Daily salivary cortisol patterns in midlife women with hot flashes.

OBJECTIVE: Diurnal salivary cortisol patterns in healthy adults are well established but have not been studied in midlife women with hot flashes. We hypothesized that frequent hot flashes are associated with aberrant cortisol patterns similar to sleep-deficient individuals. DESIGN: Cross-sectional. PARTICIPANTS: A total of 306 women, ages 40-62, randomized to a behavioural intervention for hot flashes. MEASUREMENTS: Baseline comparisons of cortisol geometric means (nmol/l) from four daily time points averaged over two consecutive days plus other calculated cortisol measures were made between groups defined by baseline: (i) mean daily hot flash frequency tertile (≤5·5, N = 103; >5·5-8·8, N = 103; >8·8, N = 100) and (ii) selected characteristics. Repeated-measures linear regression models of log-transformed cortisol evaluated group differences, adjusting for covariates. RESULTS: Women were 67% White and 24% African American, with 7·6 (SD 3·9) hot flashes per day. Salivary cortisol geometric means (nmol/l) among all women were as follows: 75·0 (SD 44·8) total, 8·6 (SD 5·6) wake, 10·0 (SD 7·5) wake +30 min, 3·7 (SD 3·3) early afternoon and 1·6 (SD 1·8) bedtime. Wake + 30-minute values showed an 18% median rise from wake values (interquartile range -24 to 96%), and means varied by hot flash frequency tertile, from lowest to highest: 11·4(SD 7·3), 10·3 (SD 6·5) and 8·6 (SD 7·8), respectively, P = 0·003. Beside the early afternoon value (P = 0·02), cortisol values did not vary by hot flash frequency. CONCLUSION: Taken together, these findings suggest that high frequency of moderate-to-severe hot flashes may be associated with subtle abnormalities in cortisol concentrations - a pattern consistent with chronic sleep disturbance.

Risk factors for major depression during midlife among a community sample of women with and without prior major depression: are they the same or different?

BACKGROUND: Women's vulnerability for a first lifetime-onset of major depressive disorder (MDD) during midlife is substantial. It is unclear whether risk factors differ for first lifetime-onset and recurrent MDD. Identifying these risk factors can provide more focused depression screening and earlier intervention. This study aims to evaluate whether lifetime psychiatric and health histories, personality traits, menopausal status and factors that vary over time, e.g. symptoms, are independent risk factors for first-onset or recurrent MDD across 13 annual follow-ups. METHOD: Four hundred and forty-three women, aged 42-52 years, enrolled in the Study of Women's Health Across the Nation in Pittsburgh and participated in the Mental Health Study. Psychiatric interviews obtained information on lifetime psychiatric disorders at baseline and on occurrences of MDD episodes annually. Psychosocial and health-related data were collected annually. Cox multivariable analyses were conducted separately for women with and without a MDD history at baseline. RESULTS: Women without lifetime MDD at baseline had a lower risk of developing MDD during midlife than those with a prior MDD history (28% v. 59%) and their risk profiles differed. Health conditions prior to baseline and during follow-ups perception of functioning (ps < 0.05) and vasomotor symptoms (VMS) (p = 0.08) were risk factors for first lifetime-onset MDD. Being peri- and post-menopausal, psychological symptoms and a prior anxiety disorder were predominant risk factors for MDD recurrence. CONCLUSIONS: The menopausal transition warrants attention as a period of vulnerability to MDD recurrence, while health factors and VMS should be considered important risk factors for first lifetime-onset of MDD during midlife.

MsFLASH participants' priorities for alleviating menopausal symptoms.

OBJECTIVE: To describe self-reported menopausal symptom priorities and their association with demographics and other symptoms among participants in an intervention trial for vasomotor symptoms (VMS). METHODS: Cross-sectional study embedded in the MsFLASH 02 trial, a three-by-two factorial design of yoga vs. exercise vs. usual activity and omega-3-fatty acid vs. placebo. At baseline, women (n = 354) completed hot flush diaries, a card sort task to prioritize symptoms they would most like to alleviate, and standardized questionnaires. RESULTS: The most common symptom priorities were: VMS (n = 322), sleep (n = 191), concentration (n = 140), and fatigue (n = 116). In multivariate models, women who chose VMS as their top priority symptom (n = 210) reported significantly greater VMS severity (p = 0.004) and never smoking (p = 0.012), and women who chose sleep as their top priority symptom (n = 100) were more educated (p ≤ 0.001) and had worse sleep quality (p < 0.001). ROC curves identified sleep scale scores that were highly predictive of ranking sleep as a top priority symptom. CONCLUSIONS: Among women entering an intervention trial for VMS and with relatively low prevalence of depression and anxiety, VMS was the priority symptom for treatment. A card sort may be a valid tool for quickly assessing symptom priorities in clinical practice and research.

Do anxiety symptoms predict major depressive disorder in midlife women? The Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS).

BACKGROUND: In women, anxiety symptoms are common and increase during midlife, but little is known about whether these symptoms predict onsets of major depressive disorder (MDD) episodes. We examined whether anxiety symptoms are associated with subsequent episodes of MDD in midlife African-American and Caucasian women, and whether they confer a different risk for first versus recurrent MDD episodes. METHOD: A longitudinal analysis was conducted using 12 years of data from the Study of Women's Health Across the Nation (SWAN) Mental Health Study (MHS). The baseline sample comprised 425 Caucasian (n=278) and African American (n=147) community-dwelling women, aged 46.1±2.5 years. Anxiety symptoms measured annually using a self-report questionnaire were examined in relation to MDD episodes in the subsequent year, assessed with the SCID. Multivariable models were estimated with random effects logistic regression. RESULTS: Higher anxiety symptoms scores were associated with a significantly higher adjusted odds of developing an episode of MDD at the subsequent annual visit [odds ratio (OR) 1.47, p=0.01], specifically for a recurrent episode (OR 1.49, p=0.03) but non-significant for a first episode (OR 1.32, p=0.27). There were no significant racial effects in the association between anxiety symptoms and subsequent MDD episodes. CONCLUSIONS: Anxiety symptoms often precede MDD and may increase the vulnerability of midlife women to depressive episodes, particularly recurrences. Women with anxiety symptoms should be monitored clinically during the ensuing year for the development of an MDD episode.

Practical clinical guidelines for assessing and managing menopausal symptoms after breast cancer.

BACKGROUND: The purpose of this study was to provide practical, evidence-based guidelines for evaluating and treating common menopausal symptoms following breast cancer. METHODS: Literature review of the causes, assessment and management of menopausal symptoms in breast cancer patients. RESULTS: A number of nonhormonal treatments are effective in treating hot flashes. Whether pharmacological treatment is given will depend on the severity of symptoms and on patient wishes. For severe and frequent hot flashes, the best data support the use of venlafaxine, paroxetine and gabapentin in women with breast cancer. Side-effects are relatively common with all these agents. For vaginal dryness, topical estrogen treatment is the most effective but the safety of estrogens following breast cancer is not established. There are limited data on effective treatments for sexual dysfunction during menopause. CONCLUSION: Menopausal symptoms after breast cancer should be evaluated and managed as warranted using a systematic approach and may benefit from multidisciplinary input.

Audience readings of media messages about MRSA.

This paper explores whether, and to what extent, national newspaper messages tally with public perceptions about meticillin-resistant Staphylococcus aureus (MRSA). It compares research on media messages about MRSA with interview data gathered from a demographically diverse sample of 60 people interviewed from the Greater London area. Across the interview sample there was a shared consensus that most people associated MRSA not with the history of antibiotic use, but with dirty and poorly managed hospitals. Some media messages, such as blaming MRSA on the alleged 'management culture' of the NHS, seemed to capture the Zeitgeist, whereas others, in particular the 'celebrity victims' of MRSA, did not seem to resonate with the audience. This study also found that ideas based on scientific understandings about germ theory and the immune system were held alongside folklore such as miasmic theory. The comparison of media and mind thus points to the existence of pre-scientific understandings of germs, contagion and blame in parallel with the biomedical story in the minds of the public. The findings contribute to our understanding of the public and patients' views of this infection.

Late ventricular arrhythmia is rare after early repair of tetralogy of Fallot.

OBJECTIVES: This study was conducted to describe the incidence of ventricular arrhythmia during prospective long-term follow-up in a group of patients who had repair of tetralogy of Fallot during early childhood. BACKGROUND: Ventricular arrhythmia has been a common finding in patients who have undergone repair of tetralogy of Fallot in late childhood or as adults. Whether earlier repair lowers the incidence of late ventricular arrhythmia or late sudden death is unknown. METHODS: Twenty-nine asymptomatic patients who underwent repair at age 1.2 to 7.7 years (mean [+/- SD] age 4 +/- 1.4 years) between 1979 and 1984 were studied. Twenty-one patients had simple repair (Group A), and eight had complex or multiple operations (Group B). All had ambulatory electrocardiographic monitoring preoperatively, postoperatively, at early follow-up (after 4.2 +/- 1.3 years) and again at late follow-up (after 11.8 +/- 1.3 years). At late follow-up, 28 subjects also underwent echocardiography, and 26 had an exercise test. RESULTS: No patient had significant ventricular arrhythmia (> or = modified Lown grade 2) before or immediately after repair. There was no significant increase in the incidence of arrhythmia at early and late follow-up (14% to 28%), but at each of these periods the incidence of ventricular arrhythmia was higher in Group B patients (3 [43%] of 7 vs. 1 [5%] of 22 with early repair, p = 0.03; 6 [75%] of 8 vs. 2 [10%] of 21 with late repair, p = 0.001). No patient had symptoms of arrhythmia, and there were no sudden deaths. Late ventricular arrhythmia did not correlate with estimated right ventricular systolic pressure, outflow tract gradient or degree of pulmonary incompetence or right ventricular dilation. On exercise, 5 (19%) of 26 patients had ventricular premature complexes at low levels of exercise that were suppressed at maximal exercise in all patients. CONCLUSIONS: Late ventricular arrhythmia is rare in patients with successful early correction of tetralogy of Fallot, unless complex or multiple operations are performed.

Efficacy of estradiol for the treatment of depressive disorders in perimenopausal women: a double-blind, randomized, placebo-controlled trial.

BACKGROUND: Results of previous studies suggest that estrogen improves somatic and mild depressive symptoms experienced by perimenopausal women. This study investigated the efficacy of 17beta-estradiol for the treatment of clinically significant depressive disorders in endocrinologically confirmed perimenopausal women. METHODS: Perimenopausal women (aged 40-55 years, with irregular menstrual periods and serum concentrations of follicle-stimulating hormone >25 IU/L), meeting criteria for major depressive disorder, dysthymic disorder, or minor depressive disorder, according to DSM-IV, were randomized to receive transdermal patches of 17beta-estradiol (100 microgram) or placebo in a 12-week, double-blind, placebo-controlled study. A 4-week washout period followed the 12-week treatment phase. Outcome measures were the Montgomery-Asberg Depression Rating Scale and Blatt-Kupperman Menopausal Index scores. RESULTS: Fifty women were enrolled in the study; 26 met DSM-IV criteria for major depressive disorder, 11 for dysthymic disorder, and 13 for minor depressive disorder. Remission of depression was observed in 17 (68%) women treated with 17beta-estradiol compared with 5 (20%) in the placebo group (P =.001). Subjects responded similarly to estradiol treatment, regardless of DSM-IV diagnosis. Patients treated with estradiol sustained antidepressant benefit of treatment after the 4-week washout period, although somatic complaints increased in frequency and intensity. Treatment was well tolerated and adverse events were rare in both groups. CONCLUSION: Transdermal estradiol replacement is an effective treatment of depression for perimenopausal women.

Estrogen, serotonin, and mood disturbance: where is the therapeutic bridge?

A growing body of literature describes the effects of estrogen and other gonadal steroids on the central nervous system. The ability of estrogen to modulate serotonergic function, in particular, raises the possibility that sex steroids may play a role in the mechanisms associated with depression and its treatment. This review will focus on those aspects of the estrogen-serotonin interaction that relate to possible increased vulnerability to affective disorders and on hormonal treatments that may be clinically applicable to women. After a discussion of the potential relationship between estrogen and mood disorders across the female life cycle, a model is proposed in which differential sensitivity to mood disorders explains the differential response by some women to periods of normal hormonal changes. Possible serotonin receptor-mediated and intracellular mechanisms by which estrogen may exert its effects on mood are also reviewed. These are compared to putative mechanisms of standard antidepressant effect. Lastly, treatment studies in which estrogen has been used as 1) monotherapy for depression, 2) an augmentation strategy, or 3) a prophylactic intervention against recurrence of depression are reviewed.

Continuous flow plasma exchange in the treatment of homozygous familial hypercholesterolemia.

We report the clinical and laboratory effects of continuous-flow plasma exchange in two patients suffering from homozygous familial hypercholesterolemia. In one (Case 1) plasmapheresis was performed at fortnightly intervals over a period of 18 months; in the other (Case 2) the necessity for surgical relief of an associated supravalvular aortic stenosis resulted in premature termination of the trial. The plasma cholesterol levels in both patients fell by 35 per cent from the mean before study in the course of treatment. In Case 1 this was associated with marked regression of the patient's xanthomas, disappearance of the S-T segment depression seen on effort electrocardiograms obtained prior to the introduction of plasmapheresis, possible widening of the stenosis present at the origin of the left anterior descending coronary artery, and a marked increase in exercise tolerance and diminished frequency of anginal attacks. Cessation of cholestyramine and clofibrate administration during this study did not in any way reverse the reduction of plasma cholesterol achieved by means of plasmapheresis combined with drug therapy. We conclude that plasmapheresis has a role to play in the management of patients with homozygous familial hypercholesterolemia.

Mitral valve replacement in children.

Mitral valve replacement (MVR) is associated with higher mortality and morbidity rates in children than in adults, and the use of heterograft valves has been encouraged. The results of MVR in 56 consecutive patients, aged 2 to 12 years, presenting between January, 1972, and January 1979, were reviewed to test these beliefs. The etiology of mitral valve disease was rheumatic in 46, congenital in eight, and acute bacterial endocarditis in two. All children were seriously disabled (NYHA Classes III and IV). Cardiac catheterization in 36 patients revealed mixed valve disease in 26, pure mitral regurgitation in seven, and pure mitral stenosis in three. Seventeen Starr-Edwards (SE), five Lillehei (L), Björk-Shiley (BS), eight Hancock (H), and 25 Carpentier-Edwards (CE) mitral prosthesis were inserted. Operative mortality was 2% (1 BS) and late mortality was 10% (three SE, one L, two CE). Serious late complications occurred in 30% of survivors, including 11 instances of calcific valve stenosis (five H, six CE), one case of valve thrombosis (1 L), and two embolic episodes (1 SER, 1 H). Survival curves were similar for patients with heterograft and mechanical valves (92% and 77% at 5 years). Event-free curves showed heterograft valves to have a far higher complication rate than mechanical valves (10% complication free at 4 years compared to 84% free at 5 years). Early operative results in children are excellent, and the overall mortality (10%) compares favorably with figures for MVR in adults. However the long-term durability and choice of prostheses remain problematical, since less than 10% of heterograft valves survive beyond 5 years.

A regional study of presentation and outcome of hypertrophic cardiomyopathy in infants.

OBJECTIVE: To describe regional incidence, presentation, and outcome of idiopathic (familial) and Noonan syndrome related infant hypertrophic cardiomyopathy (HCM) between 1969 and 1994. DESIGN: Case series. SETTING: Regional cardiac referral unit of the South West Region of England and south Wales, population approximately four million. PATIENTS: 21 cases of idiopathic (or familial) HCM, and eight infants with Noonan syndrome. MAIN OUTCOME MEASURES: Survival and persistence or resolution of symptoms or cardiac hypertrophy. RESULTS: Incidence: eight cases between 1969 and 1982 (idiopathic 6, Noonan 2), 21 cases between 1982 to 1994 (idiopathic 15, Noonan 6). Mode of presentation: cardiac failure, 17 (59%); murmur, 9 (30%); cyanosis, 2 (7%); family history, 1 (7%). Age at presentation: 0-7 days, 16 (55%); 8 days-4 months, 9 (31%); 5-12 months, 4 (14%). OUTCOME: five deaths (17%), all < 1 year, all from progressive cardiac failure (idiopathic 3, Noonan 2). Four of these five had not received beta blockade. Among the 24 survivors (follow up 1.3-23.2 years, median 5.5 years) hypertrophy had resolved in nine (38%) (idiopathic 8, Noonan 1), was mild and asymptomatic in seven (29%), and was symptomatic or severe in eight (33%). All 10 infants presenting with septal thickness > 1.3 cm have persistent cardiac hypertrophy. CONCLUSIONS: Mortality in infant HCM is much lower than previously reported and resolution is more frequent. This may reflect increased detection of less severe forms in addition to the success of aggressive medical management including beta blockade.

Parental Non-verbal Sexual Communication: Its Relationship to Sexual Behaviour and Sexual Guilt.

The study explores the link between remembered non-verbal sexual communication in the home, current sexual behaviours and feelings of sexual guilt, among a sample of young British men and women. Non-verbal sexual communication encapsulates: openness about nudity in the home; the showing of affection between parents; signs of parental sexual activity and contraceptive use; and intimation of mother's menstruation. One hundred and thirty-seven young adults completed questionnaires measuring remembered parental non-verbal sexual communication, current sexual behaviour and sexual guilt. Higher levels of parental non-verbal sexual communication were found to be linked to: earlier onset of sexual activity, fewer sexual partners and lower feelings of aspects of sexual guilt. The findings are discussed in terms of how to advance this area of study.

Adherence to health messages: a social psychological perspective.

Non-adherence to regimes recommended by health practitioners is prevalent in the health and safety area. Even the most effective of interventions does not tend to lead to substantial improvements in adherence. This paper reviews models from the health psychology sphere that predict which factors might lead people to practice health-enhancing behaviours. In terms of health messages, the paper evaluates the methods of persuasion found to be most successful. It provides an analysis of a successful intervention, in which a target audience was motivated to adopt a health-enhancing choice. The paper concludes by examining the principles that can be drawn from successful interventions, in terms of changing a target audience's health behaviours. The focus is on those that can be applied to situations in which a health practitioner hopes to convince the patient to adhere to a preventive regime.

Cavernous haemangioma with Kasabach-Merritt syndrome: treatment with alpha-interferon.

A small number of patients with haemangioma need treatment for serious complications such as Kasabach-Merritt syndrome, cardiac failure and obstruction of the airway. We report on the management of an infant with Kasabach-Merritt syndrome.

Dentistry on the couch.

This article outlines some of the occupational stresses in dental practice. In a profession which combines skillful precision with aesthetics many dentists are vulnerable to stress-yet most practitioners minimize or deny the suggestion that they face "burn-out'. Regular seminars on pressures pertaining to dental practice would provide support to practitioners (at risk).

Emotional factors in pregnancy.

Most writings on pregnancy detail the physical changes a woman undergoes during this period. This review shifts the focus to look specifically at emotional factors involving both the mother and father. Many general practitioners, obstetricians and paediatricians are unaware of and therefore insensitive to the development crisis ushered in by the state of pregnancy and so cannot offer emotional support to the couple at a time when they may require assistance.