Sharon M. Homan

Posttraumatic stress disorder in pregnancy: prevalence, risk factors, and treatment.

OBJECTIVE: To estimate the prevalence of posttraumatic stress disorder and its treatment in economically disadvantaged pregnant women. METHODS: The sample included 744 pregnant Medicaid-eligible women from Women, Infants and Children Supplemental Nutrition Program sites in 5 counties in rural Missouri and the city of St. Louis. Race (black and white) was proportional to clients seen at each site. Women were assessed by using standardized measures of posttraumatic stress disorder, 18 other psychiatric disorders, environmental stressors, and pregnancy characteristics. Logistic regression identified risk factors associated with posttraumatic stress disorder. RESULTS: Posttraumatic stress disorder prevalence was 7.7% (n = 57/744). Comorbid disorders were common. Women with posttraumatic stress disorder were 5 times more likely to have a major depressive episode (odds ratio 5.17; 95% confidence interval 2.61, 10.26) and more than 3 times as likely to have generalized anxiety disorder (odds ratio 3.25; 95% confidence interval 1.22, 8.62). Besides these comorbid disorders, risk factors for posttraumatic stress disorder included a history of maternal separation for 6 months and multiple traumatic events. Although most women with posttraumatic stress disorder reported moderate impairment in their daily lives, only 7 of the 57 women with this disorder reported speaking with any health professional about it in the last 12 months. CONCLUSIONS: The prevalence of posttraumatic stress disorder in pregnancy and low treatment rates suggest that screening for this disorder should be considered in clinical practice. LEVEL OF EVIDENCE: II-2

The effects of monitoring and feedback on compliance.

A two-group randomized experimental design was employed to assess the effects of monitoring and feedback on the compliance of 93 psychiatric outpatients treated with lithium. Compliance in both groups was measured using self-report, lithium level, appointment-keeping, and medication refill frequency. The experimental group was also monitored using a unique electronic device that records the time and day pills are removed. At the midpoint of the study, the experimental group received feedback about serum lithium levels and patterns of removing medications from the monitoring device while the control group received feedback about serum lithium levels only. The study demonstrated no sustained effect of the monitoring and feedback interventions on compliance.

Independent value of signal-averaged electrocardiography and left ventricular function in identifying patients with sustained ventricular tachycardia with coronary artery disease

To determine if the signal-averaged electrocardiographic detection of late potentials is an independent marker of sustained ventricular tachycardia (VT) in patients with documented chronic coronary artery disease (CAD), 57 patients underwent signal-averaged electrocardiography. Mean ejection fraction was 47 +/- 13% in the 14 patients with sustained VT and 56 +/- 19% in the 43 patients without VT (difference not significant). The sensitivity, specificity and accuracy of late potentials for detecting patients with VT were 64% (9 of 14), 79% (34 of 43), and 75% (43 of 57), respectively. Univariate analysis and stepwise logistic regression of angiographic and electrocardiographic variables identified late potentials as an independent marker of the patient with sustained VT. The odds ratio for late potentials to detect patients with prior sustained VT was 2.6. Six-month follow-up revealed a cardiac mortality rate of 11% and an arrhythmia event rate of 22% in patients with late potentials vs a cardiac mortality rate of 3% and an arrhythmia event rate of 13% in patients without late potentials. Thus, signal-averaged electrocardiographic detection of late potentials is useful in identifying patients with prior sustained VT independent of left ventricular function.

Relation of silent myocardial ischemia after coronary artery bypass grafting to angiographic completeness of revascularization and long-term prognosis

The prevalence and characteristics of silent myocardial ischemia as detected by 24-hour ambulatory electrocardiography ST-segment depression were prospectively assessed in 94 patients examined early (1 to 3 months) and 184 patients examined late (12 months) after coronary artery bypass grafting (CABG), and followed for a mean of 48 +/- 11 (range 4 to 62) months. The relation of ambulatory electrocardiographic silent ischemia to evidence of completeness of revascularization as defined by cardiac angiography performed 1 and 12 months after CABG, and to prognosis by follow-up of adverse clinical events was analyzed. Silent ischemia was detected early in 20% (19 of 94) and late in 27% (50 of 184) of patients, and showed a mean frequency of episodes ranging from 6 to 10 episodes/24 hours with a mean duration ranging from 15 to 23 minutes. The circadian distribution of episodes disclosed a significant peak of ischemic activity during the period of 6 A.M. to noon and a secondary peak between 6 P.M. and midnight (p less than 0.01 and p less than 0.001, respectively). Silent ischemia was not found by univariate analysis to be associated with graft or anastomotic site occlusions, low graft flow rates, grafted arteries with significant distal residual stenoses or ungrafted stenotic native coronary arteries. Kaplan-Meier analysis of time to cardiac event showed that silent ischemia was not predictive of an adverse clinical event in the early years after CABG. Cox regression analysis of 30 covariates only disclosed age (relative risk 1.06 [95% confidence interval, 1.01 to 2.94]) as having an effect on time to adverse clinical event.(ABSTRACT TRUNCATED AT 250 WORDS)

Persistent Tobacco Use During Pregnancy and the Likelihood of Psychiatric Disorders

OBJECTIVES We examined the association between psychiatric disorders and tobacco use during pregnancy. METHODS Data were derived from a population-based cohort of 744 pregnant African American and White low-income women living in urban and rural areas. The Diagnostic Interview Schedule was used to assess women for 20 different psychiatric disorders. RESULTS In comparison with nonusers, persistent tobacco users (women who had used tobacco after confirmation of their pregnancy) and nonpersistent users (women who had used tobacco but not after pregnancy confirmation) were 2.5 and 2 times as likely to have a psychiatric disorder. Twenty-five percent of persistent users had at least 1 of the following diagnoses: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and attention deficit-hyperactivity disorder. CONCLUSIONS In this cohort study, 5 diagnoses were more prevalent among persistent tobacco users than among nonusers, suggesting that several psychiatric disorders contribute to difficulty discontinuing tobacco use during pregnancy. Smoking cessation efforts focusing on pregnant women may need to address co-occurring psychiatric disorders if they are to be successful.

Evidence for Probable Sexual Transmission of the Hepatitis G Virus

A cross-sectional epidemiology study evaluated the role of sexual activity and sexually transmitted diseases (STDs) in the transmission of hepatitis G virus (HGV/GBV-C) and other hepatitis virus infections in 944 subjects. There was a statistically significant higher prevalence of HGV/GBV-C, hepatitis B virus, and hepatitis C virus exposure in the STD clinic group (i.e., subjects who were currently seeking treatment for an STD) compared with the group who never had received treatment for an STD. In a comparison of the subjects with an STD versus those without an STD, the prevalence of HGV/GBV-C was 11.3% versus 4.9%, on the basis of polymerase chain reaction (PCR) results alone, and 36.6% versus 8.8%, when results of PCR and enzyme-linked immunosorbent assay were combined. Sexual activity and, possibly, the presence of an STD increases the risk of HGB/GBV-C transmission.

Influence of Season and Temperature on the Relationship of Elemental Carbon Air Pollution to Pediatric Asthma Emergency Room Visits

Previous studies have demonstrated an association between air pollution and asthma exacerbation. Less understood is the effect of elemental carbon (EC), and the interaction of EC with temperature, on increases in pediatric asthma emergency department visits and how these relationships change across the seasons in a metropolitan area with several industries and relatively low air pollution. Measurements of EC, ozone (O3), sulfur dioxide (SO2), and total oxides of nitrogen (NOx) were available from the St. Louis EPA Supersite for June 1, 2001 to May 31, 2003. We obtained ICD-9 information on 281,763 pediatric ED visits from 27 hospitals in the St. Louis, MO metropolitan area. The relationship between EC and pediatric asthma ED visits, controlling for season, weekend exposure, allergens, and other pollutants known to exacerbate asthma, was assessed using Poisson generalized estimating equations using a 1-day lag between exposure and ED visit. We evaluated the interaction of EC and temperature and EC and weekend vs. weekday exposure. An interaction effect existed between EC and temperature for 11–17-year-olds during the summer and winter seasons. During the summer, a 0.10 μg/m3 increase in EC resulted in a 9.45% increase in asthma ED visits among 11–17-year-olds (95%CI = 1.02,1.17) at the median seasonal temperature (86.5°F). This risk increased with increasing temperature. During the winter, a 0.10 μg/m3 increase in EC resulted in 2.80% increase in asthma ED visits among 11–17-year-olds (95%CI = 1.01,1.05) at the median seasonal temperature (43.3°F). This risk increased with decreasing temperature. Among 11–17-year-olds, daily number of asthma ED visits is associated with increased levels of EC at higher temperatures in the summer and lower temperatures in the winter.

Psychiatric Disorders and Treatment in Low-Income Pregnant Women

AIMS This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment. METHOD To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there. RESULTS The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects. CONCLUSIONS With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.

Associations Between Psychiatric Disorders and Menstrual Cycle Characteristics

An understanding of the relationship between psychiatric disorders and menstrual characteristics is important to the assessment and care of women. Menstrual cycle regularity and length have significant associations with specific current and lifetime psychiatric disorders. The purpose of this study was to investigate whether psychiatric disorders are associated with menstrual cycle length or regularity. The sample included 628 pregnant Medicaid-eligible women from Women, Infants, and Childrens Supplemental Nutrition Program sites in five counties in rural Missouri and the city of St. Louis. Women were assessed for current (12-month) and lifetime psychiatric disorders with the Diagnostic Interview Schedule IV. Menstrual length and regularity were assessed by self-report. Analyses consisted of logistic regression while controlling for race. Independent of the effects of race, (a) women who reported irregular cycles were less than half as likely to have a current anxiety disorder as those that reported regular cycles, and (b) women with shorter cycles (<or=28 days) have one and a half times to two times greater risk of current affective disorder, lifetime affective disorder, lifetime anxiety disorder, lifetime substance use or dependence disorder, and lifetime drug abuse or dependence. A significant interaction effect for race and cycle length indicated that cycle length predicted likelihood of having any lifetime psychiatric disorder for Caucasians only and there was no association between cycle length and lifetime psychiatric diagnosis for African American women.

In Vitro Cyanide Release from Sodium Nitroprusside

In vitro release of cyanide from sodium nitroprusside in 5% dextrose in water solution following exposure or non-exposure to fluorescent light (500 ft candles or 791 microwatt per square cm [muWcm-2]), was measured by a cyanide-specific ion electrode at 4, 8, 24, 48, and 72 h. The cyanide concentrations were significantly increased at 24 h in the light-exposed solution. In this group, 100% of the cyanide was released from sodium nitroprusside at 72 h exposure to light. However, cyanide concentrations showed no significant changes for 72 h in the light-protected solutions, which were either exposed to 500 foot candles fluorescent light or stored in a dark room. Less than 2.5% of the cyanide was released from sodium nitroprusside at 72 h in both of the light-protected groups. No significant differences in cyanide concentrations were observed at 8 h among the exposed or non-exposed solutions. After 24 h of exposure, the cyanide concentrations in the exposed group were significantly higher than those of the two light-protected solutions. However, there were no significant differences between the cyanide concentration in the light-protected solutions. These results substantiate the safety of sodium nitroprusside solution for 24 h if the sodium nitroprusside containing solutions are properly protected from light. An additional study performed showed that a significant amount of cyanide released from sodium nitroprusside was adsorbed to the surface of polyvinylchloride.