Lonni Schultz

Sex differences in depression: a role for preexisting anxiety

The role of anxiety disorders in the development of sex differences in major depression is analyzed. Data come from a longitudinal epidemiologic study of young adults in the Detroit, Michigan area. The Diagnostic Interview Schedule, revised according to DSM-III-R, was used at baseline to measure lifetime psychiatric disorders and at follow-up to measure psychiatric disorders during the 3.5-year interval since baseline assessment. Consistent with previous reports, the lifetime prevalence of major depression was nearly two-fold higher in females than in males. The sex difference was primarily in major depression comorbid with anxiety disorders. Results from Cox-proportional hazards models, with time-dependent covariates, showed that prior anxiety disorder increased the risk for subsequent major depression in both sexes, with no evidence of an interaction. History of anxiety disorder, including number of prior anxiety disorders, accounted for a considerable part of the observed sex difference in major depression. Controlling for prior anxiety reduced by more than 50% the coefficient that estimates the association between gender and major depression. The results suggest that the higher occurrence of anxiety disorders in females than males beginning early in life might explain in large part the higher female risk for major depression. They emphasize the need for further research on sex differences in anxiety disorders.

Epidemiology of DSM-IV Insomnia in Adolescence: Lifetime Prevalence, Chronicity, and an Emergent Gender Difference

OBJECTIVE. The confluence of sleep/wake cycle and circadian rhythm changes that accompany pubertal development and the social and emotional developmental tasks of adolescence may create a period of substantial risk for development of insomnia. Although poor sleep affects cognitive performance and is associated with poor emotional and physical health, epidemiologic studies among adolescents have been limited. In this first epidemiologic study of insomnia defined by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria in a US sample of adolescents, we estimated lifetime prevalence of insomnia, examined chronicity and onset, and explored the role of pubertal development. METHODS. Data come from a random sample of 1014 adolescents who were 13 to 16 years of age, selected from households in a 400000-member health maintenance organization encompassing metropolitan Detroit. Response rate was 71.2%. The main outcome measured was DSM-IV–defined insomnia. RESULTS. Lifetime prevalence of insomnia was 10.7%. A total of 88% of adolescents with a history of insomnia reported current insomnia. The median age of onset of insomnia was 11. Of those with insomnia, 52.8% had a comorbid psychiatric disorder. In exploratory analyses of insomnia and pubertal development, onset of menses was associated with a 2.75-fold increased risk for insomnia. There was no difference in risk for insomnia among girls before menses onset relative to boys, but a difference emerged after menses onset. In contrast, maturational development was not associated with insomnia in boys. CONCLUSIONS. Insomnia seems to be common and chronic among adolescents. The often found gender difference in risk for insomnia seems to emerge in association with onset of menses.

Intravenous tissue plasminogen activator for acute ischemic stroke in patients aged 80 years and older: The tPA stroke survey experience

BACKGROUND AND PURPOSEnIntravenous tissue plasminogen activator (tPA) administered within 3 hours of symptom onset is the first available effective therapy for acute ischemic stroke (AIS). Few data exist, however, on its use in very elderly patients. We examined the characteristics, complications, and short-term outcome of AIS patients aged >/=80 years treated with tPA.nnnMETHODSnPatients aged >/=80 years (n=30) were compared with counterparts aged <80 years (n=159) included in the tPA Stroke Survey, a US retrospective survey of 189 consecutive AIS patients treated with intravenous tPA at 13 hospitals.nnnRESULTSnRisk of intracerebral hemorrhage (fatal, symptomatic, and total) was 3%, 3%, and 7% in the elderly age group and 2%, 6%, and 9%, respectively, in their younger counterparts (P=NS for all comparisons). Likelihood of favorable outcome, defined as modified Rankin score 0 to 1, National Institutes of Health Stroke Scale score </=5, or marked improvement by hospital discharge, was comparable between groups (37%, 54%, and 43% versus 30%, 54%, and 43%, respectively; P=NS for all comparisons). Elderly patients were more likely to be treated by stroke specialists (87% versus 60%; P=0.005) and less likely to have an identified protocol deviation (13% versus 33%; P=0.03). Elderly patients were discharged more often to nursing care facilities (17% versus 5%; P=0.003). In logistic regression models there were no differences in odds ratio for favorable or poor outcome, other than tendency for higher in-hospital mortality in elderly patients (odds ratio, 2.8; 95% CI, 0.81 to 9.62; P=0.10).nnnCONCLUSIONSnAmong AIS patients treated with intravenous tPA, age-related differences in characteristics and disposition were identified. No evidence for withholding tPA treatment for AIS in appropriately selected patients aged >/=80 years was identified.

A Second Look at Prior Trauma and the Posttraumatic Stress Disorder Effects of Subsequent Trauma: A Prospective Epidemiological Study

CONTEXTnPrevious studies showed increased probability of a posttraumatic stress disorder (PTSD) effect of trauma in persons who had experienced prior trauma. The evidence comes chiefly from retrospective data on earlier events, obtained from trauma-exposed persons with and without PTSD. A generally overlooked major limitation is the failure to assess the PTSD response to the prior trauma.nnnOBJECTIVEnTo estimate the risk of PTSD after traumas experienced during follow-up periods in relation to respondents prior traumatic events and PTSD.nnnDESIGNnA cohort study of young adults interviewed initially in 1989, with repeated assessments during a 10-year follow-up.nnnSETTING AND PARTICIPANTSnThe sample was randomly selected from a large health maintenance organization in Southeast Michigan, representing the geographic area.nnnMAIN OUTCOME MEASURESnThe relative risk of PTSD precipitated by traumatic events occurring during follow-up periods in relation to prior exposure and PTSD that had occurred during preceding periods, estimated by general estimating equations (n = 990).nnnRESULTSnThe conditional risk of PTSD during the follow-up periods was significantly higher among trauma-exposed persons who had experienced prior PTSD, relative to those with no prior trauma (odds ratio, 3.01; 95% confidence interval, 1.52-5.97). After adjustment for sex, race, education, and preexisting major depression and anxiety disorders, the estimates were only marginally revised. In contrast, the conditional risk of PTSD during follow-up among trauma-exposed persons who had experienced prior traumatic events but not PTSD was not significantly elevated, relative to trauma-exposed persons with no prior trauma. The difference between the 2 estimates was significant (P = .005).nnnCONCLUSIONSnPrior trauma increases the risk of PTSD after a subsequent trauma only among persons who developed PTSD in response to the prior trauma. The findings suggest that preexisting susceptibility to a pathological response to stressors may account for the PTSD response to the prior trauma and the subsequent trauma.

Are smokers with alcohol disorders less likely to quit

OBJECTIVESnThis study examined the likelihood of smoking cessation in smokers with a prior history of alcoholism.nnnMETHODSnData came from an epidemiologic study of 1007 young adults, randomly selected from those insured in a large health maintenance organization (HMO) in southeast Michigan. Cox proportional hazards models with time-dependent covariates were used to estimate the hazards ratios of quitting in smokers with current and past alcoholism, with smokers with no history of alcoholism as a reference. Sex, race, and education were controlled.nnnRESULTSnSmokers with active alcoholism in the preceding year were 60% less likely to quit than were smokers with no history of alcoholism. In contrast, smokers whose alcoholism had remitted were at least as likely to quit as smokers with no history of alcoholism. Compared with persistent alcoholism, remission of alcoholism was associated with more than a threefold increase in the likelihood of subsequent smoking cessation.nnnCONCLUSIONSnThe findings suggest that discontinuation of alcoholism might increase the potential for successful smoking cessation.

The Dysphagia Handicap Index: Development and Validation

Quality-of-life indicators for dysphagia provide invaluable information to the treating clinician regarding the success or failure of swallowing therapy. The purpose of this study was to develop a clinically efficient, statistically robust patient-reported outcomes tool that measures the handicapping effect of dysphagia on emotional, functional, and physical aspects of individual’s lives. 60 statements describing the handicapping effect of dysphagia were collected from patient reports and divided into subscales of physical, emotional, and functional problems. The statements were presented to 77 individuals with dysphagia. Respondents replied never, sometimes, or always to each statement and rated their self-perceived dysphagia severity on a 7-point equal-appearing interval scale. Cronbach’s α was performed to assess the internal consistency validation of the items within the questionnaire. The final questionnaire was reduced to 25 items and administered to 214 individuals with dysphagia and 74 controls. Test–retest was performed on 63 individuals with dysphagia. Cronbach’s α for the initial and final versions was strong at rxa0=xa00.96 and rxa0=xa00.94, respectively. Significant differences occurred between the dysphagia and control groups. Test–retest reliability was strong. We present a new, easy-to-complete, statistically robust, patient-reported outcomes measure for assessing the handicapping effect of dysphagia.

Anticardiolipin antibodies and mortality in patients with ischemic stroke: A prospective follow-up study

The purpose of the present prospective observational study was to assess whether or not the presence of anticardiolipin antibodies (aCL) in unselected first ischemic stroke patients is associated with adverse outcome. Consecutive patients (n = 300; mean age 64 years; 48% males) presenting with a first acute ischemic stroke were evaluated for IgG aCL and were systematically followed up. During a median follow-up of 21 months, 58 patients (19%) died. Mortality rates were higher in patients with aCL >20 IgG phospholipid units (GPL) [33 vs. 18%; relative risk (RR) 1.94, 95% confidence interval (CI) 1.02–3.67; p = 0.042] or >40 GPL (40 vs. 19%; RR 2.46, 95% CI 1.05–5.75; p = 0.037). Elevated aCL did not confer an increased risk during follow-up of a combined end point of stroke, myocardial infarction and vascular death or of nonfatal thrombo-occlusive events. Rates of malignancy detected during follow-up were higher among patients with aCL >20 GPL (19 vs. 5%, p = 0.007) and >40 GPL (27 vs. 6%, p = 0.01). The excess mortality associated with elevated aCL was eliminated after adjustment for age, cardiovascular risk factors and malignancy. These results demonstrate that aCL above 20–40 GPL among consecutive ischemic stroke patients is a marker of increased mortality during follow-up, but older age and higher rates of cardiovascular risk factors and malignancy detected during follow-up account for the higher mortality.

Periictal diffusion abnormalities of the thalamus in partial status epilepticus

Purpose:u2002 To identify and describe thalamic dysfunction in patients with temporal as well as extratemporal status epilepticus (SE) and to also analyze the specific clinical, radiological, and electroencephalography (EEG) characteristics of patients with acute thalamic involvement.

Factors determining headache at onset of acute ischemic stroke

Headache is a frequent accompaniment of acute ischaemic stroke. The predisposing factors and underlying mechanisms are currently incompletely defined. We analysed prospectively collected data relevant to headache occurring at ischaemic stroke onset in consecutive patients included in the Henry Ford Hospital Stroke Data Bank. Patients with headache (HA+) and without headache (HA–) were compared for demographic factors, medical history, medications, examination findings, laboratory findings, and stroke localization and subtype. Group comparisons for categorical data were performed with χ2 test, and for continuous variables with two-sample t-tests. Stepwise logistic regression analysis, including all variables with P < 0.25, was used to define the independent predictors of onset headache. Three hundred and seventy-five patients had complete headache and clinical datasets and were included in the analysis (HA+, N = 118; HA–, N = 257). Multivariate analysis revealed that the independent predictors of HA+ were: infarct in the distribution of the posterior circulation [P = 0.0076, odds ratio (OR) 2.15, 95% confidence interval (CI) 1.23, 3.77], absence of history of hypertension (P = 0.0106, OR 0.48, 95% CI 0.27, 0.84), and treatment with warfarin at the time of the index stroke (P = 0.0135, OR 4.89, 95% CI 1.39, 17.21). The occurrence of headache at onset of ischaemic stroke is determined by posterior circulation distribution of the ischaemic event, absence of history of hypertension and treatment with warfarin at the time of the index stroke. These results suggest that preserved elasticity and maintenance of the intracranial vasculature in a relaxed state, in combination with coagulation system derangements, and activation of dense perivascular afferent nerves, play a role in the pathogenesis of onset headache.

Chronic changes in brain Mg2+ concentration after forebrain ischemia in the rat

Brain Mg2+ ion concentrations, [Mg2+], were evaluated in three groups of animals subjected to either 8 minutes (n=10), or 12 minutes (n=10) of near-complete forebrain ischemia, or sham operation (n=10), from their31P NMR spectra. No significant differences were observed in [Mg2+] among sham operated animals prior to or at any time point after surgery. In the 8-min ischemia group, mean [Mg2+] were significantly lower at 48 (0.28 ± 0.06 mM, p=0.014) and 72 (0.29 ± 0.07 mM, p=0.005) hours post-ischemia when compared to their mean pre-ischemia levels (0.39 ± 0.08 mM). [Mg2+] was restored to preischemia values at 96 hours after induction of ischemia. In the 12 min ischemia group, [Mg2+] were lower at all time points post-ischemia when compared to their pre-ischemia levels. Our data shows that forebrain ischemia causes a chronic decline of cerebral Mg2+ concentration, and the observed reduction of this cation can be partially attributed to concurrent brain tissue alkalosis.