What's in it for the community? Public academic liaison and local mental health agencies

This paper reviews a triangular relationship in which a state mental health administration, a university, and a local mental health authority (and by extension, community mental health programs) co-exist. The relationship is based on mutual trust and interdependence, both of which are reinforced when certain key positions are developed such that individuals can work in two or more of the three arenas. It is essential that representatives of each group be encouraged to recognize the needs and assets of the other two groups. Specific examples of the benefits of this arrangement are described based on experiences in the state of Oregon.This work is supported in part by NIMH grant number P50 MH43458 to the Western Mental Health Research Center at Oregon Health Sciences University. Dr. McFarland is Burroughs-Wellcome Scholar in Pharamacoepidemiology.     

Diagnostic criteria for multiple sclerosis: 2005 revisions to the "McDonald Criteria"

New diagnostic criteria for multiple sclerosis integrating magnetic resonance image assessment with clinical and other paraclinical methods were introduced in 2001. The "McDonald Criteria" have been extensively assessed and used since 2001. New evidence and consensus now strengthen the role of these criteria in the multiple sclerosis diagnostic workup to demonstrate dissemination of lesions in time, to clarify the use of spinal cord lesions, and to simplify diagnosis of primary progressive disease. The 2005 Revisions to the McDonald Diagnostic Criteria for MS should simplify and speed diagnosis, whereas maintaining adequate sensitivity and specificity.     

Spatial organization of human perioral reflexes

Reflex responses recorded from the upper and lower divisions of the human orbicularis oris muscle were studied as a function of the site of stimulation. Stimuli were applied to 11 sites, ranging from the glabrous skin of the upper and lower lip vermilion borders to the hairy skin of the cheek. Highly localized, innocuous mechanical stimuli were created by displacing a servo-controlled probe over the surface of the perioral skin. Reflex response amplitude was strongly dependent on the site of stimulation. Stimulation of some sites, for example the ipsilateral corner of the mouth, the chin, and cheek, produced no responses, whereas stimulation of other sites, particularly the ipsilateral vermilion borders, produced large reflex responses. Changes in response amplitude as a function of stimulation site were the same for the upper lip and lower lip muscle recordings, with the largest responses at both recording sites produced by stimulation of the ipsilateral upper lip vermilion border. These results suggest that the upper and lower divisions of orbicularis oris share common synaptic drive, at least from inputs generated via reflex pathways, and that the upper vermilion border may be more densely innervated with mechanoreceptors than the lower. The latter hypothesis was supported by an additional experiment examining two-point discrimination thresholds for the glabrous skin of the upper and lower lips. Two-point thresholds were significantly smaller for the upper compared with the lower lip vermilion border.     

Efficacy of propranolol therapy after acute myocardial infarction related to coronary arterial anatomy and left ventricular function

The effect of the beta-adrenergic blocking agent propranolol on morbidity and mortality risk after acute myocardial infarction was studied relative to coronary anatomy and left ventricular (LV) ejection fraction in a subset of 406 patients participating in a randomized study of 3,837 patients in the Beta Blocker Heart Attack Trial (BHAT). Median follow-up for this subset of patients was 28 months. The mortality rate was 2% (2 of 100) in patients with 2- and 3-vessel coronary artery disease taking propranolol and 10% (12 of 126) in those taking placebo (p less than 0.02). In patients with 2- and 3-vessel coronary artery disease with decreased LV function (defined as ejection fraction less than 50%), no patient taking propranolol died, whereas 17% (7 of 42) taking placebo died (p less than 0.04). The salutary effect of propranolol on mortality in the larger BHAT after acute myocardial infarction also was evident in this population studied in regard to their coronary and LV anatomy and function.     

Ventricular arrhythmias during coronary angiography in patients with angina pectoris or chest pain syndromes

Of 7,915 patients undergoing coronary angiography from 1978 to 1983, 39 (25 men and 14 women with a mean age of 57 years [range 37 to 79]) had sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during the procedure. Nine patients had atypical chest pain and 30 had typical angina. Fifteen had had a previous myocardial infarction. One patient had a history of VT or VF. Electrocardiograms taken at rest revealed a prolonged QT interval in 14. A normal ejection fraction was found in 79%. Coronary angiography revealed that 10 patients had 3-vessel disease, 15 had 1- or 2-vessel disease and 14 had normal coronary arteries. The VT or VF was seen with injection of contrast medium into the right coronary artery in 24, the left coronary artery in 10 and vein bypass grafts in 5 patients. Of the episodes of VT or VF, 67% occurred after injection of contrast medium into a minimally diseased coronary artery. In patients in whom VT or VF occurred after injection into a minimally diseased coronary artery, the arrhythmia was preceded by bradycardia, usually with pronounced widening of the QRS and QT intervals. This response was significantly different from that in patients in whom VT or VF occurred after injection into a coronary artery with significant stenosis; in these patients, VT or VF was initiated by a single premature ventricular contraction on a T wave. VT or VF was successfully cardioverted in all instances, without further arrhythmias.     

An EEG-based brain-computer interface for cursor control.

This study began development of a new communication and control modality for individuals with severe motor deficits. We trained normal subjects to use the 8-12 Hz mu rhythm recorded from the scalp over the central sulcus of one hemisphere to move a cursor from the center of a video screen to a target located at the top or bottom edge. Mu rhythm amplitude was assessed by on-line frequency analysis and translated into cursor movement: larger amplitudes moved the cursor up and smaller amplitudes moved it down. Over several weeks, subjects learned to change mu rhythm amplitude quickly and accurately, so that the cursor typically reached the target in 3 sec. The parameters that translated mu rhythm amplitudes into cursor movements were derived from evaluation of the distributions of amplitudes in response to top and bottom targets. The use of these distributions was a distinctive feature of this study and the key factor in its success. Refinements in training procedures and in the distribution-based method used to translate mu rhythm amplitudes into cursor movements should further improve this 1-dimensional control. Achievement of 2-dimensional control is under study. The mu rhythm may provide a significant new communication and control option for disabled individuals.     

Multiple sclerosis: serial study of gadolinium-enhanced MR imaging

Thirteen patients with definite multiple sclerosis (MS), studied 16-24 months previously with magnetic resonance (MR) imaging with and without enhancement by intravenously administered gadolinium diethylenetriaminepentaacetic acid (DTPA) dimeglumine, were reexamined with a similar protocol. Assessment of enhancement and clinical activity in both studies revealed that enhancement was observed in 13 of 14 cases in which clinical activity had changed within 4 weeks of the study and thus appeared more sensitive than clinical examination in determining active disease. The 3-minute postinjection, short repetition time image (TR) was the most efficient for depicting enhancement. Enhancing lesions (active plaques) arose from previously hyper- or isointense regions on long TR images. Previously active lesions reverted to areas of iso- or hyperintensity on long TR images. Serial comparison of long TR images in this population reveals a decrease in high-intensity lesions on long TR images in some cases and an increase in others. The findings of high-intensity regions on long TR images and previously enhancing lesions both becoming isointense suggests that transient inflammatory changes with concomitant edema without demyelination and/or with significant remyelination may occur in some MS lesions. MS lesions are dynamic; both active and inactive lesions may show dramatic change on longitudinal MR imaging studies.     

Violence,mental health,and physical symptoms in an academic internal medicine practice

OBJECTIVE: To assess how physical and/or sexual intimate partner violence (IPV), child abuse, and community violence relate to long-term mental and physical problems; to examine the overlap between different forms of violence and the impact of experiencing multiple forms of violence. DESIGN: Cross-sectional survey. SETTING: Three general internal medicine practices affiliated with an academic medical center. PARTICIPANTS: English-speaking women aged 25 to 60. MEASUREMENTS: Telephone or in-person interview and chart review. RESULTS: One hundred seventy-four women completed interviews. A majority of participants experienced more than one form of violence. In separate multivariate analyses, each form of violence was associated with depressive symptoms or with at least 6 chronic physical symptoms, after adjustment for demographic factors and substance abuse. The degree of association with health outcomes was similar for each form of violence (odds ratio [OR], 2.4 to 3.9; P < .003). The association with chronic physical symptoms remained significant for IPV (OR, 3.3; P < .002) and community violence (OR, 3.4; P < .003), even after adjustment for depression and posttraumatic stress disorder. There were dose-response relationships between the number of forms of violence experienced and the odds of depressive symptoms and the odds of multiple chronic physical symptoms. CONCLUSIONS: Multiple types of victimizations may contribute to patients' current mental health and physical problems. Research or clinical protocols that only focus on one form of violence may underestimate the complexity of women's experiences and needs.