Regional cerebral blood flow in children from 3 to 5 months of age.

BACKGROUND AND PURPOSE: Understanding the relationship between brain and behavior in early childhood requires a probe of functional brain development. We report the first large study of regional CBF by use of arterial spin-labeling in young children. MATERIALS AND METHODS: Cerebral blood flow by use of arterial spin-labeling was measured in 61 healthy children between the ages of 3 and 5 months. Blood flow maps were parcellated into 8 broadly defined anatomic regions of each cerebral hemisphere. RESULTS: There was no sex effect; however, group analysis demonstrated significantly greater CBF in the sensorimotor and occipital regions compared with dorsolateral prefrontal, subgenual, and orbitofrontal areas (P < .0001). A significant age effect was also identified, with the largest increase in blood flow between 3 and 5 months occurring in the following regions: orbitofrontal (P < .009), subgenual (P < .002), and inferior occipital lobe (P = .001). CONCLUSIONS: These results are consistent with prior histologic studies demonstrating regional variation in brain maturation and suggest that arterial spin-labeling is sensitive to regional as well as age-related differences in CBF in young children.

Indicators for serious kidney complications associated with toxic exposures: an analysis of the National Poison Data System.

CONTEXT: Over two million poisoning exposures are reported to U.S. poison control centers annually. A broad population-based survey of toxic exposures and the correlated patterns of reported kidney injury (acute or chronic) have not been systematically characterized. OBJECTIVE: Our objective was to study the demographic and exposure patterns associated with indicators for serious kidney complications (ISKC), as defined by the variables in the NPDS. MATERIALS AND METHODS: This was a retrospective, case-control study using the data elements available in the NPDS. We assessed data related to patient characteristics, substance exposure, and management. Cases and controls were derived from adult and pediatric exposures documented in NPDS (2001-2007) as having "renal effects." For substance-specific analyses, cases were restricted to those involving single substances or single entity pharmaceutical preparations. ISKC cases presented with one or more of the following NPDS codes: increased creatinine, and/or oliguria/anuria, and/or renal failure. Controls were subjects with "renal effects" but did not have increased creatinine, nor anuria/oliguria, nor renal failure. Univariate and multivariate logistic regression analyses identified factors associated with ISKC and determined the relationship between these factors. RESULTS: From the approximate 16.8 million exposures reported to the NPDS within the study timeframe, there were 16,444 single substance exposures with renal effects of which 9,074 cases experienced ISKC (55.2%) compared to 7,370 controls without ISKC. Cases with ISKC tended to be males, adults, and reported to involve intentional exposures. Cases with ISKC had higher rates of reported hemodialysis/hemofiltration (27.7%; N = 2,517) and death (10.9%; N = 990) compared to controls, respectively, (2.1%; N = 155) and (0.8%; N = 60), p < 0.001. Substances considered a priori to be nephrotoxic were associated with a higher risk of ISKC. DISCUSSION AND CONCLUSION: The NPDS provided insight into the subjects and types of exposures that associate with ISKC. Subjects with ISKC experienced higher rates of morbidity and mortality compared to subjects without ISKC. We identified subject characteristics and classes of compounds associated with ISKC. We hope that the hypotheses generated from this study of the NPDS will raise awareness of the possible risk factors and complications associated with ISKC.

Familial versus sporadic cavernous malformations: differences in developmental venous anomaly association and lesion phenotype.

BACKGROUND AND PURPOSE: CCMs are commonly associated with DVAs, but the incidence of association in familial CCM is unknown. The presence of a DVA significantly complicates surgical management of a CCM because of the risk of compromised venous drainage. In this investigation, we compared the incidence of a DVA in the presence of a CCM in sporadic and familial CCM cases comprising predominantly familial CCM with the Southwestern US common Hispanic mutation (or Q455X mutation) of CCM1. MATERIALS AND METHODS: Retrospective review was performed of 112 patients identified with CCM. MR imaging review included the presence or absence of a DVA and number, location, size, and signal-intensity characteristics of CCMs. Record review included patient and family history and documented genetic mutations. Statistical analysis was performed by using the Fisher exact and 2-sample t tests. RESULTS: Eighty-one cases were familial, 18 were sporadic, and 13 were indeterminate. There were a total of 2212 CCMs: 2176, 21, and 15 in the familial, sporadic, and indeterminate groups, respectively. There was a close association of CCM and DVA (an apparent combined vascular lesion) in 8 of 18 (44%) sporadic cases and only 1 possible such association in the familial cases. The difference was highly statistically significant (P < .0001). CONCLUSIONS: Familial CCMs are unlikely to be associated with DVAs, and sporadic CCMs have a high rate of association with DVA. This difference in imaging features of familial and sporadic CCMs suggests the possibility of a different developmental mechanism.

Patent foramen ovale in patients with migraine headache. Should it be closed?

UNLABELLED: Our objective is to review the epidemiology and proposed pathophysiology of migraine headache and its association with patent foramen ovale (PFO). We further elucidate the technical aspects of PFO closure and its possible impact on migraine headache. Upon reviewing English-language publications listed in MEDLINE relating to migraine headache, PFO; and transcatheter closure of PFO, we selected case series, retrospective and prospective studies relevant to the topic. PFO closure is being performed in annually increasing numbers worldwide for a variety of indications. The percutaneous technique of PFO closure has been shown to be safe and effective in multiple case series. Further, primarily retrospective case-control studies demonstrate a link between PFO closure and improvement of migraine headache. Few prospective data confirm the initial RESULTS: However, the only randomized, controlled trial finished to date analyzing the effect of PFO closure on migraine failed to reach its primary outcome of resolution of migraine following the intervention. The evidence of a benefit on migraine headache following PFO closure is not convincing, but certainly intriguing. With currently ongoing trials, more information related to this topic can be expected. In the meantime, the question whether we should close PFOs in patients with migraine headaches cannot be answered.

Metabolic pathway analysis web service (Pathway Hunter Tool at CUBIC).

MOTIVATION: Pathway Hunter Tool (PHT), is a fast, robust and user-friendly tool to analyse the shortest paths in metabolic pathways. The user can perform shortest path analysis for one or more organisms or can build virtual organisms (networks) using enzymes. Using PHT, the user can also calculate the average shortest path (Jungnickel, 2002 Graphs, Network and Algorithm. Springer-Verlag, Berlin), average alternate path and the top 10 hubs in the metabolic network. The comparative study of metabolic connectivity and observing the cross talk between metabolic pathways among various sequenced genomes is possible. RESULTS: A new algorithm for finding the biochemically valid connectivity between metabolites in a metabolic network was developed and implemented. A predefined manual assignment of side metabolites (like ATP, ADP, water, CO(2) etc.) and main metabolites is not necessary as the new concept uses chemical structure information (global and local similarity) between metabolites for identification of the shortest path.

[Thrombus attached to a Sideris septal occluder system 6 years later]. / Thrombus am Sideris-Okkludersystem nach 6 Jahren.

HISTORY AND CLINICAL FINDINGS: A 61-year-old man was admitted to hospital because of right-sided hypaesthesia. Additionally he reported a brief speech disturbance some weeks before. Neurological examination indicated right-sided sensomotoric hemiparesis and left-sided upper quadrant anopia. 6 years ago recurrent transient ischaemic attacks (TIA) was diagnosed caused by paradoxical embolism through a persistent foramen ovale (PFO). The PFO was closed with a 45 mm Sideris button occluder device. After this, he reported no symptoms of cerebral ischaemia and he did not take any antiplatelet therapy. INVESTIGATIONS: Transesophageal echocardiography (TEE) showed a left atrial thrombus attached to the occluder. Cerebral computed tomography revealed infarction in regions supplied by the right posterior cerebral artery and left media cerebral artery. As additional risk factor for thrombosis a heterozygous factor V Leiden mutation was diagnosed. DIAGNOSIS: Multiple cerebral infarctions caused by a thrombus attached to an occluder system 6 years after interventional closure of persistent foramen ovale in a patient with heterozygous factor V Leiden mutation. TREATMENT AND COURSE: The patient was anticoagulated (phenprocoumon) and the thrombus gradually dissolved. CONCLUSION: A thrombosis on a Sideris occluder device may cause cerebral infarctions even years after transcatheter closure of a PFO.

ProClust: improved clustering of protein sequences with an extended graph-based approach.

MOTIVATION: The problem of finding remote homologues of a given protein sequence via alignment methods is not fully solved. In fact, the task seems to become more difficult with more data. As the size of the database increases, so does the noise level; the highest alignment scores due to random similarities increase and can be higher than the alignment score between true homologues. Comparing two sequences with an arbitrary alignment method yields a similarity value which may indicate an evolutionary relationship between them. A threshold value is usually chosen to distinguish between true homologue relationships and random similarities. To compensate for the higher probability of spurious hits in larger databases, this threshold is increased. Increasing specificity however leads to decreased sensitivity as a matter of principle. Sensitivity can be recovered by utilizing refined protocols. A number of approaches to this challenge have made use of the fact that proteins are often members of some larger protein family. This can be exploited by using position-specific substitution matrices or profiles, or by making use of transitivity of homology. Transitivity refers to the concept of concluding homology between proteins A and C based on homology between A and a third protein B and between B and C. It has been demonstrated that transitivity can lead to substantial improvement in recognition of remote homologues particularly in cases where the alignment score of A and C is below the noise level. A natural limit to the use of transitivity is imposed by domains. Domains, compact independent sub-units of proteins, are often shared between otherwise distinct proteins, and can cause substantial problems by incorrectly linking otherwise unrelated proteins. RESULTS: We extend a graph-based clustering algorithm which uses an asymmetric distance measure, scaling similarity values based on the length of the protein sequences compared. Additionally, the significance of alignment scores is taken into account and used for a filtering step in the algorithm. Post-processing, to merge further clusters based on profile HMMs is proposed. SCOP sequences and their super-family level classification are used as a test set for a clustering computed with our method for the joint data set containing both SCOP and SWISS-PROT. Note, the joint data set includes all multi-domain proteins, which contain the SCOP domains that are a potential source of incorrect links. Our method compares at high specificities very favorably with PSI-Blast, which is probably the most widely-used tool for finding remote homologues. We demonstrate that using transitivity with as many as twelve intermediate sequences is crucial to achieving this level of performance. Moreover, from analysis of false positives we conclude that our method seems to correctly bound the degree of transitivity used. This analysis also yields explicit guidance in choosing parameters. The heuristics of the asymmetric distance measure used neither solve the multi-domain problem from a theoretical point of view, nor do they avoid all types of problems we have observed in real data. Nevertheless, they do provide a substantial improvement over existing approaches. AVAILABILITY: The complete software source is freely available to all users under the GNU General Public License (GPL) from http://www.bioinformatik.uni-koeln.de/~proclust/download/

Clustering protein sequences--structure prediction by transitive homology.

MOTIVATION: It is widely believed that for two proteins Aand Ba sequence identity above some threshold implies structural similarity due to a common evolutionary ancestor. Since this is only a sufficient, but not a necessary condition for structural similarity, the question remains what other criteria can be used to identify remote homologues. Transitivity refers to the concept of deducing a structural similarity between proteins A and C from the existence of a third protein B, such that A and B as well as B and C are homologues, as ascertained if the sequence identity between A and B as well as that between B and C is above the aforementioned threshold. It is not fully understood if transitivity always holds and whether transitivity can be extended ad infinitum. RESULTS: We developed a graph-based clustering approach, where transitivity plays a crucial role. We determined all pair-wise similarities for the sequences in the SwissProt database using the Smith-Waterman local alignment algorithm. This data was transformed into a directed graph, where protein sequences constitute vertices. A directed edge was drawn from vertex A to vertex B if the sequences A and B showed similarity, scaled with respect to the self-similarity of A, above a fixed threshold. Transitivity was important in the clustering process, as intermediate sequences were used, limited though by the requirement of having directed paths in both directions between proteins linked over such sequences. The length dependency-implied by the self-similarity-of the scaling of the alignment scores appears to be an effective criterion to avoid clustering errors due to multi-domain proteins. To deal with the resulting large graphs we have developed an efficient library. Methods include the novel graph-based clustering algorithm capable of handling multi-domain proteins and cluster comparison algorithms. Structural Classification of Proteins (SCOP) was used as an evaluation data set for our method, yielding a 24% improvement over pair-wise comparisons in terms of detecting remote homologues. AVAILABILITY: The software is available to academic users on request from the authors. CONTACT: e.bolten@science-factory.com; schliep@zpr.uni-koeln.de; s.schneckener@science-factory.com; d.schomburg@uni-koeln.de; schrader@zpr.uni-koeln.de. SUPPLEMENTARY INFORMATION: http://www.zaik.uni-koeln.de/~schliep/ProtClust.html.

Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial.

CONTEXT: Chronic nightmares occur frequently in patients with posttraumatic stress disorder (PTSD) but are not usually a primary target of treatment. OBJECTIVE: To determine if treating chronic nightmares with imagery rehearsal therapy (IRT) reduces the frequency of disturbing dreams, improves sleep quality, and decreases PTSD symptom severity. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted from 1995 to 1999 among 168 women in New Mexico; 95% had moderate-to-severe PTSD, 97% had experienced rape or other sexual assault, 77% reported life-threatening sexual assault, and 58% reported repeated exposure to sexual abuse in childhood or adolescence. INTERVENTION: Participants were randomized to receive treatment (n = 88) or to the wait-list control group (n = 80). The treatment group received IRT in 3 sessions; controls received no additional intervention, but continued any ongoing treatment. MAIN OUTCOME MEASURES: Scores on the Nightmare Frequency Questionnaire (NFQ), Pittsburgh Sleep Quality Index (PSQI), PTSD Symptom Scale (PSS), and Clinician-Administered PTSD Scale (CAPS) at 3- and 6-month follow-up. RESULTS: A total of 114 participants completed follow-up at 3 and/or 6 months. Comparing baseline to follow-up (n = 97-114), treatment significantly reduced nights per week with nightmares (Cohen d = 1.24; P<.001) and number of nightmares per week (Cohen d = 0.85; P<.001) on the NFQ and improved sleep (on the PSQI, Cohen d = 0.67; P<.001) and PTSD symptoms (on the PSS, Cohen d = 1.00; P<.001 and on the CAPS, Cohen d = 1.53; P<.001). Control participants showed small, nonsignificant improvements for the same measures (mean Cohen d = 0.21). In a 3-point analysis (n = 66-77), improvements occurred in the treatment group at 3-month follow-up (treatment vs control group, Cohen d = 1.15 vs 0.07 for nights per week with nightmares; 0.95 vs -0.06 for nightmares per week; 0.77 vs 0.31 on the PSQI, and 1.06 vs 0.31 on the PSS) and were sustained without further intervention or contact between 3 and 6 months. An intent-to-treat analysis (n = 168) confirmed significant differences between treatment and control groups for nightmares, sleep, and PTSD (all P<.02) with moderate effect sizes for treatment (mean Cohen d = 0.60) and small effect sizes for controls (mean Cohen d = 0.14). Posttraumatic stress symptoms decreased by at least 1 level of clinical severity in 65% of the treatment group compared with symptoms worsening or not changing in 69% of controls (chi(2)(1) = 12.80; P<.001). CONCLUSIONS: Imagery rehearsal therapy is a brief, well-tolerated treatment that appears to decrease chronic nightmares, improve sleep quality, and decrease PTSD symptom severity.

Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility.

PURPOSE: To evaluate imagery rehearsal therapy for the treatment of chronic nightmares in a sample of adolescent girls. METHODS: Adolescent girls ranging in age from 13 to 18 years were recruited from the Wyoming Girls School in Sheridan, Wyoming (treatment group, n = 9; control group, n = 10). These girls had previously suffered a high prevalence of unwanted sexual experiences in childhood and adolescence, and thus many suffered from nightmares, sleep complaints, and posttraumatic stress symptoms. Imagery rehearsal therapy was provided in a 1-day (6-h) workshop. Imagery rehearsal consists of three steps, all of which are performed in the waking state: (a) select a nightmare, (b) "change the nightmare any way you wish," and (c) rehearse the images of the new version ("new dream") 5 to 20 min each day. Control participants received no intervention. RESULTS: At baseline, these girls had been suffering from nightmares, on average, for 4.5 years, and they reported experiencing 20 nightmares per month, which occurred at a frequency of at least one bad dream every other night. At 3 months, self-reported, retrospectively assessed nightmare frequency measured in nights per month decreased 57% (p =.01, d = 1.4) and measured in nightmares per month decreased 71% (p =.01, d = 1.7) in the treatment group, compared with no significant changes in the control group. No significant changes were noted for sleep and posttraumatic stress disorder measures in either group. CONCLUSION: Imagery rehearsal therapy was an effective treatment option for chronic nightmares in this adjudicated adolescent population.

Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD.

BACKGROUND: Sleep disturbance in posttraumatic stress disorder is very common. However, no previous posttraumatic stress disorder studies systematically examined sleep breathing disturbances, which might influence nightmares, insomnia, and posttraumatic stress disorder symptoms. METHODS: Forty-four consecutive crime victims with nightmares and insomnia underwent standard polysomnography coupled with a nasal pressure transducer to measure airflow limitation diagnostic of obstructive sleep apnea and upper airway resistance syndrome. RESULTS: Forty of 44 participants tested positive on objective sleep studies based on conservative respiratory disturbance indices of more than 15 events per hour; 22 patients suffered from obstructive sleep apnea and 18 suffered from upper airway resistance syndrome. CONCLUSIONS: In an uncontrolled study, insomnia and sleep-disordered breathing were extremely prevalent in this small and select sample of crime victims. Research is needed to study 1) prevalence of sleep-disordered breathing in other posttraumatic stress disorder populations using appropriate controls and nasal pressure transducers and 2) effects of sleep treatment on posttraumatic stress symptoms in trauma survivors with comorbid obstructive sleep apnea or upper airway resistance syndrome. In the interim, some posttraumatic stress disorder patients may benefit from sleep medicine evaluations.

Patent foramen ovale closure in patients with transient ischemia attack/stroke.

Paradoxical embolism through a patent foramen ovale (PFO) has been recognized as a potential cause of transient ischemia attack (TIA) and stroke especially in younger patients. The therapeutic options are medical treatment (antiaggregation or anticoagulation) with an annual recurrence rate of 3% to 4% for stroke or TIA, surgical PFO closure, or catheter closure. Randomized studies are ongoing; however, the results will not be available soon. Since August 1994, we have attempted catheter closure of a PFO in 281 patients (age 17 to 79 years, mean 46.8 +/- 13.2) with paradoxical embolism. Of these, 184 patients had at least one embolic stroke, 112 patients at least one TIA, and 15 patients at least one peripheral embolism. The diameter of the PFO, measured with a balloon catheter, ranged from 3 mm to 24 mm with a mean of 10 +/- 3.5 mm. Implantation of the occluder was technically successful in all patients (two attempts in four patients). Seven different devices were used: 26 Sideris buttoned, 11 ASDOS, 19 Angel Wings, 98 PFO-Star, 37 Cardioseal-Starflex, 57 Amplatzer and, 33 Helex devices. One patient suffered from septicemia and subsequently died. In 2 patients, device embolization occurred during or after the procedure (1 Sideris, 1 PFO-Star; catheter retrieval successful). Thirty-seven patients had other minor complications without long-term sequelae: atrial fibrillation within the first weeks after implantation in five patients, asymptomatic thrombus on the device at routine transesophageal echocardiogram (TEE) in 7 patients (1 Angel Wings, 1 ASDOS, 1 CardioSeal, 4 PFO-Star), and device frame fracture in 25 patients (2 Sideris, 4 ASDOS, 1 Angel Wings, 1 CardioSeal, 17 PFO-Star). No complications occurred with the newer devices (Amplatzer and Helex). A residual shunt after 6 months was found in 5.5% of the patients who had completed their 6-month TEE follow-up. In two patients, a second occluder was implanted because of a residual shunt. During a follow-up period of 1 month to 71 months (mean 12 +/- 16 months, 268 patient years), a recurrence of an embolic event (seven TIA, two stroke) occurred in eight patients. None of these occurred with the newer devices (Amplatzer, Helex). Freedom from recurrence of the combined end point of TIA, ischemic stroke, and peripheral embolism was 95.7% (95% CI: 89.0%-98.4%) at 1 year and 94.1% (95% CI: 80.1-98.4%) at 3 years. Catheter PFO closure is a technically simple procedure. With the newer devices and increasing experience, the success rate has improved and the complication rate has decreased. The advantage of the procedure is that closing the defect means a causal treatment. However, catheter closure of PFO despite a very low morbidity has inherent potential risks like any other interventional procedure. Furthermore, selection of patients who definitely have PFO as the cause of their cerebral event has not been defined. For these reasons, further studies are warranted.

Catheter closure of atrial septal defects and patent foramen ovale in patients with an atrial septal aneurysm using different devices.

BACKGROUND: Atrial septal aneurysm is frequently associated with patent foramen ovale (PFO) and atrial septal defects (ASD). Moreover, a relationship between atrial septal aneurysm and embolic cerebrovascular events has been suggested. The aims of this study were to analyze morphological and functional characteristics of atrial septal aneurysm in PFO and ASD patients and to assess the feasibility and efficacy of different devices for transcatheter closure and the influence of atrial septal aneurysm. METHODS: Between March 1997 and May 2000 transcatheter ASD or PFO closure was attempted in 63 patients (mean age 47 +/- 13 years) with an atrial septal aneurysm using one of the following devices: Angelwings (n = 3), Cardioseal (n = 5), Cardioseal-Starflex (n = 7), Amplatzer (n = 11), Amplatzer-PFO (n = 5), PFO-Star (n = 25), or Helex (n = 7). RESULTS: Implantation was primarily successful (after the first or second attempt) in all patients. One PFO-Star device embolized 12 hours after the procedure. During follow-up (0.6-37 months, mean 10.4 +/- 9.2) a residual shunt could be detected by transesophageal echocardiography after 2 weeks in four patients and after 6 months in one patient. Three PFO patients had cerebrovascular events after implantation. Two patients had a transient ischemic attack (TIA) and one patient a stroke. A thrombus formation on the device detected in three patients disappeared after antithrombotic therapy. CONCLUSION: We conclude that ASDs and PFOs with an associated atrial septal aneurysm can be closed with different available devices. There seem to be no additional risks compared with patients without atrial septal aneurysm.

The relationship of sleep quality and posttraumatic stress to potential sleep disorders in sexual assault survivors with nightmares, insomnia, and PTSD.

Sleep quality and posttraumatic stress disorder (PTSD) were examined in 151 sexual assault survivors, 77% of whom had previously reported symptoms of sleep-disordered breathing (SDB) or sleep movement disorders (SMD) or both. Participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Posttraumatic Stress Scale (PSS). High PSQI scores reflected extremely poor sleep quality and correlated with PSS scores. PSQI scores were greater in participants with potential SDB or SMD or both. PSQI or PSS scores coupled with body-mass index and use of antidepressants or anxiolytics predicted potential sleep disorders. The relationship between sleep and posttraumatic stress appears to be more complex than can be explained by the current PTSD paradigm; and, sleep breathing and sleep movement disorders may be associated with this complexity.

[Second and Third Annual Report of the German Society of Coronary Angiography and Interventions in Private Practice (BNK) concerning quality assurance in invasive cardiology]. / Zweiter und dritter Jahresbericht des BNK zur Qualitätssicherung in der Invasivkardiologie.

Since 1995, the German Society for Cardiac Angiography and Interventions in Private Practice (BNK) has been intensely involved in quality assurance; since 1996, it has registered relevant data for diagnostic left heart catheterization (DIAG) and coronary interventions (PTCA). The following data are based on a total of 72,777 cardiac catheters, of which 54,513 were DIAG and 18,264 were PTCA (DIAG in 1996: 10,316; in 1997: 15,692 and in 1998: 28,505. PTCA in 1996: 2,597; in 1997: 5,600 and in 1998: 10,067). The mean patient age was 61.9 years for males and 65.3 years for females (31%). DIAG was performed on an out-patient basis in 60% of the cases. The proportion of self-referrals is circa one-third and has not increased over time. A s/p PTCA was present in 21% of the DIAG patients; those after coronary bypass surgery showed a steadily increasing trend towards a follow-up DIAG (8% of the patients). There was a distinctive decrease in the use of contrast medium from an average of 164 ml (1996) to 138 ml (1998). The symptoms leading to DIAG did not substantially change in the years from 1996 to 1998; the angiographic range of the coronary disease and the degree of an impaired myocardial function have remained virtually unchanged. The treatment recommendations appear to tend towards medical therapy with decreasing indications for PTCA (20%) and open heart surgery (16%). The mean duration of a PTCA procedure decreased from 57 +/- 8 (1996) to 44.6 +/- 25 (1998) minutes. The success rates remained unchanged for coronary stenoses as well as for recanalization of chronic total occlusions. PTCA complications: the incidence of abrupt coronary occlusions was 2% and of emergency bypass surgery 0.4%; mortality was 0.1%.

A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report.

Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

Sleep breathing and sleep movement disorders masquerading as insomnia in sexual-assault survivors.

A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). They completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. Seventy-seven percent of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual-assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia--the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography (PSG) are needed to test these hypotheses.

Stent or angioplasty after recanalization of chronic coronary occlusions? (The SARECCO Trial).

This study tests whether stent implantation without anticoagulation after catheter recanalization of coronary occlusions can improve outcome compared with balloon angioplasty alone. One hundred ten patients were randomly assigned to angioplasty alone (no stent group) or stent implantation (stent group) after successful recanalization and balloon angioplasty. The type of stent and angioplasty technique utilized were decided by the operator. The acute procedural success in both groups was 100%. The acute minimal lumen diameter (MLD) was 1.85 +/- 0.44 mm in the no stent group versus 2.54 +/- 0.53 mm in the stent group (p <0.01). The diameter stenosis was 21 +/- 13% versus 3 +/- 14% (p <0.01). This was achieved not only by the stent implantation itself but primarily by a larger maximum balloon diameter in the stent group after stent implantation (3.32 +/- 0.55 mm vs 2.86 +/- 0.4 mm, p <0.05). After 4 months, the MLD was 1.15 +/- 0.73 mm in the no stent group versus 1.81 +/- 0.9 mm in the stent group (p <0.01). The diameter stenosis was 56 +/- 29% versus 34 +/- 28% (p <0.01). After 2 years, event-free survival was 26% in the no stent group and 52% in the stent group (p <0.05). Thus, acute and long-term procedural and angiographic success of stent implantation without anticoagulation after recanalization of total coronary occlusions is superior to that of balloon angioplasty alone. This beneficial effect is mainly the result of the larger balloon diameters, which may be used after stent implantation.