment Scale for positive symptoms (r = -0.48), but not negative symptoms, and with ventricular brain ratios (r = -0.48). Patients with abnormal ventricular enlargements had much lower concentrations of p-MIAA than those with normal ventricles. These results suggest that processes that reduce accumulation of p-MIAA in CSF may be associated with increased severity of symptoms among patients with chronic schizophrenia.

The relationship between urine excretion and biogenic amines and their metabolites in cerebrospinal fluid of schizophrenic patients

Concentrations of norepinephrine and metabolites of biogenic amines were measured in lumbar cerebrospinal fluid of 30 patients with chronic schizophrenia, nine of whom were polyuric. The mean level of norepinephrine was two-fold higher (p < or = 0.025) in polyuric patients than in patients whose excretion of urine was within the normal range. CSF levels of histamine's primary metabolite, tele-methylhistamine, an index of brain histaminergic activity, were positively correlated (p < 0.005) with daily urine volume. These results are consistent with the known influence of norepinephrine and histamine on fluid regulation and suggest that norepinephrine and histamine may be involved in psychogenic polydipsia-polyuria in schizophrenic patients.

Bone formation in hydroxyapatite orbital implants

PURPOSE

We examined the histopathologic features of two hydroxyapatite orbital implants that were removed from two patients.

METHODS

Two surgically removed hydroxyapatite orbital implants were decalcified and processed for routine light microscopic examination.

RESULTS

Both implants demonstrated fibrovascular ingrowth and foci of bone formation.

CONCLUSION

Bone may form in hydroxyapatite orbital implants.

Nasopharyngeal carcinoma. A study examining Asian patients treated in the United States

From 1972 to 1991, 126 Asian patients with nasopharyngeal carcinoma underwent definitive radiation therapy for locoregional disease: 86 men, 40 women. Median age was 50. All patients received external-beam irradiation with cobalt 60 or 4-18 MV x-rays. Local recurrence, regional recurrence, and distant metastases were 22%, 11%, and 23%, respectively. Local recurrence progressively increased with increasing T stage, but doses in those who recurred did not differ from the group as a whole. Regional recurrence was not associated with T or N stage or dose. Patients with N2 disease had the highest distant metastatic rate. The 5- and 10-year overall survival rates were 54% and 38%, respectively. Of age, gender, and histology, only age less than 50 was found to be favorably prognostic. No severe long-term complications were observed, and acute reactions were acceptable. Our survival results are comparable with results found both in Asia and North America. Nonetheless, altered fractionation techniques and/or other radiation modalities should be further explored to improve locoregional control.

Release of glutamate from striatum of freely moving rats by pros-methylimidazoleacetic acid

The effect of pros-methylimidazoleacetic acid (p-MIAA) was measured on the release of glutamate and aspartate from cerebral cortex, hippocampus, and striatum of freely moving rats, and on the uptake of 14C by striatal slices incubated in the presence of L-[14C]-glutamate. Twenty-four hours after implantation of a dialysis fiber, striatum, hippocampus, or cerebral cortex spontaneously released both glutamate and aspartate in the micromolar range. p-MIAA (1 microM to 1 mM), added to the dialysis perfusate, elicited a concentration-dependent increase of glutamate release from striatum with a maximal increase of about threefold. This effect did not occur in hippocampus or cortex. In none of these regions did p-MIAA increase aspartate release significantly. The p-MIAA effect was not mimicked by its isomer tele-methyl-imidazoleacetic acid. p-MIAA did not influence the uptake of glutamate by striatal slices. The glutamate-releasing action of p-MIAA may affect striatal function and explain the positive correlation between levels of p-MIAA in CSF and the severity of Parkinson's disease.

Histamine metabolites in cerebrospinal fluid of patients with chronic schizophrenia: their relationships to levels of other aminergic transmitters and ratings of symptoms

Levels of the histamine metabolites, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), and metabolites of other aminergic transmitters and of norepinephrine were measured in cerebrospinal fluid of 36 inpatients with chronic schizophrenia and eight controls. The mean t-MH level from controls was nearly identical to the levels seen previously in healthy volunteers. Compared with controls, the mean level of t-MH in the schizophrenic patients was 2.6-fold higher (p = 0.006); 21 of the patients had levels exceeding the range of controls. There was no significant difference (p > 0.05) in levels of other analytes, although the levels of t-MH correlated significantly with those of t-MIAA, homovanillic acid, 3,4-dihydroxyphenylacetic acid, norepinephrine, 3-methoxy-4-hydroxyphenylglycol and 5-hydroxyindoleacetic acid. The difference in levels of t-MH were not attributable to medication, since those taking (n = 10) or withdrawn from (n = 26) neuroleptic drugs had nearly the same mean levels of t-MH; each group had higher levels than controls (ANOVA: p < 0.05). Patients with or without tardive dyskinesia showed no significant differences in means of any analyte. Only levels of t-MH among those with schizophrenia correlated with positive symptom scores on the Psychiatric Symptom Assessment Scale (rs = 0.45, p < 0.02). The elevated levels of t-MH in cerebrospinal fluid, which represent histamine that was released and metabolized, suggest increased central histaminergic activity in patients with chronic schizophrenia.

Reasoning abilities in Psy.D. and Ph.D. clinical graduate students: a preliminary study

Clinical students in regionally representative Psy.D. and Ph.D. programs responded to a questionnaire that assessed everyday reasoning and psychological knowledge. Ph.D.s scored higher on the Methodology Reasoning test and the Conditional Probability test, while there were no differences on the Verbal or Statistical Reasoning tests or the Psychology questions. Calibration curves indicated that Psy.D.s tended to be somewhat more overconfident in their responses than Ph.D.s. Similarities and differences between the performance of the Psy.D.s and Ph.D.s are discussed, as well as the limitations and implications of the study.

Measurement of histamine metabolites in brain and cerebrospinal fluid provides insights into histaminergic activity

Measurements of the concentrations of histamine's metabolites, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), in brain have been used to evaluate histamine turnover in brains of animals, and the same measurements in CSF have been used to infer histaminergic activity in brains of man. In regions of rat brain, half-lives of histamine are shorter than those of dopamine, 5-hydroxytryptamine and norepinephrine. Studies of human CSF suggest that brain histaminergic activity increases with age and is higher in females than in males.

Clinical and research attitudes of Psy.D. and Ph.D. clinical graduate students

A survey of 137 Psy.D. and Ph.D. clinical graduate students out of 561 at 4 Ph.D. schools and 4 Psy.D. schools indicated that these Ph.D. students found knowledge of statistics and research design to be more useful than the 98 Psy.D. students. A need to replicate and to ascertain the basis for such differences was discussed.

Physicians practicing other occupations, especially literature

Literature has been the favored nonmedical pursuit of physicians probably because the practice of medicine is suffused with narratives, the patient's history being one. Arthur Conan Doyle regarded medicine as a "grim romance," Somerset Maugham as an opportunity to see "life in the raw," and William Carlos Williams treated "the patient as a work of art." These sentiments may be linked to humanistic medicine. At some medical schools, literature is taught in the context of and integrated with medicine in an attempt to enhance ethics and empathy which were explicitly expressed by some physician-writers.

Paralysis of downgaze in two patients with clinical-radiologic correlation

Selective downgaze paralysis was correlated with discrete bilateral lesions at the mesencephalic-diencephalic junction in a 9-year-old girl following severe pneumococcal meningitis, and in a 64-year-old man who suffered an embolic infarction. Magnetic resonance imaging demonstrated bilateral lesions in the region of the rostral interstitial nucleus of the medial longitudinal fasciculus. Clinical-radiologic correlation allowed identification of the likely vascular cause in both patients.

Pseudomemory in hypnotized and task-motivated subjects

Highly hypnotizable hypnotized (H; n = 16) and task-motivated (TM; n = 13) subjects received pseudomemory suggestions (see Orne, 1979). TM subjects reported being more awake and motivated than did H subjects and were more likely to pass the target noise suggestion. However, 69% of subjects in both conditions who passed the noise suggestion reported pseudomemories. Pseudomemory rate (for H subjects, 69% and for TM subjects, 46%) was not reduced by informing subjects that they could distinguish reality and fantasy in a state of deep concentration. At final inquiry, after deep concentration, pseudomemories remained stable (for H subjects, 75% and for TM subjects, 54%). As predicted, H subjects reported more unsuggested noises and more pseudomemories of novel noises than did TM subjects. Subjects who reported pseudomemories were more confident in the accuracy of their memories than were subjects who reported that the suggested noises were imagined.

Finding the hypnotic virtuoso--another look: a brief communication

Student volunteers who scored 9 (N = 20), 10 (N = 19), 11 (N = 26), and 12 (N = 15) on a live-administered Harvard Group Scale of Hypnotic Susceptibility (HGSHS:A) of Shor and E. Orne (1962) were retested with the individually administered Stanford Hypnotic Susceptibility Scale (SHSS:C) of Weitzenhoffer and Hilgard (1962). There appeared to be a break in HGSHS:A's predictive ability at 11 suggestions passed. Whereas a majority of Ss who passed at least 11 HGSHS:A suggestions retested in SHSS:C "virtuoso" range (i.e., passed at least 11 suggestions), a relatively small percentage of Ss who passed fewer than 11 HGSHS:A suggestions retested as SHSS:C virtuosos. These results are generally consistent with previous research (Register & Kihlstrom, 1986) using a standard taped-recorded HGSHS:A induction.

Pseudomemory in hypnotized and task-motivated subjects

Highly hypnotizable hypnotized (H; n = 16) and task-motivated (TM; n = 13) subjects received pseudomemory suggestions (see Orne, 1979). TM subjects reported being more awake and motivated than did H subjects and were more likely to pass the target noise suggestion. However, 69% of subjects in both conditions who passed the noise suggestion reported pseudomemories. Pseudomemory rate (for H subjects, 69% and for TM subjects, 46%) was not reduced by informing subjects that they could distinguish reality and fantasy in a state of deep concentration. At final inquiry, after deep concentration, pseudomemories remained stable (for H subjects, 75% and for TM subjects, 54%). As predicted, H subjects reported more unsuggested noises and more pseudomemories of novel noises than did TM subjects. Subjects who reported pseudomemories were more confident in the accuracy of their memories than were subjects who reported that the suggested noises were imagined.

Decreasing junk-food consumption through the use of self-management procedures: a case study

By using a self-management program, a 25-yr.-old white male was able to decrease the amount of junk food and beverage consumed while increasing the amount of healthier food and beverage ingested during evening snacks. This change was evident at 6 wk. and at a 6-mo. follow-up. Factors contributing to this success were discussed.

Levels of pros-methylimidazoleacetic acid: correlation with severity of Parkinson's disease in CSF of patients and with the depletion of striatal dopamine and its metabolites in MPTP-treated mice

The cerebrospinal fluid (CSF) levels of pros-methylimidazoleacetic acid (p-MIAA) in thirteen medication-free patients with mild to moderate Parkinson's disease were highly correlated (Spearman's rho = 0.749, p less than 0.005) with the severity of signs of the disease as scored on the Columbia University Rating Scale. Levels of p-MIAA in males (n = 8) and females (n = 5) were each significantly correlated with scores of severity (rho = 0.78, p less than 0.05 and rho = 1.0, p less than 0.05, respectively). In C57BL/6 mice treated with 1-methyl-4-phenyl-1,2,3,6-tetra-hydropyridine (MPTP), levels of p-MIAA were significantly correlated with the depleted levels of dopamine (r = 0.85, p less than 0.01), homovanillic acid (r = 0.79, p less than 0.02), 3,4-dihydroxyphenylacetic acid (r = 0.84, p less than 0.01) and norepinephrine (r = 0.91, p less than 0.002) in striatum, but not in cortex of the same mice. No such correlations were observed in either striatum or cortex of saline-treated control mice. Mean levels of p-MIAA in CSF did not differ significantly between patients and age-matched controls; and mean levels of p-MIAA in striatum did not differ between MPTP-treated mice and controls. The simplest hypothesis to account for these strong correlations in the absence of differences in mean levels of p-MIAA is that accumulation of p-MIAA [or process(es) that govern its accumulation] influences a failing nigrostriatal system. It is also possible (in analogy with findings in other diseases and with other drugs) that measurements of the putative metabolite(s) of p-MIAA may distinguish the patients and the MPTP-treated mice from their respective controls. Elucidation of the processes that regulate formation and disposition of p-MIAA in brain and information on the neural effects of p-MIAA, its precursors and its putative metabolites may yield insight into factors that regulate the progression of Parkinson's disease, and may shed additional light on the cause(s) of this disease.

Influence of age and gender on the levels of histamine metabolites and pros-methylimidazoleacetic acid in human cerebrospinal fluid

The metabolites of histamine, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), were measured in cerebrospinal fluid (CSF) from 47 subjects with neurological disorders and healthy controls. In lumbar CSF, concentrations of these metabolites were significantly correlated. Levels of t-MH, t-MIAA and their sum (which represents virtually all histamine metabolized in brain) were significantly higher in CSF from older subjects and were positively correlated with age. Females had higher levels of histamine metabolites than males. Males had higher levels of pros-methylimidazoleacetic acid (p-MIAA), an isomer of t-MIAA that is not a metabolite of histamine. Levels of p-MIAA increased with age among men. Analysis of covariance indicated that the subjects' health status had little or no effect on age- or sex-related differences in levels of analytes in CSF; sex-related differences were independent of changes attributed to age. These results are in contrast to those of age-related effects on levels of other aminergic transmitter metabolites in CSF and suggest that metabolic activity of histamine in brain may increase with age.

Serotonergic modulation of the release of endogenous norepinephrine from rat hypothalamic slices

Ca+(+)-dependent release of endogenous norepinephrine (NE) and dopamine from superfused rat hypothalamic slices was stimulated by 40 mM K+. 20 mM K+ released only NE. Two consecutive exposures to 20 mM K+ (S1 and S2, respectively) produced NE release of similar magnitude (S2/S1 = 1.03 +/- 0.08). Serotonin (5-HT), 3 to 10 microM, in the presence of methylsergide or ritanserin (antagonists at 5-HT1-like and 5-HT2 receptors), caused a concentration-dependent decrease of K(+)-evoked NE release. 5-HT alone did not alter K(+)-evoked NE release. 2-Methyl-serotonin, 2-methyl-5-hydroxytryptamine, 3 to 10 microM (a selective 5-HT3 agonist), mimicked the 5-HT response in the presence and in the absence of ritanserin. A highly selective 5-HT3 antagonist, (3 alpha-tropanyl)1H-indole-3-carboxylic acid ester (ICS 205-930), 1 nM, inhibited the effect of both agonists. The isomers of another highly selective 5-HT3 antagonist, zacopride, inhibited the effect of 2-methyl-serotonin, 2-methyl-5-hydroxytryptamine, at a concentration range, 0.03 to 20 nM, characteristic of their interaction with 5-HT3 receptors. alpha-Methyl-serotonin, alpha-methyl-5-hydroxytryptamine, a selective 5-HT1-like/5-HT2 agonist, failed to affect the K(+)-evoked NE release, but antagonized the effect of 2-methyl-serotonin, 2-methyl-5-hydroxytryptamine. These observations provide direct evidence that, in rat hypothalamus, 5-HT modulates release of endogenous NE through activation of 5-HT3 and, possibly, 5-HT1C receptors.

Histamine metabolites and pros-methylimidazoleacetic acid in human cerebrospinal fluid

In cerebrospinal fluid, levels of the histamine metabolites, tele-methylhistamine and tele-methylimidazole-acetic acid, were higher in elderly than in young people, and women had higher levels than men. Therefore, age and gender should be considered in studies of histamine metabolites as exemplified by their measurements in cerebrospinal fluid of patients with Huntington's disease. Levels of pros-methylimidazoleacetic acid, an isomer of tele-methylimidazoleacetic acid and not a metabolite of histamine, were higher in cerebrospinal fluid of men than of women. Levels of pros-methylimidazoleacetic acid in cerebrospinal fluid were highly positively correlated with the severity of Parkinson's disease in a group of non-medicated, mildly to moderately affected patients.

Literalism and hypnosis: hypnotic versus task-motivated subjects

To extend previous literalism research with hypnotized and simulating subjects, we compared literalism rates of hypnotized, highly hypnotizable subjects (N = 12) with nonhypnotized, task-motivated subjects (N = 12) who were also highly hypnotizable. Six questions of the type used by Erickson (e.g., "Do you mind telling me your name?") constituted tests of literalism (scored if response is "Yes" or "No," either verbally or nonverbally). Whereas Erickson claimed that 97% of his "deep trance" subjects and 90% of his "medium trance" subjects exhibited literal responses, we found that 87.5% of hypnotized, high-hypnotizable subjects' responses were nonliteral. Hypnotized and task-motivated subjects did not differ in their literal responding to the individual questions or when their scores were summed across questions. No support was secured for Erickson's assertion that literalism is a cardinal feature of hypnosis.

Influence of age and gender on the levels of histamine metabolites and pros-methylimidazoleacetic acid in human cerebrospinal fluid

The metabolites of histamine, tele-methylhistamine (t-MH) and tele-methylimidazoleacetic acid (t-MIAA), were measured in cerebrospinal fluid (CSF) from 47 subjects with neurological disorders and healthy controls. In lumbar CSF, concentrations of these metabolites were significantly correlated. Levels of t-MH, t-MIAA and their sum (which represents virtually all histamine metabolized in brain) were significantly higher in CSF from older subjects and were positively correlated with age. Females had higher levels of histamine metabolites than males. Males had higher levels of pros-methylimidazoleacetic acid (p-MIAA), an isomer of t-MIAA that is not a metabolite of histamine. Levels of p-MIAA increased with age among men. These results are in contrast to those of age-related effects on levels of other aminergic transmitter metabolites in CSF and suggest that metabolic activity of histamine in brain may increase with age.

Literalism as a marker of hypnotic "trance": disconfirming evidence

The responses given by highly hypnotizable, hypnotic subjects and those of unhypnotizable subjects who simulated hypnosis to questions of the type, "Do you mind telling me your name?" and "Do you mind standing up?" were contrasted. The purpose was to examine Erickson's (1980) assertion that literalism (answering "yes" or "no" verbally or nonverbally without any cognitive elaboration) is a marker of hypnotic "trance." Simulators exhibited a greater rate of literalism than hypnotic "virtuosos" (i.e., extreme scorers on both group and individual hypnotizability measures). Hypnotized subjects and nonhypnotized subjects approached in the campus library responded comparably. Because less than a third of hypnotic virtuosos responded literally, our results strongly refuted Erickson's assertion that literalism is a cognitive feature of hypnosis.

Pharmacological receptors: the need for a compendium of classification, nomenclature and structure

In an attempt to contain the chaos of receptor nomenclature, the supplement distributed with this issue of TiPS catalogues cell surface receptors and their subtypes according to the most commonly used nomenclature and describes them in pharmacological, biochemical and molecular terms. This reporting of the status quo will be an invaluable aid to communication, but all scientists (not just pharmacologists) working on receptors would agree that a radical and rational classification of receptors also needs to be initiated. In this article, Jack Peter Green proposes a system of (and mechanism for) classification that should satisfy both the 'taxonomic realists' and the 'taxonomic skeptics'.

Literalism as a marker of hypnotic "trance": Disconfirming evidence

The responses given by highly hypnotizable, hypnotic subjects and those of unhypnotizable subjects who simulated hypnosis to questions of the type, "Do you mind telling me your name?" and "Do you mind standing up?" were contrasted. The purpose was to examine Erickson's (1980) assertion that literalism (answering "yes" or "no" verbally or nonverbally without any cognitive elaboration) is a marker of hypnotic "trance." Simulators exhibited a greater rate of literalism than hypnotic "virtuosos" (i.e., extreme scorers on both group and individual hypnotizability measures). Hypnotized subjects and nonhypnotized subjects approached in the campus library responded comparably. Because less than a third of hypnotic virtuosos responded literally, our results strongly refuted Erickson's assertion that literalism is a cognitive feature of hypnosis.

Release of endogenous dopamine by stimulation of 5-hydroxytryptamine3 receptors in rat striatum

5-Hydroxytryptamine (5-HT) caused a persistent, concentration-dependent increase of spontaneous release of endogenous dopamine (DA) from superfused rat striatal slices. 2-Methyl-5-HT, a selective 5-HT3 agonist, mimicked the 5-HT response with a potency only slightly less than that of 5-HT. A highly selective 5-HT3 antagonist, ICS 205-930 [(3-alpha-tropanyl)1H-indole-3-carboxylic acid ester], inhibited the effect of both agonists with a pKB value characteristic of 5-HT3 receptors. 5-HT-evoked DA release was resistant to antagonism by methiothepin and methysergide, antagonists at 5-HT 1-like and 5-HT2 receptors. Neither (2,5-dimethoxy-4-iodophenyl)-2-aminopropane, the selective 5-HT2 receptor agonist, nor 5-carboxamidotryptamine, the selective 5-HT 1-like receptor agonist, altered DA release. The release of DA by 5-HT3 stimulation was Ca++-dependent and partially sensitive to tetrodotoxin. 5-HT and 2-methyl-5-HT also increased K+-evoked DA release. These observations constitute direct, unambiguous evidence that in rat striatum 5-HT3 receptors modulate release of DA.