Utilization of the Psoriasis Epidemiology Screening Tool (PEST): A Risk Stratification Strategy for Early Referral of Psoriatic Arthritis Patients to Minimize Irreversible Erosive Joint Damage.

Psoriatic arthritis (PsA) can affect a diverse range of anatomical sites and its heterogeneous presentation contributes to misdiagnosis and delayed treatment with conventional and biologic disease-modifying antirheumatic drugs (DMARDs). Up to 15% of psoriasis (PsO) patients affected by PsA remain undiagnosed. Early detection and referral to a rheumatologist are crucial to optimize care and minimize irreversible erosive joint damage. To improve the rheumatology referral process, the authors propose a risk stratification tool to identify and triage patients with possible psoriatic arthritis. With the aim of ultimately assisting in early treatment initiation, this risk stratification algorithm can be used in both dermatology and primary care clinics. It is based on the Psoriasis Epidemiology Screening Tool (PEST) combined with the ClASsification criteria for Psoriatic Arthritis (CASPAR). This article intends to provide a rationale for further prospective studies whose objective would be to validate this screening algorithm.

Blink detection and magnetic force generation for correction of lagophthalmos, with specific regard to implant compatibility testing.

PURPOSE: The overall goal was to restore a normal and synchronous blink in unilateral lagophthalmos. We describe the biocompatibility profiling of a novel ferromagnetic implant used for electromagnetic eyelid force generation. METHODS: A non-contact blink detection system and an electromagnetic stimulation system were designed and tested. A modified Lester-Burch speculum equipped with strain gauge technology was used in blinking force measurement. Samarium-cobalt magnets were prototyped and coated with parylene-C. Biocompatibility testing was performed using NIH/3T3 mouse fibroblast cells with MTT colorimetric assay cytotoxic quantification. OUTCOME MEASURES: Cellular viability and interleukin concentrations. RESULTS: Our system was capable of detecting 95.5 ± 3.6% of blinks in various lighting conditions. Using our force measuring device, the difference between non-paralyzed and paralyzed orbicularis oculi (OO) for normal and forceful blinking closure was 40.4 g and 101.9 g, respectively. A 16.6 × 5.0 × 1.5 mm curved shaped samarium cobalt eyelid implant was successfully developed and showed a reproducible blink at 100 ms with full corneal coverage with external eyelid taping. Compared to gold weights, parylene-C coated samarium cobalt implants showed not only excellent cell viability (82.0 ± 4.9% vs. 88.4 ± 0.9%, respectively, p > .05), but also below detection threshold for pro-inflammatory marker concentrations (interleukin-6 < 2 pg/mL and interleukin-10 < 3 pg/mL). CONCLUSIONS: We demonstrated excellent in-vitro biocompatibility of our parylene-C coated samarium cobalt implants. We believe that our novel approach can improve the quality-of-life of affected individuals and provides new understanding of blinking biomechanics.

Can cognitive deficits differentiate between schizophrenia with and without obsessive-compulsive symptoms?

BACKGROUND: The frequent occurrence of obsessive-compulsive symptoms (OCS) in the course of schizophrenia and their impact on the functional outcome of the illness underlie the suggestion that the presence of OCS represents a separate subtype of schizophrenia, with a distinct clinical presentation and prognosis and specific neurobiological characteristics. This study investigated whether the presence of OCS in schizophrenia is associated with worse cognitive functioning in the domains of processing speed, executive functions and visuospatial memory. We also explored whether the degree of impairment in any of these cognitive domains could predict group membership (i.e. Schizophrenia with OCS [Sch-OCS] and Schizophrenia without OCS) and if there was a relationship between cognitive functioning and severity of OCS within the Sch-OCS group. METHODS: Forty patients with schizophrenia, 20 with and 20 without OCS, individually matched for age, gender, years of education and severity of psychotic symptoms and 20 healthy controls underwent a comprehensive neuropsychological assessment. RESULTS: Only lower performance in processing speed discriminated patients with OCS from patients without OCS. Processing speed impairment not only classified patients in OCS or non-OCS group but was also independent of the severity of OCS symptoms. CONCLUSIONS: The notion of additive effects of both schizophrenia and OCD on the structural and functional integrity of the brain circuits that support cognitive functions warrants further investigation in longitudinal neuropsychological and neuroimaging studies with larger samples and sufficient variation in the severity of OCS.

An atypical case of bullous systemic lupus erythematosus in a 16-year-old boy.

Bullous systemic lupus erythematosus (BSLE) is a rare autoimmune subepidermal blistering disease with a female predominance characterized as an acute vesicobullous eruption in patients with systemic lupus erythematosus (SLE). Here we report a case of BSLE in a 16-year-old boy that does not adhere to the criteria originally established and suggest a new outlook on this condition.

The impact of living with severe lower extremity lymphedema: a utility outcomes score assessment.

BACKGROUND: Debilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual's life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema. METHODS: A utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors. RESULTS: A total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema (0.50 ± 0.18, 0.76 ± 0.22, and 0.76 ± 0.21, respectively) were significantly different (P < 0.001) from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness (0.35 ± 0.17, 0.61 ± 0.28, and 0.62 ± 0.26, respectively). CONCLUSIONS: We found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

Quality of life and psychopathology in different COVID-19 pandemic periods: A longitudinal study.

Τhe aim of this longitudinal study was to investigate the effect of the COVID-19 pandemic on the mental health and quality of life (QoL) of the general population in the region of Attica, Greece, during the third year of the pandemic (2022), and tο compare the findings with those of a survey conducted in the first year (2020). Our sample consisted of 130 participants and the study was conducted through phone interviews. The instruments used were: the World Health Organisation QoL instrument, the Depression-Anxiety-Stress Scale, the Body Vigilance Scale, the Dimensional Obsessive-Compulsive Scale, as well as socio-demographic data and questions on stressors related to COVID-19. The findings of the study were the following: (1) Regarding the comparison of the variables between the first and the third year of the pandemic in the total sample: a) In comparison to the first year, in the third year we observed a significant decrease in negative feelings caused by the pandemic; b) obsessive compulsive (OC) and hypochondriacal symptomatology were significantly reduced, and the fact that participants felt safe following vaccination had a statistically significant effect on this decrease; c) job insecurity was aggravated; d) QoL remained low and even deteriorated in the Environment domain; f) no changes were found in Depression-Stress. (2) Regarding participants who were contaminated, there was a significant increase in negative feelings during the third year of the pandemic. Moreover, QoL decreased in the Physical, Psychological health, Environment domains, as well as in OC symptomatology. (3) Depression-Stress, hypochondriacal symptomatology, and the case of contamination were the predominant factors negatively associated with the dependent variables of QoL. (4) Vaccination was found to contribute to high levels of the QoL Environment domain score. (5) Anxiety, hypochondriacal symptomatology, fear of contamination, and negative feelings seemed to predict OC symptomatology. (6) The most vulnerable groups, in terms of QoL and mental health, were men, older and lower-educated people. Overall, it was found that the negative psychosocial impact of the pandemic persisted, especially on people who had fallen ill during the third year of the pandemic. Therefore, targeted psychotherapeutic interventions should be implemented, especially for those who got infected.

The state of psychiatry in Greece.

Greek psychiatry is presently in a transitional period. Following a large-scale reform effort that started in the mid 1980s, de-institutionalization and establishment of numerous community services has been achieved to a great extent. However, sectorization, development of primary care policies, inter-sectoral communication and long-range planning have not been achieved and deficiencies in the provision of care for children, adolescents, old people, individuals with autism, with intellectual disabilities and with eating disorders as well as deficiencies in forensic psychiatric services have been identified. Thus, the Greek psychiatric reform is an unfinished reform. The financial crisis that has recently hit the country has had a serious impact on the population and especially on vulnerable groups such as individuals with psychiatric disorders. Continuation of psychiatric reform to its desired extent has become problematic. This situation calls for re-orientation of the national mental health strategy towards more realistic and priority-orientated goals, i.e. securing a satisfactory level of function of the existing services, persisting in the implementation of the basic targets of psychiatric reform, creating the necessary infrastructure but avoiding the creation of expensive facilities of secondary importance.

Utility outcome scores for unilateral facial paralysis.

BACKGROUND: Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. METHODS: Utility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. RESULTS: A total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56±0.18, 0.78±0.21, and 0.79±0.21 respectively] were significantly different (P<0.0001) from the corresponding outcome scores for monocular blindness [0.61±0.21, 0.83±0.21, and 0.85±0.18, respectively] and binocular blindness [0.33±0.18, 0.65±0.28, and 0.65±0.29, respectively]. Linear regression analysis using age, race, income, and education as predictors of each of the utility scores for facial paralysis showed no statistical significance. CONCLUSIONS: In samples of the general population and medical students, all utility score outcome measures for facial paralysis were lower than those for monocular blindness. Our sample population, if faced with unilateral facial paralysis, would theoretically undergo facial reanimation procedures with a willingness to sacrifice 8 years of life and be willing to undergo a procedure with a 21% chance of mortality to attain perfect health, respectively.

The effect of COVID-19 pandemic on mental health and quality of life in the Athens area - Greece.

This study examines the associations of the COVID -19 pandemic stressors with mental health and quality of life (QoL) of the general population in different demographic areas of Athens. The random sample of the study consisted of 602 participants, 389 (64,6%) women and 213 (35,4%) men residing in Attica (Greece). It was conducted with telephone interviews during the first wave of the pandemic. The instruments used were: World Health Organization Quality of Life Instrument (WHOQOL-BREF), Depression Anxiety Stress Scale (DASS - 21), Body Vigilance Scale (ΒVS), Dimensional Obsessive-Compulsive Scale (Category 1: contamination obsessions -decontamination compulsions) (DOCS) and a set of socio-demographic data and questions on stressors related to the COVID-19 outbreak. A range of statistical analyses were used, including descriptive statistics, examination of the questionnaires' internal consistency, calculating Cronbach's alpha coefficient, as well as multiple linear regression analyses with dependent variables the WHOQOL-BREF, DASS-21, DOCS, and BVS scales. According to the results of our study: a) The greater the extent of negative emotions due to the pandemic and the imposed restrictive measures, such as worry and fear, the higher the score of depression, anxiety, stress, obsessive-compulsive symptomatology, body vigilance and the lower the scores of the WHOQOL domains (Physical Health, Psychological Health, Social Relationships, Environment), b) the fear of being contaminated by the virus seems to have intensified depression-anxiety-stress (DASS-21), obsessive-compulsive (DOCS) and hypochondriacal (BVS) symptomatology. c) The independent variables of depression, stress and anxiety and obsessive - compulsive and hypochondriacal symptomatology were negatively associated with QoL d) The most vulnerable groups in terms of QoL and mental health indicators in our study were those with psychiatric or/and physical illness, the elderly, the unemployed during the lockdown period, those with low educational/ socioeconomic status and those living alone. In conclusion, the negative emotions associated with the COVID-19 outbreak and the imposed restrictive measures had a serious impact on mental health and QoL of the population. This and other similar findings should be taken into account by authorities and decision-makers to prevent and deal with the effects of the pandemic. Unfortunately, the COVID-19 pandemic is still continuing and the imposition of new restrictive measures is considered. This increases the relevance of research like the one presented here.

Utility assessment of body contouring after massive weight loss.

BACKGROUND: The number of surgical procedures performed for obesity and massive weight loss (MWL) is increasing. The authors set out to quantify the health state utility assessment of living with MWL that can occur after such procedures. METHODS: Utility assessments using the visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) were used to obtain utilities for MWL, monocular blindness, and binocular blindness from a sample of the general population and medical students. RESULTS: All the measures for MWL of the 100 volunteers (VAS, 0.79 ± 0.13; TTO, 0.89 ± 0.12; SG, 0.89 ± 0.15) were significantly different (p < 0.005) from the corresponding measures for monocular blindness (0.63 ± 0.18, 0.84 ± 0.17, and 0.86 ± 0.16, respectively) and binocular blindness (0.31 ± 0.17, 0.63 ± 0.28, and 0.66 ± 0.27, respectively) except for the SG utility measure comparing monocular blindness with MWL. Age was inversely proportional to the TTO utility scores for MWL (p < 0.05). Caucasian race and medical education were independent predictors of SG utility scores (p < 0.05). CONCLUSION: In a sample of the general population and medical students, SG utility assessments for MWL were comparable with those for monocular blindness. Utility assessment of living with MWL varied with race (VAS and SG) and education (SG). The sample population, if faced with MWL, would consent to undergo a procedure such as body contouring with an 11% chance of death and be willing to trade 4 years of their life.

Phantom breast syndrome: The effect of in situ breast carcinoma.

Phantom breast syndrome (PBS) represents the experience of the continued presence of the breast, after mastectomy. Our aim was to assess PBS appearance by means of a structured questionnaire and to look into possible associations to disease and treatment parameters, in 105 women with breast cancer treated by mastectomy. PBS was recorded in 22.9% of the patients. In the majority of cases phantom experience had the size (88.9%), shape (76.5%) and weight (64.7%) of the normal breast and was localised in the entire breast (50%). Concerning disease parameters, no association with primary tumour size (T) or lymph node status was detected, but interestingly, in situ breast cancer (DCIS) was found to be more frequently associated with PBS, compared with invasive tumours. No significant associations of PBS with previous sensory experiences of the breast, radiotherapy or systemic treatment were assessed. The results are interpreted within the frame of Melzack's theory of a neuromatrix, assuming that PBS represents the continued existence, even after amputation, of a sensory engram of the breast. The absence of infiltration in primary tumour histology, probably through an unknown pathophysiological mechanism, might play a role for the significantly higher incidence of PBS in women undergoing mastectomy for DCIS.

Does Cozen's phenomenon warrant surgical intervention?

PURPOSE: Proximal tibial metaphyseal fractures can be complicated by a late valgus deformity, referred to as Cozen's phenomenon. We studied children with such fractures to determine whether the child's age at the time of injury influenced the development of Cozen's as well as the occurrence of elongation. In addition, we explored whether the deformity resolved at long-term follow-up. METHODS: We conducted a retrospective study of 33 patients (six months to 14 years old). Mean follow-up was 8.8 years (3 to 25). We measured angulation of the fractured limb post-treatment, at maximum deformity and final follow-up, as well as elongation and compared them with the uninjured limb. RESULTS: Three of the fractures were treated surgically whereas the rest, nonoperatively. In all, 15 out of 33 fractures developed late valgus deformity between eight and 19 months (mean time 12.5 months). A total of 24 fractures developed elongation. We found no association of either of these with age. Angulation increased to a statistically significant level, from post-treatment to maximum deformity, and then decreased at final follow-up, leaving no statistically significant difference from the initial measurement. The difference in valgus between fractured and uninjured limb increased to a statistically significant level from post-treatment to maximum deformity and then decreased, leaving an excess from the initial measurement. CONCLUSION: In almost half the patients, late valgus deformity developed within two years post-fracture and corrected to the initial post-treatment angles. Patients should be warned of this possibility and reassured of its natural resolution. LEVEL OF EVIDENCE: IV.

The delusional misidentification syndromes: strange, fascinating, and instructive.

The delusional misidentification syndromes (Capgras' syndrome, Frégoli syndrome, intermetamorphosis syndrome, syndrome of subjective doubles) are rare psychopathologic phenomena that occur primarily in the setting of schizophrenic illness, affective disorder, and organic illness. They are grouped together because they often co-occur and interchange, and their basic theme is the concept of the double (sosie). They are distinguished as hypoidentifications (Capgras' syndrome) and hyperidentifications (the other three syndromes). In this review, we present the basic hypotheses that have been put forward to explain these syndromes and propose that the appearance of these syndromes must alert physicians to investigate the existence of possible organic contributions.

Quality of life in mentally ill, physically ill and healthy individuals: the validation of the Greek version of the World Health Organization Quality of Life (WHOQOL-100) questionnaire.

OBJECTIVE: The World Health Organization Quality of Life (WHOQOL-100) questionnaire is a generic quality of life (QoL) measurement tool used in various cultural and social settings and across different patient and healthy populations. The present study examines the psychometric properties of the Greek version, with an emphasis on the ability of the instrument to capture QoL differences between mentally ill, physically ill and healthy individuals. METHODS: A total of 425 Caucasian participants were tested, as to form 3 groups: (a) 124 psychiatric patients (schizophrenia n = 87, alcohol abuse/dependence n = 37), (b) 234 patients with physical illness (hypertension n = 139, cancer n = 95), and (c) 67 healthy control individuals. RESULTS: Confirmatory factor analysis was performed indicating that a four-factor model can provide an adequate instrument structure for the participating groups (GFI 0.92). Additionally, internal consistency of the instrument was shown to be acceptable, with Cronbach's alpha values ranging from 0.78 to 0.90 regarding the four -domain model, and from 0.40 to 0.90 regarding the six-domain one. Evidence based on Pearson's r and Independent samples t-test indicated satisfactory test/retest reliability, as well as good convergent validity tested with the General Health Questionnaire (GHQ-28) and the Life Satisfaction Inventory (LSI). Furthermore, using Independent samples t-test and one-way ANOVA, the instrument demonstrated good discriminatory ability between healthy, mentally ill and physically ill participants, as well as within the distinct patient groups of schizophrenic, alcohol dependent, hypertensive and cancer patients. Healthy individuals reported significantly higher QoL, particularly in the physical health domain and in the overall QoL/health facet. Mentally ill participants were distinctively differentiated from physically ill in several domains, with the greatest difference and reduction observed in the social relationships domain and in the overall QoL/health facet. Within the four distinct patient groups, alcohol abuse/dependence patients were found to report the most seriously compromised QoL in most domains, while hypertensive and cancer patients did not report extensive and significant differences at the domain level. However, significant differences between patient groups were observed at the facet level. For example, regarding the physical domain, physically ill participants reported more compromised scores in the pain/discomfort facet, while mentally ill participants in the facets of energy/fatigue, daily living activities and dependence on medication. CONCLUSION: The findings of the study indicate that the Greek version of WHOQOL-100 provided satisfactory psychometric properties supporting its use within general and pathological populations and in the context of national and crosscultural QoL measurement.

Designing Cost-Sharing Methods for Bayesian Games.

We study the design of cost-sharing protocols for two fundamental resource allocation problems, the Set Cover and the Steiner Tree Problem, under environments of incomplete information (Bayesian model). Our objective is to design protocols where the worst-case Bayesian Nash equilibria have low cost, i.e. the Bayesian Price of Anarchy (PoA) is minimized. Although budget balance is a very natural requirement, it puts considerable restrictions on the design space, resulting in high PoA. We propose an alternative, relaxed requirement called budget balance in the equilibrium (BBiE). We show an interesting connection between algorithms for Oblivious Stochastic optimization problems and cost-sharing design with low PoA. We exploit this connection for both problems and we enforce approximate solutions of the stochastic problem, as Bayesian Nash equilibria, with the same guarantees on the PoA. More interestingly, we show how to obtain the same bounds on the PoA, by using anonymous posted prices which are desirable because they are easy to implement and, as we show, induce dominant strategies for the players.

Type IV capitellum fractures in children.

Capitellum fractures represent 1% of elbow fractures. A coronal shear fracture which involves the trochlea is classified as a type IV McKee fracture. The combination of its rarity in the paediatric population as well as its unique appearance on X-ray make diagnosis of this fracture a challenge. We present the case of a 14-year-old boy who sustained this fracture falling from his bike. It was diagnosed from the double arc sign on X-ray. In addition, a CT scan was obtained to aid preoperative planning. It was treated by open reduction and fixation with two headless compression screws. Follow-up at 6 months showed no avascular necrosis. The patient could achieve full extension, while flexion was reduced only by 5°. Final follow-up was conducted at 15 months. Anatomic reduction and stable internal fixation are essential for a good outcome in these uncommon paediatric fractures.

On the Efficiency of All-Pay Mechanisms.

We study the inefficiency of mixed Nash equilibria, expressed as the price of anarchy, of all-pay auctions in three different environments: combinatorial, multi-unit and single-item auctions. First, we consider item-bidding combinatorial auctions where m all-pay auctions run in parallel, one for each good. For fractionally subadditive valuations, we strengthen the upper bound from 2 (Syrgkanis and Tardos in Proceedings of the 45th symposium on theory of computing (STOC '13), 2013) to 1.82 by proving some structural properties that characterize the mixed Nash equilibria of the game. Next, we design an all-pay mechanism with a randomized allocation rule for the multi-unit auction. We show that, for bidders with submodular valuations, the mechanism admits a unique, 75 % efficient, pure Nash equilibrium. The efficiency of this mechanism outperforms all the known bounds on the price of anarchy of mixed Nash equilibria in mechanisms used for multi-unit auctions. Finally, we analyze single-item all-pay auctions motivated by their connection to contests and show tight bounds on the price of anarchy with respect to social welfare, revenue and maximum bid.

Assessing the efficiency of a coastal Managed Aquifer Recharge (MAR) system in Cyprus.

Managed Aquifer Recharge (MAR) is becoming an attractive water management option, with more than 223 sites operating in European countries. The quality of the produced water, available for drinking or irrigation processes is strongly depended on the aquifer's hydrogeochemical characteristics and on the MAR system design and operation. The objective of this project is the assessment of the operation efficiency of a MAR system in Cyprus. The coupling of alternative methodologies is used such as water quality monitoring, micro-scale sediment sorption experiments, simulation of groundwater flow and phosphate and copper transport in the subsurface using the FEFLOW model and evaluation of the observed change in the chemical composition of water due to mixing using the geochemical model PHREEQC. The above methodology is tested in the Ezousa MAR project in Cyprus, where treated effluent from the Paphos Waste Water Treatment Plant, is recharged into the aquifer through five sets of artificial ponds along the riverbed. Additionally, groundwater is pumped for irrigation purposes from wells located nearby. A slight attenuation of nutrients is observed, whereas copper in groundwater is overcoming the EPA standards. The FEFLOW simulations reveal no effective mixing in some intermediate infiltration ponds, which is validated by the inverse modeling simulation of the PHREEQC model. Based on the results, better control of the infiltration capacity of some of the ponds and increased travel times are some suggestions that could improve the efficiency of the system.

Early post-traumatic stress disorder in relation to acute stress reaction: an ICD-10 study among help seekers following an earthquake.

Disaster research related to earthquakes has almost exclusively dealt with their long-term psychosocial impact; besides, diagnoses were previously based only on DSM criteria. Therefore, it is pertinent to assess stress-related reactions of earthquake victims during the early post-disaster period through the application of ICD-10 criteria. For the first 3 weeks following an earthquake, 102 help-seekers were assessed based on a checklist of sociodemographic variables and a semi-structured interview for the detection of acute stress reaction (ASR) and posttraumatic stress disorder (PTSD) according to ICD-10. Forty-four subjects (43%) fulfilled the ICD-10 criteria for PTSD; all but one of them had suffered ASR. Moreover, among a series of potential predictors for PTSD, ASR was found to be the only significant one; this indicates a definite association between ASR and early development of PTSD. Logistic regression to predict group membership (PTSD/no PTSD) based on specific ASR symptoms showed that accelerated heart rate and feelings of derealization were the only significant predictors for early PTSD. Individuals who fulfill the ICD-10 diagnostic criteria for ASR following an earthquake are at high risk for subsequent occurrence of early PTSD. Increased heart rate and feelings of derealization within the first 48 h after the traumatic event appear to be the principal factors associated with the development of early PTSD. In addition to their potential value for timely prevention and treatment, these findings raise important nosological issues pertaining to the current diagnostic classification of stress-related disorders (ICD-10 versus DSM-IV).