Milton Kramer

Gastroesophageal reflux in infants: Relation to apnea

The temporal relationship between apnea and gastroesophageal reflux was examined in 14 infants with abnormal GER scores and histories of prolonged apnea. Simultaneous polysomnographic and intraesophageal pH recordings were performed for each infant. GER episodes were compared to control segments of the recording (without GER) for frequency and type of apnea. Apnea was equally likely to occur during the control segments as during the GER episodes. Brief obstructive apneic episodes were more common during the onset of GER episodes than the onset of control segments. GER duration appeared prolonged during sleep. GER and apnea were not temporally related in the majority of instances, and may be two manifestations of a more general developmental delay.

Intermediate Use of Triazolam: A Sleep Laboratory Study

The present study was undertaken to evaluate the intermediate effects of triazolam 0.5 mg on the sleep of insomniac patients. The results showed that triazolam is effective in inducing and maintaining sleep without producing any major effects on sleep staging. Triazolam did not lead to significant subjective complaints or any deterioration in the physical condition of the patients. The effectiveness of triazolam did not vary over a two-week period.

Dreams and demography.

This survey makes two contributions to the study of man. The first deals with the subject of dreams per se and the careful examination of these dreams leading to establishing norms pertinent for a generalized population. This can be seen as complementary to the earlier studies of Hall and Van de Castle which established norms for a limited population. The second contribution concerns the insights into current societal preoccupations which the dream reveals. Making a direct translation of manifest dream content into sociological factors is fraught with difficulty. Nevertheless, it is tempting to describe this middle city of the United States as reflecting the larger situation of America and perhaps of western urban culture. In this respect, human beings are seen as coping with death anxiety as they grow older, accentuated by such conditions as widowhood. Blacks and whites are seen as essentially similar in their preoccupations, aggressions and good fortunes. We see a reaffirmation that anatomy is destiny, for the single most important factor in determining dream themes is the sex into which one is born. How much this difference is biological and how much cultural is unknown. At the present time in the United States and as exemplified by a recent book (37), being a woman involves less striving for achievement, more involvement with interpersonal relations and in general a more passive role in the aggressive themes of life. Attention to inner processes and inner space would seem to be biologically based although certainly reinforced by the cultural substrate in which the woman operates. This study deals with two of the three great themes of life — birth, marriage and death. In terms of marriage it can be observed that the single person seems happier but suffers the greatest misfortunes. Women are preoccupied with marriage and personal relationships and men with work. Death overshadows both men and women and age and death are partners.

Dreams and dementia: a laboratory exploration of dream recall and dream content in chronic brain syndrome patients.

Seventeen (seven mild and ten severe) chronic brain syndrome patients were tested in the sleep laboratory for dream recall and content. The mildly organic patients had 57 per cent recall while the severely organic patients had 35 per cent recall. We also studied four aged severely organic patients. These patients showed a recall rate of 8 per cent. The difference between the recall rates in mildly and severely organic middle-aged patients was not statistically significant. The difference between the recall rates of the aged severely organic patients and either or both of the middle-aged groups was statistically significant (p < .001). In addition, we found dream content differences between the mildy and severely organic middle-aged groups and between the combined group and normal young men.

Sleep-onset REM sleep: comparison of narcoleptic and obstructive sleep apnea patients.

The Multiple Sleep Latency Test (MSLT) has been shown to be an effective measure of excessive daytime sleepiness (EDS), or pathological sleep tendency. 1,2 Further, Mitler et al. 3 have demonstrated that narcoleptic and control subjects can be discriminated by the frequent occurrence of REM sleep during the MSLT of narcoleptics. Such an occurrence of REM within 10 minutes of sleep onset has been termed a sleep-onset REM period (SOREMP), and the occurrence of two or more SOREMPs during the MSLT is commonly used as one diagnostic indicator of narcolepsy. Patients with obstructive sleep apnea (OSA) also frequently report EDS. A preliminary report indicated that sleep-onset REM periods occur during multiple sleep latency tests of this patient population, although to a much lesser extent than in narcoleptic patients. The necessity to eliminate obstructive sleep apnea and other sleep disturbances as precipitants of sleep-onset REM periods have been mentioned by other authors. 3 However, little has been published concerning the likelihood of sleep-onset REM periods in nonnarcoleptic persons. This report presents rnultlple sleep latency test (MSLT) data of narcoleptics and patients with obstructive sleep apnea (OSA), to compare sleep tendency and the frequency of sleep-onset REM periods (SOREMPs) in two patient populations with excessive daytime sleepiness (EDS) as a primary symptom.

Training international medical graduates [IMGs] in psychiatry: A cultural adventure

International medical graduates (IMGs) currently make up about 25% of physicians practicing in the US. IMGs and U.S. medical school graduates (USMGs) have a great deal in common. The quality of the medical skills of more recent IMGs has improved as measured by the scores they obtain on the clinical skills assessment examination and has begun to approach that of USMGs, 89% compared to 80% (Whelan, Gary, Kostis, Boulet, & Hallock, 2002). In clinical practice, IMGs provide services comparable in effectiveness to USMGs (Norcini et al., 2010). However, the specific educational needs of IMGs must be recognized by training programs. IMGs face a series of concurrent issues having to do with immigration (Akhtar, 1999), which may result in loneliness and social isolation, a decrease in social status with diminishment of self-esteem, concerns related to the family left behind, and the impact of migration on the family they may have brought with them. Some IMGs are also concerned about the vagaries of their visa status. Group and individual resident social interaction with faculty is enormously valuable in reducing the sense of isolation. The central role of language and culture lies at the heart of the challenges that IMGs face in psychiatric training in the American context, particularly in learning psychological theory and therapy. Without mastery of the dominant language, both formal and informal (i.e., slang and idioms), IMGs may have difficulty understanding and being understood by their patients and teachers. In some settings, IMG psychiatric residents have asked for more intensive training including more demonstrations of interviewing, opportunities for oral presentations, and examinations and feedback. Fully 41% of psychiatric residents in the US are from Asia (Gangure, 2002) and their values and conceptions of personhood may be different from those

An overview of the dreaming process and the selective affective theory of sleep and dreams

The dream exists as an experience extended in time which can be captured in the dream report as an excellent approximation of the experience. Dreams can be adequately collected and reliably measured. Dream reports are both stable and variable across time. Dream reports show meaningful content differences in group and individual situations where psychological differences are known to exist. Dreams and waking life are linked and dreams are responsive to the immediate emotional concern of the dreamer. The dream is sufficiently orderly that the search for its meaning is justified. Methods exist to establish the meaning of the dream experience working with dreamer through associations or amplification. A method “Dream Translation” is described in which the meaning of the dream report is explored using the associations of the translator rather than of the dreamers. The translation approach could be used by the clinician to assess whether the patient has improved and to establish the immediate current emotional concern of the patient at initial contact or at points of block in the therapy. Although the dream report has the necessary characteristics to establish a meaning from it; this does not address the possible functional significance of dreaming. I describe here my selective, mood regulatory function of sleep and dreaming. We have explored this question more thoroughly in a monograph on dream function (Moffitt et al., The functions of dreaming, Albany, State University of New York Press, 1993)

Emerging roles for international medical graduates (IMGs) as educators for the future.

International Medical Graduates (IMGs) now comprise over a third of residents in US psychiatric residency programs, as well as over 25% of American Psychiatric Association (APA) members (Hales, 2004; A. Bondurant, Department of Minority/ National Affairs, APA, personal communication, 2005). IMGs have been shown to serve populations that their United States Medical Graduate (USMG) counterparts often do not, including rural populations, the poor, psychotic, and elderly (Blanco, Carvalho, Olfson, Finnerty, & Pincus, 1999). However, recent evidence indicates that, in addition to their traditional role as providers of clinical care to disadvantaged populations, IMGs are playing an increasingly important role in education and research, in psychiatry and the rest of medicine. IMGs now constitute nearly a fifth of full-time faculty at USmedical schools and of principal investigators (PIs) on National Institutes of Health (NIH) research project grants. The proportion of IMG full-time physician faculty who are in basic science departments is about twice that of their US and Canadian counterparts, as is the proportion of IMG physician principal investigators (Alexander, Heinig, Fang, Dickler, & Korn, 2007).

The History of International Medical Graduate Physicians in Psychiatry and Medicine in the United States: A Perspective

International medical graduate (IMG) physicians are vital to the physician workforce in the United States, and over the past few decades have become especially important in the provision of psychiatric care in this country. IMG physicians have assumed crucial roles in caring for the underserved, and they have had greater opportunities in public psychiatry than in other areas of the field. In this chapter, key historical patterns in medical training in the United States are outlined. Medical training in India is described to illustrate issues experienced by medical graduates not born in the United States. It is suggested that IMG physicians are collaborators who bring wisdom, expertise, effort, and valuable traditions, and yet IMG physicians have often faced prejudice and obstacles to their professional advancement. It is hoped that IMG physicians in the future will be more respectfully embraced and will have robust professional opportunities in the health system of the United States and other economically established countries.

Training Needs of International Medical Graduate Physicians in Psychiatry: A Perspective

The heterogeneity in the cultural, linguistic, and medical educational background of international medical graduate (IMG) physicians in psychiatry poses significant challenges in assessing their training needs. This chapter addresses the complex determination of training needs and their recommended solutions. To that end, inter-group differences within the IMG physician spectrum are discussed, with an emphasis on the imperatives within each culture. The recent literature on training needs for IMG physicians was reviewed and the following needs were identified as most relevant (in descending order): communication and language skills, medical/pharmacologic knowledge, dealing with social isolation, other acculturation issues, adequacy of supervision, psychosocial/patient management focus, cultural diversity training, understanding the health care systems, understanding the hospital culture, and medical documentation. This chapter highlights the role of psychotherapy training as an acculturative experience, along with the importance of a program development paradigm for needs evaluation and training implementation. Specific recommendations will be listed to assist training directors and IMG physicians in this crucial training area.