Longitudinal Strain Patterns in Stress (Takotsubo) Cardiomyopathy: Evidence of Global Myocardial Injury and Incomplete Recovery

Stress cardiomyopathy develops after abrupt sympathetic stimulation, likely from catecholamine-induced myocardial toxicity. The evolution of myocardial strain during and after an episode have not been previously characterized. We aimed to determine whether preexisting contractile abnormalities may explain the observed regional dysfunction during an acute episode and to investigate the persistence of strain abnormalities after clinical recovery. We identified patients who were diagnosed with stress cardiomyopathy and had an echocardiogram performed before their episode, during their episode, and within 1 year after. The diagnosis was confirmed based on the absence of obstructive coronary lesions. Left ventricular (LV) longitudinal strain was calculated using speckle-tracking software and compared between baseline, episode, and follow-up echocardiograms. The LV strain analysis was performed on 23 patients. The LV ejection fraction was 64 ± 8.7% at baseline, 45 ± 12% during the episode, and 5 9 ± 10% after a median follow-up of 46 days. The LV global longitudinal strain was 24 ± 4.7% at baseline, 11 ± 4.9% during the episode, and 19 ± 4.6% after the follow-up. The mean ejection fraction (p <0.01) and global longitudinal strain (p <0.001) remained below baseline levels at follow-up. Longitudinal strain was reduced (<18%) in 80 ± 23% of myocardial segments during an episode and 41 ± 21% of myocardial segments at follow-up. During the acute episode, 35 ± 6% of the abnormal segments were in the base, outside of the region of ballooning. Our findings suggests that stress cardiomyopathy is associated with global rather than regional myocardial injury and that contractile abnormalities persist after clinical improvement. These findings challenge our previous understanding of stress cardiomyopathy and may guide future pathophysiologic understanding of this complex disease.

An Assessment of Carotid Flow Time Using a Portable Handheld Ultrasound Device: The Ideal Tool for Guiding Intraoperative Fluid Management?

Volume resuscitation is a cornerstone of modern anesthesia care. Finding the right balance to avoid inadequate or excess volume administration is often difficult to clinically discern and can lead to negative consequences. Pulse pressure variation is often intraoperatively used to guide volume resuscitation; however, this requires an invasive arterial line and is generally only applicable to patients who are mechanically ventilated. Unfortunately, without a pulmonary artery catheter or another costly noninvasive device, performing serial measurements of cardiac output is challenging, time-consuming, and often impractical. Furthermore, noninvasive measures such as LVOT VTI require significant technical expertise as well as access to the chest, which may not be practical during and after surgery. Other noninvasive techniques such as bioreactance and esophageal Doppler require the use of costly single-use sensors. Here, we present a case report on the use of corrected carotid flow time (ccFT) from a portable, handheld ultrasound device as a practical, noninvasive, and technically straightforward method to assess fluid responsiveness in the perioperative period, as well as the inpatient and outpatient settings.

Portable Handheld Point-of-Care Ultrasound for Detecting Unrecognized Esophageal Intubations

Esophageal intubations are not an uncommon occurrence in prehospital settings, occurring as high as 17%. These "never events" are associated with significant morbidity and mortality especially when unrecognized or when there is delayed recognition. Here, we review the currently available techniques for confirming endotracheal tube intubation and their limitations, and present the case for the application of portable handheld point-of-care ultrasound as an emerging technology for detection of potentially unrecognized esophageal intubations such as during cardiac arrest. We also provide algorithms for confirmation of tracheal intubation.

Lag times to steady state drug delivery by continuous intravenous infusion: direct comparison of peristaltic and syringe pump performance identifies contributions from infusion system dead volume and pump startup characteristics

Time lags between the initiation of a continuous drug infusion and achievement of a steady state delivery rate present an important safety concern. At least 3 factors contribute to these time lags: (1) dead volume size, (2) the ratio between total system flow and dead volume, and (3) startup delay. While clinicians employ both peristaltic pumps and syringe pumps to propel infusions, there has been no head-to-head comparison of drug delivery between commercially available infusion pumps with these distinct propulsion mechanisms. We quantified the delivery of a model drug by peristaltic and syringe pumps at clinically relevant flow rates using spectrophotometric absorbance. Delivery curves were modeled and compared, and the time required to reach 5% (T5), 50% (T50), and 95% (T95) of the intended delivery rate was reported. The ability to overcome the combined effects of startup delay and dead volume differed between syringe and peristaltic pumps. T5, T50, and T95 were shorter for the peristaltic pump at higher flow rates. T50 and T95 were shorter for the syringe pump at lower flow rates. The ability to overcome the effects of dead volume was overall similar between the syringe and peristaltic pumps, as was the response to consecutive changes in drug infusion rates. Startup delay and dead volume in carrier-based infusion systems cause substantial time lags to reaching intended delivery rates. Peristaltic and syringe pumps are similarly susceptible to dead volume effects. Startup performance differed between peristaltic and syringe pumps; their relative performance may be dependent on flow rate.

Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia

BACKGROUND

Inhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19).

METHODS

This is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients.

RESULTS

Twenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred. In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4-8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up.

CONCLUSIONS

In spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.

Right Ventricular Strain Is Common in Intubated COVID-19 Patients and Does Not Reflect Severity of Respiratory Illness

BACKGROUND

Right ventricular (RV) dysfunction is common and associated with worse outcomes in patients with coronavirus disease 2019 (COVID-19). In non-COVID-19 acute respiratory distress syndrome, RV dysfunction develops due to pulmonary hypoxic vasoconstriction, inflammation, and alveolar overdistension or atelectasis. Although similar pathogenic mechanisms may induce RV dysfunction in COVID-19, other COVID-19-specific pathology, such as pulmonary endothelialitis, thrombosis, or myocarditis, may also affect RV function. We quantified RV dysfunction by echocardiographic strain analysis and investigated its correlation with disease severity, ventilatory parameters, biomarkers, and imaging findings in critically ill COVID-19 patients.

METHODS

We determined RV free wall longitudinal strain (FWLS) in 32 patients receiving mechanical ventilation for COVID-19-associated respiratory failure. Demographics, comorbid conditions, ventilatory parameters, medications, and laboratory findings were extracted from the medical record. Chest imaging was assessed to determine the severity of lung disease and the presence of pulmonary embolism.

RESULTS

Abnormal FWLS was present in 66% of mechanically ventilated COVID-19 patients and was associated with higher lung compliance (39.6 vs 29.4 mL/cmH2O, P = 0.016), lower airway plateau pressures (21 vs 24 cmH2O, P = 0.043), lower tidal volume ventilation (5.74 vs 6.17 cc/kg, P = 0.031), and reduced left ventricular function. FWLS correlated negatively with age (r = -0.414, P = 0.018) and with serum troponin (r = 0.402, P = 0.034). Patients with abnormal RV strain did not exhibit decreased oxygenation or increased disease severity based on inflammatory markers, vasopressor requirements, or chest imaging findings.

CONCLUSIONS

RV dysfunction is common among critically ill COVID-19 patients and is not related to abnormal lung mechanics or ventilatory pressures. Instead, patients with abnormal FWLS had more favorable lung compliance. RV dysfunction may be secondary to diffuse intravascular micro- and macro-thrombosis or direct myocardial damage.

TRIAL REGISTRATION

National Institutes of Health #NCT04306393. Registered 10 March 2020, https://clinicaltrials.gov/ct2/show/NCT04306393.

The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials

Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.

Multisystem effects of COVID-19: a concise review for practitioners

While COVID-19 has primarily been characterized by the respiratory impact of viral pneumonia, it affects every organ system and carries a high consequent risk of death in critically ill patients. Higher sequential organ failure assessment (SOFA) scores have been associated with increased mortality in patients critically ill patients with COVID-19. It is important that clinicians managing critically ill COVID-19 patients be aware of the multisystem impact of the disease so that care can be focused on the prevention of end-organ injuries to potentially improve clinical outcomes. We review the multisystem complications of COVID-19 and associated treatment strategies to improve the care of critically ill COVID-19 patients.

Ensuring competency in focused cardiac ultrasound: a systematic review of training programs

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS.

METHODS

Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study.

RESULTS

Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time.

CONCLUSION

A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.

Sodium-glucose cotransporter-2 (SGLT2) inhibitor-induced euglycemic diabetic ketoacidosis complicating the perioperative management of a patient with type 2 diabetes mellitus (T2DM) and Fournier's gangrene: A case report

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This case highlights two serious side effects of empagliflozin occurring concurrently. Those being diabetic ketoacidosis and Fournier’s gangrene.

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Diabetic ketoacidosis is an important cause of perioperative high anion gap metabolic acidosis in the context of SGLT2 inhibitors and needs to be carefully managed.

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SGLT2 inhibitors should be held up to 48 h prior to surgery to minimize the risk of diabetic ketoacidosis perioperatively.

Introduction

Sodium glucose cotransporter-2 inhibitors (SGLT2) are an increasingly administered class of medication used to lower blood glucose levels in patients with type 2 diabetes mellitus. Diabetic ketoacidosis (DKA) and Fournier’s gangrene are rare, but potentially catastrophic side effects of SGLT2 inhibitors. This manuscript reports a case of both DKA and Fournier’s gangrene in the context of SGLT2 inhibitor use.

Presentation of case

A 51-year-old morbidly obese man with hypertension and poorly controlled Type 2 Diabetes Mellitus presented to the emergency department with a clinical presentation consistent with Fournier’s gangrene. He was promptly taken to the operating room by the urology team where he had extensive debridement of the perineum and abdomen. Intra-operatively he was found to have DKA, which was managed appropriately. The acidosis and Fournier’s gangrene were deemed a likely side effect of SGLT2 inhibitor use. After a thirty-day hospital admission, the patient was discharged to a rehabilitation facility where he is progressing well. His SGLT2 inhibitor was discontinued upon admission to hospital.

Discussion

Perioperative providers should have a high index of suspicion for diabetic ketoacidosis (DKA) and Fournier’s gangrene in patients prescribed SGLT2 inhibitors. Prompt treatment of DKA through correction of underlying triggers, aggressive fluid resuscitation, insulin to close the anion gap, and appropriate potassium repletion is vital to optimize patient outcomes.

Conclusion

The use of SGLT2 inhibitors among surgical populations is increasing. This case highlights the importance of being aware of the mechanism and side effects of SGLT2 inhibitors, and the management of DKA.

Variants of Takotsubo syndrome in the perioperative period: A review of potential mechanisms and anaesthetic implications

Takotsubo syndrome (TS) is a condition of transient cardiac dysfunction that develops in the setting of abrupt sympathetic stimulation. Although classically identified by ballooning of the apical segment, TS can also present in atypical forms with abnormalities of the basal, mid-ventricular, or other focal segments. In the perioperative setting, anaesthetic effects and physiologic perturbations from surgery can further confound the diagnosis. We present a narrative review of the most recent evidence for underlying pathophysiologic mechanisms of the variable ballooning patterns and highlight important anaesthetic considerations in the diagnosis and management of these patients.

Application of Lung Ultrasound During the COVID-19 Pandemic: A Narrative Review

This review highlights the ultrasound findings reported from a number of studies and case reports and discusses the unifying findings from coronavirus disease (COVID-19) patients and from the avian (H7N9) and H1N1 influenza epidemics. We discuss the potential role for portable point-of-care ultrasound (PPOCUS) as a safe and effective bedside option in the initial evaluation, management, and monitoring of disease progression in patients with confirmed or suspected COVID-19 infection.

Comparison of Invasive and Noninvasive Blood Pressure Measurements for Assessing Signal Complexity and Surgical Risk in Cardiac Surgical Patients

BACKGROUND

Continuous arterial blood pressure (ABP) is typically recorded by placement of an intraarterial catheter. Recently, noninvasive ABP monitors have been shown to be comparable in accuracy to invasive measurements. In a previous study, we showed that the fluctuations in beat-to-beat ABP measurements were not random variations but had a complex dynamical structure, and that ABP dynamical complexity was inversely associated with surgical risk estimated using the Society of Thoracic Surgeons (STS) index. Dynamical complexity is a mathematical construct that reflects the capacity of a physiological system to adapt to stimuli. The objectives of present study were to: (1) determine whether noninvasive beat-to-beat ABP measurements also exhibit a complex temporal structure; (2) compare the complexity of noninvasive versus invasive ABP time series; and (3) quantify the relationship between the complexity of noninvasive ABP time series and the STS risk scores.

METHODS

Fifteen adult patients undergoing coronary artery bypass graft, valve, or combined coronary artery bypass graft/valve surgery were enrolled in this observational study. Preoperative ABP waveforms were simultaneously recorded for ≥15 minutes using a radial artery catheter (invasive) and a continuous noninvasive arterial pressure monitor. Beat-to-beat systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP), and mean arterial pressure (MAP) time series were extracted from the continuous waveforms. Complexity was assessed using the multiscale entropy method. The Wilcoxon signed-rank test was used to compare the mean ranks of indices derived from invasive versus noninvasive ABP time series. Spearman correlation coefficients were used to quantify the relationship between invasive and noninvasive indices. Linear regression analysis was used to quantify the association between each of the complexity indices and the STS risk scores.

RESULTS

Beat-to-beat fluctuations in noninvasive ABP measurements were not random but complex; however, their degree of complexity was lower than that of fluctuations in invasively obtained ABP signals (SBP: 7.05 vs 8.66, P < .001; DBP: 7.40 vs 8.41, P < .001; PP: 6.83 vs 8.82, P < .001; and MAP: 7.17 vs 8.68, P < .005). Invasive and noninvasive indices for MSEΣ·slope showed good correlation (rs) (0.53 for SBP, 0.79 for DBP, 0.42 for PP, 0.60 for MAP). The complexity of noninvasive ABP time series (-0.70 [-1.28 to -0.11]; P = .023 for DBP), like that of invasive time series (-0.94 [-1.52 to -0.35]; P = .004 for DBP), was inversely associated with estimated surgical risk in patients undergoing cardiovascular operations.

CONCLUSIONS

Our results support the use of noninvasive ABP monitoring in computations of complexity-based indices that correlate with estimated surgical risk.

In-hospital airway management of COVID-19 patients

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.

Measuring energy, macro and micronutrient intake in UK children and adolescents: a comparison of validated dietary assessment tools

Background

Measuring dietary intake in children and adolescents can be challenging due to misreporting, difficulties in establishing portion size and reliance on recording dietary data via proxy reporters. The aim of this review was to present results from a recent systematic review of reviews reporting and comparing validated dietary assessment tools used in younger populations in the UK.

Methods

Validation data for dietary assessment tools used in younger populations (≤18 years) were extracted and summarised using results from a systematic review of reviews of validated dietary assessment tools. Mean differences and Bland-Altman limits of agreement (LOA) between the test and reference tool were extracted or calculated and compared for energy, macronutrients and micronutrients.

Results

Seventeen studies which reported validation of 14 dietary assessment tools (DATs) were identified with relevant nutrition information. The most commonly validated nutrients were energy, carbohydrate, protein, fat, calcium, iron, folate and vitamin C. There were no validated DATs reporting assessment of zinc, iodine or selenium intake. The most frequently used reference method was the weighed food diary, followed by doubly labelled water and 24 h recall. Summary plots were created to facilitate comparison between tools. On average, the test tools reported higher mean intakes than the reference methods with some studies consistently reporting wide LOA. Out of the 14 DATs, absolute values for LOA and mean difference were obtained for 11 DATs for EI. From the 24 validation results assessing EI, 16 (67%) reported higher mean intakes than the reference. Of the seven (29%) validation studies using doubly labelled water (DLW) as the reference, results for the test DATs were not substantially better or worse than those using other reference measures. Further information on the studies from this review is available on the www.nutritools.org website.

Conclusions

Validated dietary assessment tools for use with children and adolescents in the UK have been identified and compared. Whilst tools are generally validated for macronutrient intakes, micronutrients are poorly evaluated. Validation studies that include estimates of zinc, selenium, dietary fibre, sugars and sodium are needed.

A systematic review of reviews identifying UK validated dietary assessment tools for inclusion on an interactive guided website for researchers: www.nutritools.org

Background: Health researchers may struggle to choose suitable validated dietary assessment tools (DATs) for their target population. The aim of this review was to identify and collate information on validated UK DATs and validation studies for inclusion on a website to support researchers to choose appropriate DATs.Design: A systematic review of reviews of DATs was undertaken. DATs validated in UK populations were extracted from the studies identified. A searchable website was designed to display these data. Additionally, mean differences and limits of agreement between test and comparison methods were summarized by a method, weighting by sample size.Results: Over 900 validation results covering 5 life stages, 18 nutrients, 6 dietary assessment methods, and 9 validation method types were extracted from 63 validated DATs which were identified from 68 reviews. These were incorporated into www.nutritools.org. Limits of agreement were determined for about half of validations. Thirty four DATs were FFQs. Only 17 DATs were validated against biomarkers, and only 19 DATs were validated in infant/children/adolescents.Conclusions: The interactive www.nutritools.org website holds extensive validation data identified from this review and can be used to guide researchers to critically compare and choose a suitable DAT for their research question, leading to improvement of nutritional epidemiology research.

Differential expression of interferon-induced genes and other tissue-based biomarkers in acute graft-versus-host disease vs. lupus erythematosus in skin

BACKGROUND

In both acute graft-versus-host disease (GVHD) and lupus erythematosus (LE), the patient's own tissues are subjected to immunological assault via complex mechanisms influenced by interferon (IFN) and other cytokines. Although not typically confused clinically, these entities have overlapping histopathological findings in the skin.

AIM

To assess whether GVHD can be differentiated from LE using molecular methods on skin specimens.

METHODS

We developed a quantitative reverse transcription PCR assay based on previously identified tissue-based biomarkers of cutaneous GVHD, and compared gene expression in GVHD with that in LE.

RESULTS

Both entities showed robust expression of IFN-induced genes and of genes encoding proteins involved in antigen presentation, cell signalling and tissue repair. Levels of gene expression differed significantly in GVHD compared with LE, particularly those of IFN-induced genes such as MX1, OAS3, TAP1 and STAT3 (P < 0.01). Three logistic regression models could differentiate the two entities with a high degree of certainty (receiver operating characteristic area under the curve of 1.0).

CONCLUSION

The study demonstrates the feasibility of distinguishing between microscopically similar inflammatory dermatoses using tissue-based molecular techniques.

Attentional biases and trauma status: Do psychotic-like experiences matter?

OBJECTIVE

In a large undergraduate sample, we explored whether attentional biases were similar between individuals reporting positive psychotic-like experiences (PLEs) with a history of traumatic life events (TLEs) compared with individuals with a TLE history alone.

METHOD

Participants completed the Emotional Stroop Task, and self-report questionnaires of TLEs and PLEs.

RESULTS

Although reaction time (RT) to physical, sexual, emotional, and overall trauma words was associated with TLEs, only RT to physical abuse and overall trauma words remained significantly associated with TLE status after controlling for age, race, and neutral word RT. Contrary to our hypotheses, PLEs were not associated with RT to TLE words and there were no significant interactions between TLE history and PLEs on RT to TLE-salient stimuli.

CONCLUSION

Findings suggest that psychosis risk alone does not appear to exacerbate attentional biases and that TLE history may exert similar influence on attention regardless of psychosis risk. In conclusion, phenotypes associated with TLEs may be similar in populations potentially at risk for psychosis. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Characterization of Plasmodium Lactate Dehydrogenase and Histidine-Rich Protein 2 Clearance Patterns via Rapid On-Bead Detection from a Single Dried Blood Spot

A rapid, on-bead enzyme-linked immunosorbent assay for Plasmodium lactate dehydrogenase (pLDH) and Plasmodium falciparum histidine-rich protein 2 (HRP2) was adapted for use with dried blood spot (DBS) samples. This assay detected both biomarkers from a single DBS sample with only 45 minutes of total incubation time and detection limits of 600 ± 500 pM (pLDH) and 69 ± 30 pM (HRP2), corresponding to 150 and 24 parasites/μL, respectively. This sensitive and reproducible on-bead detection method was used to quantify pLDH and HRP2 in patient DBS samples from rural Zambia collected at multiple time points after treatment. Biomarker clearance patterns relative to parasite clearance were determined; pLDH clearance followed closely with parasite clearance, whereas most patients maintained detectable levels of HRP2 for 35–52 days after treatment. Furthermore, weak-to-moderate correlations between biomarker concentration and parasite densities were found for both biomarkers. This work demonstrates the utility of the developed assay for epidemiological study and surveillance of malaria.

Plasmodium falciparum HRP2 ELISA for analysis of dried blood spot samples in rural Zambia

Background

Dried blood spots are commonly used for sample collection in clinical and non-clinical settings. This method is simple, and biomolecules in the samples remain stable for months at room temperature. In the field, blood samples for the study and diagnosis of malaria are often collected on dried blood spot cards, so development of a biomarker extraction and analysis method is needed.

Methods

A simple extraction procedure for the malarial biomarker Plasmodium falciparum histidine-rich protein 2 (HRP2) from dried blood spots was optimized to achieve maximum extraction efficiency. This method was used to assess the stability of HRP2 in dried blood spots. Furthermore, 328 patient samples made available from rural Zambia were analysed for HRP2 using the developed method. These samples were collected at the initial administration of artemisinin-based combination therapy and at several points following treatment.

Results

An average extraction efficiency of 70% HRP2 with a low picomolar detection limit was achieved. In specific storage conditions HRP2 was found to be stable in dried blood spots for at least 6 months. Analysis of patient samples showed the method to have a sensitivity of 94% and a specificity of 89% when compared with microscopy, and trends in HRP2 clearance after treatment were observed.

Conclusions

The dried blood spot ELISA for HRP2 was found to be sensitive, specific and accurate. The method was effectively used to assess biomarker clearance characteristics in patient samples, which prove it to be ideal for gaining further insight into the disease and epidemiological applications.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-017-1996-4) contains supplementary material, which is available to authorized users.

The association between traumatic life events and psychological symptoms from a conservative, transdiagnostic perspective

Exposure to traumatic life events (TLEs) is strongly linked to the onset and exacerbation of an array of psychological sequelae. While studies yield minimal evidence of specificity for one disorder emerging in the aftermath of TLEs versus another, most studies do not adopt a conservative approach in controlling for multiple psychological symptoms linked to TLEs. The present study explored the association between TLEs and eight psychological constructs before and after adjusting for concurrent symptomatology in a diverse sample of 2342 undergraduates. We predicted three symptom domains would withstand conservative adjustments in their relationship to TLEs: posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and attenuated positive psychotic symptoms (APPS). Results indicated that exposure to at least one TLE, but especially four or more TLEs, was significantly associated with PTSD and BPD symptoms even after controlling for concurrent symptoms. Additionally, the association between four or more TLEs and APPS persisted despite adjusting for covariates. Findings underscore the critical role that TLE histories play in posttraumatic stress, borderline personality, and attenuated psychotic symptom expression. The relationship between TLEs and depression, cannabis and other drug use, generalized anxiety, and social anxiety disappeared after adjusting for comorbid symptoms.

Coping as a mediator of stress and psychotic-like experiences

BACKGROUND

There is evidence that individuals along the whole psychosis continuum have increased responsiveness to stress; however, coping responses to stressors have not been extensively explored in subthreshold psychotic symptoms.

METHODS

In 454 undergraduates, psychotic-like experiences (PLEs) were evaluated using the positive items of the Prodromal Questionnaire. Perceived stress and traumatic life events were assessed using the Life Events Checklist and Perceived Stress Scale, and coping was measured using the Brief COPE. We also examined whether different coping styles mediated the relationship between perceived stress and PLEs, as well as whether different coping styles mediated the relationship between traumatic life events and PLEs.

RESULTS

Both number of traumatic life events and current level of perceived stress were significantly associated with PLEs. These relationships were both mediated by higher levels of maladaptive coping.

CONCLUSIONS

Results have the potential to inform treatment strategies, as well as inform targets for exploration in longitudinal studies of those at risk for psychosis.

Magnetically-enabled biomarker extraction and delivery system: towards integrated ASSURED diagnostic tools

Diagnosis of asymptomatic malaria poses a great challenge to global disease elimination efforts. Healthcare infrastructure in rural settings cannot support existing state-of-the-art tools necessary to diagnose asymptomatic malaria infections. Instead, lateral flow immunoassays (LFAs) are widely used as a diagnostic tool in malaria endemic areas. While LFAs are simple and easy to use, they are unable to detect low levels of parasite infection. We have developed a field deployable Magnetically-enabled Biomarker Extraction And Delivery System (mBEADS) that significantly improves limits of detection for several commercially available LFAs. Integration of mBEADS with leading commercial Plasmodium falciparum malaria LFAs improves detection limits to encompass an estimated 95% of the disease reservoir. This user-centered mBEADS platform makes significant improvements to a previously cumbersome malaria biomarker enrichment strategy by improving reagent stability, decreasing the processing time 10-fold, and reducing the assay cost 10-fold. The resulting mBEADS process adds just three minutes and less than $0.25 to the total cost of a single LFA, thus balancing sensitivity and practicality to align with the World Health Organization's ASSURED criteria for point-of-care (POC) testing.

Attenuated Positive Psychotic Symptoms in Relation to Cigarette Smoking in a Nonclinical Population

INTRODUCTION

This study explored the association between cigarette smoking and attenuated positive psychotic symptoms in a young adult nonclinical sample.

METHODS

Undergraduates (N = 930), aged 18-35 years (26.3% male), completed a battery of self-report measures assessing subthreshold psychotic symptoms, cigarette smoking behavior/dependence, and drug use.

RESULTS

Individuals endorsing a greater number of attenuated positive psychotic symptoms were more likely to be smokers. Exploratory analyses indicated that the odds of being a smoker were two times greater for those at potential higher risk for psychosis compared with individuals at lower risk. Results were consistent after adjusting for sex and other drug use.

CONCLUSIONS

In line with findings from psychotic populations, results suggest that attenuated positive psychotic symptoms, particularly those endorsed as distressing in a nonclinical, undergraduate population, are related to cigarette smoking.

IMPLICATIONS

Even in nonclinical, undergraduate populations, subthreshold psychotic symptoms are related to cigarette smoking, and cigarette smokers are twice as likely to be considered at potentially higher risk for psychosis compared with noncigarette smokers. In summary, there may be a threshold whereby psychotic symptoms confer increased risk for nicotine consumption, with endorsement of a greater number of distressing subthreshold psychotic symptoms increasing the likelihood of cigarette use.

Trauma and the psychosis spectrum: A review of symptom specificity and explanatory mechanisms

Traumatic life events have been robustly associated with various psychosis outcomes, including increased risk of psychotic disorders, the prodrome of psychosis, and dimensional measures of psychotic symptoms, such as attenuated positive psychotic symptoms. However, trauma exposure has been linked to various mental disorders; therefore, the specificity of trauma exposure to psychosis remains unclear. This review focuses on two understudied areas of the trauma and psychosis literature: 1) the specificity between trauma and psychosis in relation to other disorders that often result post-trauma, and 2) proposed mechanisms that uniquely link trauma to psychosis. We begin by discussing the underlying connection between trauma exposure and the entire psychosis spectrum with a focus on the influence of trauma type and specific psychotic symptoms. We then consider how the principles of multifinality and equifinality can be useful in elucidating the trauma-psychosis relationship versus the trauma-other disorder relationship. Next, we discuss several cognitive and neurobiological mechanisms that might uniquely account for the association between trauma and psychosis, as well as the role of gender. Lastly, we review important methodological issues that complicate the research on trauma and psychosis, ending with clinical implications for the field.

Sensitive Method for Biomolecule Detection Utilizing Signal Amplification with Porphyrin Nanoparticles

Disease diagnosis requires identification of biomarkers that occur in small quantities, making detection a difficult task. Effective diagnosis is an even greater challenge in low-resource areas of the world. Methods must be simple, stable, and sensitive so that tests can be easily administered and withstand uncontrolled environmental conditions. One approach to this issue is development of stable signal amplification strategies. In this work, we applied the nanocrystal-based signal amplification method to tetra(4-carboxyphenyl)porphyrin nanoparticles (TCPP NPs). The dissolution of the nanoparticle into thousands of porphyrin molecules results in amplified detection of the biomarker. By using nanoparticles as the signal-generating moiety, stability of the detection method is increased relative to commonly used enzyme-based assays. Additionally, the inherent fluorescent signal of TCPP molecules can be measured after nanoparticle dissolution. The ability to directly read the TCPP fluorescent signal increases assay simplicity by reducing the steps required for the test. This detection method was optimized by detecting rabbit IgG and then was applied to the detection of the malarial biomarker Plasmodium falciparum histidine-rich protein II (pfHRPII) from a complex matrix. The results for both biomarkers were assays with low picomolar limits of detection.

Anxiety mediates the association between cannabis use and attenuated positive psychotic symptoms

Cannabis use has been associated with a continuum of psychotic experiences. However, it is unclear whether mood and anxiety symptoms account for increases in attenuated positive psychotic symptoms (APPS) among cannabis users. We predicted that depression and anxiety symptoms would mediate the relation between cannabis use and APPS, and between cannabis use and endorsement of eight or more distressing APPS (D-APPS), a potentially more clinically meaningful group. Young adults (n=674) completed the Prodromal Questionnaire (PQ); Drug Use Frequency measure; Center for Epidemiologic Studies Depression Scale; State-Trait Anxiety Inventory, Trait Form, Anxiety Subscale; and Social Phobia Scale. Results indicated that symptoms of trait anxiety, but not symptoms of depression or social anxiety, mediated the relationship between cannabis use and APPS, as well as the relationship between cannabis use and D-APPS. Results indicate that symptoms of trait anxiety may play a role in the relation between cannabis use and APPS. Findings underscore the importance of considering clinical characteristics co-occurring with psychotic symptoms, such as affective symptoms, when examining the association between cannabis use and psychotic symptoms.

Stress sensitivity mediates the relationship between traumatic life events and attenuated positive psychotic symptoms differentially by gender in a college population sample

The purpose of this study was to investigate whether stress sensitivity mediates the relationship between traumatic life events and total attenuated positive psychotic symptoms, as well as the relationship between traumatic life events and endorsement of 8 or more attenuated positive psychotic symptoms as distressing (a threshold that has been associated with higher risk for psychosis in clinical groups). Participants (n = 671, aged 17-35, 29% male) were college students who were administered the Prodromal Questionnaire, the Perceived Stress Scale and the Life Events Checklist. Bootstrapping results indicated that stress sensitivity significantly mediated the relationships between traumatic life events and the number of attenuated positive psychotic symptoms endorsed and between traumatic life events and those who endorsed 8 or more distressing attenuated positive psychotic symptoms. Stratified gender analyses indicated the findings were specific to females. Results suggest that stress sensitivity may represent a specific vulnerability factor for risk of attenuated psychotic symptoms in those previously exposed to traumatic life events and that this liability appears stronger in females.

Simple sample processing enhances malaria rapid diagnostic test performance

Lateral flow immunochromatographic rapid diagnostic tests (RDTs) are the primary form of medical diagnostic used for malaria in underdeveloped nations. Unfortunately, many of these tests do not detect asymptomatic malaria carriers. In order for eradication of the disease to be achieved, this problem must be solved. In this study, we demonstrate enhancement in the performance of six RDT brands when a simple sample-processing step is added to the front of the diagnostic process. Greater than a 4-fold RDT signal enhancement was observed as a result of the sample processing step. This lowered the limit of detection for RDT brands to submicroscopic parasitemias. For the best performing RDTs the limits of detection were found to be as low as 3 parasites per μL. Finally, through individual donor samples, the correlations between donor source, WHO panel detection scores and RDT signal intensities were explored.

Schizophrenia and co-occurring substance use disorder: reward, olfaction and clozapine

Co-occurring substance use disorders (SUD), including alcohol, are common in schizophrenia (SZ) and are associated with poor outcome. Emerging data suggest that individuals with SZ have a dysfunctional brain reward circuit that may underlie their frequent use of alcohol and other substances, and further, that the atypical antipsychotic, clozapine (CLOZ), limits alcohol/substance use in these individuals, potentially by ameliorating this brain reward circuit dysfunction. To explore this hypothesis, reward functioning in a SZ sample with a history of co-occurring SUD, treated with either CLOZ (n=13) or typical antipsychotic agents (TYP), haloperidol or fluphenazine (n=14), as well as healthy controls (n=16), was evaluated through ratings of pleasurable and aversive odors, stimuli that are processed by several neural structures thought to play a key role in processing rewarding stimuli. Results suggest that CLOZ treatment is associated with broadening and strengthening the hedonic experience of these rewarding olfactory stimuli, both of a pleasant and unpleasant nature. This hedonic appraisal of odors appeared to be independent of odor perception (intensity ratings) and clinical symptoms. These preliminary findings provide important new data in support of the hypothesis that CLOZ ameliorates some aspects of abnormal brain reward functioning in individuals with co-occurring SZ and SUD. Further research may have valuable treatment implications for this population including interventions for other reward-associated deficits in learning, social interactions and other aspects of behavior and cognition.

The impact of child sexual abuse and stigma on methods of coping with sexual assault among undergraduate women

OBJECTIVE

The aim of the current study was to determine whether a prior history of child sexual abuse increased the likelihood of using disengagement methods of coping with a sexual assault that had occurred within the past year. Once this was established, a mediational model was tested in which it was hypothesized that specific traumagenic dynamics and changed world views would mediate the association between child and/or adolescent sexual abuse and increased use of disengagement coping methods in response to a recent sexual assault.

METHOD

One thousand and fifty women undergraduates from a New England state university completed a survey for research credit. Respondents were asked detailed questions regarding experiences of sexual assault within the past year, histories of child and/or adolescent sexual abuse, traumagenic dynamics, and world assumptions. Analyses were based on 106 participants who had experienced a sexual assault within the past year.

RESULTS

Sexually assaulted young women with a history of child sexual abuse used more disengagement methods of coping to deal with the adult sexual assault than women without this history. In addition, the relationship between prior sexual abuse and the use of disengagement coping strategies was mediated by feelings of stigma, but not by feelings of betrayal and powerlessness or beliefs in the meaningfulness and benevolence of the world.

CONCLUSIONS

This is the first study to find that sexually revictimized young women may be particularly at-risk of relying on disengagement methods of coping with sexual assault. Furthermore, this association is mediated by feelings of shame or stigma. Directions for further research and clinical implications are discussed.

Cutaneous vasculitis update

The classification of cutaneous vasculitis and its general principles, including clinical patterns, pathogenesis, and causes, are reviewed in this article. Several types of cutaneous vasculitis are discussed in detail, including Henoch-Schonlein purpura, erythema elevatum diutinum, and cutaneous polyarteritis nodosum. The approach to treatment for cutaneous vasculitis also is reviewed.

Cutaneous involvement by angioimmunoblastic T-cell lymphoma with remarkable heterogeneous Epstein-Barr virus expression

INTRODUCTION

Initially described as an abnormal immune reaction, most cases of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD)-like T-cell infiltrates are now regarded as a peripheral T-cell lymphoma (AILD T-NHL). AILD T-NHL is characterized clinically with constitutional symptoms, generalized lymphadenopathy, hepatosplenomegaly, skin rash, and polyclonal hypergammaglobulinemia. Epstein-Barr virus (EBV) is frequently detected in involved lymph nodes, but the presence of EBV in cutaneous infiltrates of AILD T-NHL has rarely been examined. We present a patient with AILD T-NHL with cutaneous involvement that shows marked heterogeneity of EBV expression in the lymph node and skin biopsies, and review the histological findings of AILD T-NHL in the skin.

METHODS

Two skin biopsies of a diffuse maculopapular rash and a lymph node were examined and immunophenotyped. In situ hybridization for detection of EBV in the lymph node and skin biopsies was utilized. In order to attempt to delineate which lymphocytes were EBV positive, skin biopsies were dual labeled with CD3, CD45RO, CD20 and EBV. The skin biopsies and lymph node were submitted for gene rearrangement studies by polymerase chain reaction (PCR). Capillary electrophoresis of fluorescently labeled PCR products was utilized for PCR product quantitation.

RESULTS

The histological features of the lymph node were diagnostic of AILD T-NHL and a T-cell clone was identified by PCR. The skin biopsies showed an atypical superficial and deep perivascular polymorphous infiltrate consistent with cutaneous involvement by AILD T-NHL. Both skin biopsies showed the same clonal T-cell receptor gene rearrangement as the lymph node. In situ hybridization of the lymph node and one skin biopsy showed a few scattered EBV-positive lymphocytes (<1% of the infiltrate). A second skin biopsy revealed 40-50% of the lymphocytes as EBV positive. Dual staining for CD20 and EBV identified a minority of EBV-infected lymphocytes as B-cells, but most of the EBV-positive cells lacked staining for CD3 and CD45RO.

CONCLUSIONS

In our patient, the same T-cell receptor gene rearrangement was found by PCR in all three biopsy sites. Most cases of AILD T-NHL contain only a few EBV-positive cells, but in our patient the extent of EBV expression ranged from <1% to 40-50% of the AILD T-NHL cutaneous infiltrate. To our knowledge, this case is the most extensive and heterogeneous expression of EBV in cutaneous AILD T-NHL to date.

Beard dermatitis due to para-phenylenediamine use in Arabic men

The most common active ingredient in hair coloring is para-phenylenediamine (PPDA), which can produce contact dermatitis, particularly in persons who dye their scalp hair and in hairdressers. We have identified another group of patients also at risk, namely men from Arab countries, who commonly grow beards and dye them. We searched the computerized patient database at the Mayo Clinic for patients with beard dermatitis associated with dye use. Eight Arabic men presented to the Mayo Clinic between 1994 and 1999 with beard dermatitis and a positive patch test to PPDA. The lesions were described as pruritic, erythematous, papular eruptions that developed in the jaw area after each application of beard dye. The symptoms subsided after the patients discontinued use of the PPDA-containing dye and received treatment with topical corticosteroids. Allergic contact dermatitis in the beard area due to PPDA occurs in Arabic men as a result of their propensity to dye their beards.

Clinicopathologic, immunophenotypic, and molecular characterization of primary cutaneous follicular B-cell lymphoma

OBJECTIVE

To determine the clinicopathologic, immunophenotypic, and molecular characteristics of primary follicular cutaneous B-cell lymphoma (CBCL) as defined by the revised European-American lymphoma classification.

DESIGN

A retrospective survey of the medical records, an immunohistochemical study of archival biopsy specimens. and molecular studies of preserved DNA of all patients with follicle center lymphoma-follicular (FCL-F) primary CBCL from 1987 to 1997.

SETTING

A single-center outpatient specialty clinic at an academic medical center.

PATIENTS

Twenty-one patients (68% of all new primary CBCL cases), including 14 men and 7 women (age range, 33-88 years; mean, 55 years).

RESULTS

The head and neck region was the most frequent primary site. Following treatment, recurrences were relatively frequent, but the overall mortality rate during 1.0 to 11.3 years (mean, 6.3 years) of follow-up was 4.8%. Immunohistochemical analysis for B- and T-cell lineages was helpful in enhancing the folliclelike structures. CD10, bcl-2, and CD43 were expressed by the neoplastic cells in 9 (47%) of 19 cases, 4 (21%) of 19 cases, and 2 (13%) of 16 cases, respectively. Immunohistochemical detection of cytoplasmic immunoglobulin light chains, using steaming in EDTA as the antigen-retrieval technique, was successful in 12 (71%) of 17 cases. The Ig heavy-chain gene rearrangements, using the Southern blot technique, detected clonality in 17 (94%) of 18 cases. The bcl-2 gene rearrangements were detected in only 2 (13%) of 15 of the primary cutaneous FCL-F cases, compared with 9 (75%) of 12 of the primary nodal FCL-F cases (P =.002).

CONCLUSIONS

Primary cutaneous FCL-F is a relatively common subtype of CBCL, with a relatively indolent course. It has many features in common with primary nodal FCL-F, except for low rates of bcl-2 expression and bcl-2 gene rearrangements.

Foreign bodies in sarcoidosis

Sarcoidosis is a multisystem disease of unknown etiology. The demonstration of polarizable foreign bodies in cutaneous granulomas is generally thought to exclude a diagnosis of sarcoidosis. Nevertheless. some investigators have reported systemic sarcoidosis with cutaneous manifestations in which polarizable particles were associated with granuloma formation in the skin. We searched the biopsy specimens of granulomatous lesions from 50 patients with cutaneous sarcoidosis using polarization microscopy to estimate the frequency of polarizable foreign bodies in cutaneous lesions of sarcoidosis. Using electron probe microanalysis, we sought to determine what elements compose these foreign bodies. Polarizable foreign bodies were found in the granulomatous skin lesions of 12 of 50 patients with cutaneous sarcoidosis. All 12 patients also had at least one other granulomatous systemic lesion, and 4 had biopsy specimens of a systemic lesion available for review. Polarizable foreign bodies were found in two cases. The elements identified were calcium, phosphorus, silicon, and aluminum. Polarizable foreign bodies were found in cutaneous sarcoidosis far more often than expected. Foreign bodies were also found in granulomatous systemic lesions. The foreign body may serve as an inciting stimulus for granuloma formation in selected cases of sarcoidosis.

Child sexual abuse prevention programs: do they decrease the occurrence of child sexual abuse?

OBJECTIVE

The primary goal of the current study was to determine whether rates of child sexual abuse differed among undergraduate women who either had or had not participated in a sexual abuse prevention program during childhood. A secondary goal was to determine whether differences emerged in sexual satisfaction or avoidance of sexual activity between those women who had or had not participated in such a program.

METHOD

Eight hundred and twenty-five women undergraduates from a New England state university filled out a survey on "sexual experiences" for research credit. Respondents were asked detailed questions regarding past histories of child sexual abuse and participation in school-based prevention programs during childhood. Additionally, they responded to questions about their current sexual satisfaction and sexual behaviors.

RESULTS

Sixty-two percent of the sample reported having participated in a "good touch-bad touch" sexual abuse prevention program in school. Eight percent of respondents who reported ever having had a prevention program also reported having been subsequently sexually abused, compared to 14% of respondents who did not ever have a prevention program. No differences were found in adult sexual satisfaction or on behavioral measures of sexual activity between those respondents who had and had not participated in a prevention program.

CONCLUSIONS

This is the first study to find that school-based child sexual abuse prevention programs are associated with a reduced incidence of child sexual abuse. Additionally, contrary to concerns voiced in the literature, there was no evidence that prevention programs are associated with decreased sexual satisfaction or avoidance of sex in adulthood. Implications of the results for further study are discussed.

Necrobiotic xanthogranuloma: long-term outcome of ocular and systemic involvement

PURPOSE

To report long-term outcomes of patients with necrobiotic xanthogranuloma, to investigate the propriety of therapeutic surgical excision or debulking, and to study tissue specimens by immunoperoxidase staining and in situ hybridization.

METHODS

Medical records of all patients at the Mayo Clinic, Rochester, Minnesota, with necrobiotic xanthogranuloma between 1980 and 1997 were reviewed. A follow-up letter was sent to each patient inquiring about the current status of the lesions, the treatment regimen, and associated systemic diseases.

RESULTS

The average age (+/- standard deviation) of the 15 men and 11 women was 56.8 +/- 14.8 years. Of the 26 patients, 21 (81%) had lesions of the ocular adnexa. Ulceration of the lesions occurred in 11 patients (42%). The lesions recurred after surgical removal in 11 patients (42%) and on prior incision sites from unrelated operations in three patients (12%). The average duration of follow-up from the appearance of characteristic skin lesions was 10 +/- 6.1 years. Four patients had multiple myeloma, five had a plasma cell dyscrasia, and one had a lymphoproliferative disorder during this period. Time to development of associated malignancy ranged from 8 years before the skin lesions to 11 years after the skin lesions. Overall survival was 100% at 10 years and 90% at 15 years (95% confidence limit, 0.73 to 1.00). Immunoperoxidase stains demonstrated that most histiocytes are not of Langerhans cell lineage. Monoclonal immune globulins were not identified in tissue specimens.

CONCLUSION

Care of patients with necrobiotic xanthogranuloma should include avoidance of surgical removal, if possible, and lifelong follow-up to detect the development of associated malignancy.

The epidemiology of psoriatic arthritis in Olmsted County, Minnesota, USA, 1982-1991

OBJECTIVE

To determine the incidence, prevalence, and outcomes of psoriatic arthritis (PsA) in a geographically defined community.

METHODS

Using the Rochester Epidemiology Project computerized medical record system, we screened all records of Olmsted County, Minnesota, residents with any diagnosis consistent with psoriasis and/or PsA made between January 1, 1982 and December 31, 1991. Medical records were reviewed using a pretested data collection form. Only those cases of psoriasis where the diagnosis was confirmed by a dermatologist were included. PsA was defined as inflammatory arthritis associated with a definite diagnosis of psoriasis. All identified cases were followed until death, migration from the county, or January 1, 1992. Cases with seropositive rheumatoid arthritis, systemic lupus erythematosus, crystal induced arthritis, Reiter's syndrome, arthritis associated with inflammatory bowel diseases, and inflammatory osteoarthritis were excluded. Clinical characteristics were described using summary statistics. Age and sex adjusted incidence and prevalence rates were calculated. Survival was estimated using the Kaplan-Meier method.

RESULTS

We reviewed the records of 1844 patients with a diagnosis of psoriasis. In 1056 of these, the diagnosis was confirmed by a dermatologist. Among these 1056 psoriasis cases, we identified 66 cases (34 female, 32 male) of PsA first diagnosed between 1982 and 1991. The average age and sex adjusted incidence rate per 100,000 US population was 6.59 (95% confidence interval, CI, 4.99, 8.19) and the prevalence on January 1, 1992, was about one per 1000 (95% CI 0.81, 1.21). The average age at diagnosis was 40.7 years. At diagnosis, 91, 3, and 6% of cases had oligoarthritis, polyarthritis, and spondylitis, respectively. Over the 477.8 person-years of followup, 25 developed extraarticular manifestations (enthesitis, n = 15; ocular inflammation, n = 11; urethritis, n = 9), 10 patients received disease modifying antirheumatic drug treatment (methotrexate, n = 7; sulfasalazine, n = 5; intramuscular gold, n = 1; oral gold, n = 1), 3 received corticosteroids, and 5 had surgical interventions (synovectomy, n = 3; arthroplasty, n = 1; other reconstructive surgery, n = 2). Survival was not significantly different from the general population (p = 0.546).

CONCLUSION

Unlike results from previous referral based studies, our findings indicate that PsA is a mild, uncommon inflammatory arthritis, not associated with a significant increase in mortality.

An examination of antecedent traumas and psychiatric comorbidity among male inmates with PTSD

Despite substantially higher rates of posttraumatic stress disorder (PTSD) among male inmates than among men in the general population, there is a dearth of research on PTSD among incarcerated men. The current study addresses traumatic events that precede PTSD and psychiatric disorders that are comorbid with PTSD in an inmate sample. Seeing someone seriously injured or killed, being sexually abused, and being physically assaulted were the three most commonly reported antecedent traumas to PTSD. Lifetime and current rates of mood disorders, anxiety disorders, and antisocial personality disorder were elevated among inmates with a diagnosis of PTSD. Two hundred and thirteen inmates participated in the study. Sixty-nine participants (33%) met lifetime DSM-III-R criteria for PTSD, and 45 (21%) met current criteria. The findings are compared with general population samples, and implications of the findings are discussed.