Potential influence of Type A personality on plasma C-reactive protein levels in people with diabetes.

AIM: Type A personality, although classically known as a factor linked to increased vascular risk, has recently been associated with increased survival in patients with diabetes. As low-grade inflammation predicts a poor outcome, the present study explored the potential associations between Type A and plasma levels of C-reactive protein (CRP) in diabetes. METHODS: Type A personality was assessed by the Bortner questionnaire in people with diabetes. The association between Type A and plasma CRP levels was examined by multivariable linear regression, and structural equation modelling (SEM) was performed to determine the impact of the major clinical, biological and psychological confounders. RESULTS: The study included 626 participants with type 1 and type 2 diabetes from the Diabetes and Psychological Profile study. Multivariable analyses showed an independent inverse association between Type A score and CRP levels. The structural model adjusted for age, gender, diabetes type and duration, body mass index (BMI), smoking status, alcohol abuse, oral antidiabetic and statin treatments, HbA1c levels, lipids, perceived stress, anxiety and depression revealed significant associations between CRP and Type A (ß=-0.135, 95% CI: -0.242, -0.028; P=0.014), BMI (ß=0.194, 95% CI: 0.038, 0.350; P=0.015) and HDL cholesterol (ß=-0.132, 95% CI: -0.245, -0.020; P=0.014). CONCLUSION: Our present study data indicate that Type A personality is independently associated with lower CRP levels. This lower level of inflammation might explain the better clinical outcomes associated with Type A personality in patients with diabetes.

Successful aging.

OBJECTIVE: Until now, prospective studies of aging have begun with 50-60-year-olds, not adolescents. Premature death, childhood variables, and alcohol abuse have been often ignored, as has successful aging. METHOD: The authors reviewed the existing literature on health in late life in order to highlight that, increasingly, successful aging is not an oxymoron. The present study followed two cohorts of adolescent boys (237 college students and 332 core-city youth) for 60 years or until death. Complete physical examinations were obtained every 5 years and psychosocial data every 2 years. Predictor variables assessed before age 50 included six variables reflecting uncontrollable factors: parental social class, family cohesion, major depression, ancestral longevity, childhood temperament, and physical health at age 50 and seven variables reflecting (at least some) personal control: alcohol abuse, smoking, marital stability, exercise, body mass index, coping mechanisms, and education. The six outcome variables chosen to assess successful aging at age 70-80 included four objectively assessed variables (physical health, death and disability before age 80, social supports, and mental health) and two self-rated variables (instrumental activities of daily living and life enjoyment). RESULTS: Multivariate analysis suggested that "good" and "bad" aging from age 70-80 could be predicted by variables assessed before age 50. More hopeful still, if the seven variables under some personal control were controlled, depression was the only uncontrollable predictor variable that affected the quality of subjective and objective aging. CONCLUSIONS: One may have greater personal control over one's biopsychosocial health after retirement than previously recognized.

Healthy aging among inner-city men.

OBJECTIVE: Until now, prospective studies of aging have begun with 50- to 60-year olds, not adolescents. Premature deaths, childhood variables, and alcohol abuse have been often ignored. So has positive aging. As people live longer, gerontology needs to understand the determinants of health as well as illness in the later years. METHOD: The present study follows a cohort of adolescent boys (332 inner-city youths) for 60 years or until death. Complete physical exams were obtained every 5 years and psychosocial data every 2 years. Predictor variables assessed prior to age 50 include six variables reflecting uncontrollable factors--parental social class, environmental strengths, number of family problems, major depression, ancestral longevity, and premorbid physical health at age 50--and six variables reflecting (at least some) personal control: alcohol abuse, smoking, marital stability, body mass index, coping mechanisms, and education. The four outcome variables chosen to assess healthy aging at 70 reflected both "mind" and "body." They included objectively assessed variables (death and/or disability prior to 70, and objective mental health) and two subjectively assessed variables (perceived instrumental activities of daily living and life enjoyment). RESULTS: Multivariate analysis suggested that positive aging at 70 could be predicted by variables assessed prior to age 50. More hopeful still, if the six variables under some personal control were controlled, depression was the only uncontrollable variable that affected the quality of subjective and objective aging. CONCLUSIONS: First, we may have greater personal control over our biopsychosocial health after retirement than previously recognized. Second, in this cohort, psychiatric rather than sociological predictors appeared more important.

[Treatment of parathyroid adenomas with ethanol injection under ultrasonographic guidance]. / Traitement des adénomes parathyroïdiens par alcoolisation sous contrôle échographique.

STUDY OBJECTIVE: The objective of this retrospective study was to report the results of ethanol injection in parathyroid adenomas. PATIENTS AND METHOD: Since 1988, 31 patients with inoperable primary hyperthyroidism have been treated by ultrasound-guided percutaneous ethanol injection into the adenoma. The main surgical contraindications were heart failure (n = 12) and age over 85 years (n = 11). Plasma calcium and PTH were measured 48 hours after ethanol injection and during subsequent follow-up. RESULTS: Patients had one to three ethanol injections. With a mean 5-year follow-up, total success with normal plasma calcium and PTH levels was achieved in 20 patients (64.5%), 4 of whom underwent another ethanol injection after 1 to 3 years. Partial success with correction of plasma calcium only was achieved in 9 patients (29%) resulting in an obvious clinical benefit. Failure was observed in 2 patients (6.5%) with nodular goiter, probably due to incorrect localization of the adenoma. Treatment was always well tolerated and no major side effect was observed. CONCLUSION: Ultrasound-guided percutaneous ethanol injection of parathyroid adenoma is effective in most cases of hyperparathyroidism and very useful in patients with a high surgical risk. The need for precise ultrasound localization of the adenoma is the main limitation of this treatment.

A systematic review of the mortality of depression.

OBJECTIVE: The literature on the mortality of depression was assessed with respect to five issues: 1) strength of evidence for increased mortality, 2) controlling for mediating factors, 3) the contribution of suicide, 4) variation across sample types, and 5) possible mechanisms. METHOD: All relevant English language databases from 1966 to 1996 were searched for reviews and studies that included 1) a formal assessment of depressive symptoms or disorders, 2) death rates or risks, and 3) an appropriate comparison group. RESULTS: There were 57 studies found; 29 (51%) were positive, 13 (23%) negative, and 15 (26%) mixed. Twenty-one studies (37%) ranked among the better studies on the strength of evidence scale used in this study, but there are too few comparable, well-controlled studies to provide a sound estimate of the mortality risk associated with depression. Only six studies controlled for more than one of the four major mediating factors. Suicide accounted for less than 20% of the deaths in psychiatric samples, and less than 1% in medical and community samples. Depression seems to increase the risk of death by cardiovascular disease, especially in men, but depression does not seem to increase the risk of death by cancer. Variability in methods prevents a more rigorous meta-analysis of risk. CONCLUSION: The studies linking depression to early death are poorly controlled, but they suggest that depression substantially increases the risk of death, especially death by unnatural causes and cardiovascular disease. Future well-controlled studies of high risk groups may guide efforts to develop treatments that reduce the mortality risk of depression.

[Dermoid cyst of the ovary. False positive diagnosis in iodine 131 scintigraphy of differentiated thyroid cancers]. / Kyste dermoïde de l'ovaire. Faux positif à reconnaître lors de la surveillance scintigraphique à l'iode 131 des cancers différenciés thyroïdiens.

BACKGROUND: Total body 131-iodine labeled scintiscan is used to screen for residual tumoral tissue after ablation of differentiated thyroid carcinoma. At therapeutic doses, radioactive iodine can also be used for treatment. Thyroglobulin level, usually undetectable a few months after total thyroidectomy and metabolic irradiation with 131-iodine in patients without initial metastases, is absolutely necessary for interpreting the scintiscans. Iodine uptake occur in dermoid cysts which usually contain thyroid tissue. CASE REPORT: A 44-year old woman underwent total thyroidectomy with node dissection for papillary carcinoma of the thyroid with a vesicular architecture. Four months later, the total body 131-iodine scintiscan demonstrated a round zone of uptake in the pelvic area. The lesion was found to be a typical dermoid cyst. No thyroid or tumoral tissue could be demonstrated. DISCUSSION: Dermoid cysts can be the cause of false positive 131-scintiscans in patients followed after resection of differentiated thyroid carcinoma. Unlike previously reported cases, the dermoid cyst in this patient was totally devoid of thyroid tissue.

Are social supports in late midlife a cause or a result of successful physical ageing?

BACKGROUND: Many studies have noted a strong association between poor social support and premature mortality. A limitation of such studies has been their failure to control adequately for confounders that damage both social supports and physical health. METHODS: A 50-year prospective multivariate study of 223 men was used to examine the possible causal relationships between social supports and health. Alcohol abuse, prior physical health and mental illness prior to age 50 were controlled. Relative social supports were quantified over the period from age 50 to 70. RESULTS: Adequacy of social supports from age 50 to 70 was powerfully correlated with physical health at age 70 (P < 0.001). However, such social supports were also powerfully predicted by alcohol abuse (P < 0.001), smoking (P < 0.001) and indicators of major depressive disorder (P < 0.01) assessed at age 50. When prior smoking, depression and alcohol abuse were controlled, then the association of physical health with social supports was very much attenuated. Some facets of social support like religion and confidantes were unassociated with health even at a univariate level. Surprisingly, in this sample friends seemed more important for sustained physical health than closeness to spouse and to children. CONCLUSIONS: While social supports undoubtedly play a significant role in maintaining physical well-being in late life, much of the association between poor social supports and mortality may be mediated by alcoholism, smoking and pre-morbid psychopathology.

Intravenous methylprednisolone pulse therapy in the treatment of Graves' ophthalmopathy.

Graves' ophthalmopathy (GO) is a specific immune-mediated disorder, whose treatment is sometimes difficult. In order to investigate the efficacy of intravenous methylprednisolone (MP) pulse therapy in GO, we studied eight patients with GO, followed up for at least 6 months by clinical patient self-assessment, ophthalmological examination and orbital computed tomography (OCT). A 12.5 mg/kg dose of MP was administered intravenously over a 10 hour period, once every month. Three to six MP pulse administrations were performed in each patient. All patients were outpatients. A 0.5 mg/kg/day oral prednisone dose was given to each patient as interpulse therapy. Clinical assessment of MP pulse therapy showed a good response in 87.5% and no response in 12.5% of patients. The treatment was rapidly efficient, mostly on patient self-assessment, soft tissue inflammation, ophthalmoplegia, corneal involvement, visual acuity and extraocular muscle enlargement on OCT. Post-treatment ophthalmic index was significantly improved (6.75 +/- 3.06 vs. 2.5 +/- 1.41: p < 0.05). MP pulse therapy had less effect on proptosis (22.94 +/- 2.32 mm vs. 21.56 +/- 2.22 mm: p < 0.05). No adverse effects were noted with MP pulse therapy. Patients showed no relapse of eye involvement during a mean follow up of 31.8 months (2-77 months). In conclusion, our results suggest that intravenous MP pulse therapy is a good immunosuppressive therapy for GO. Moreover, in comparison with the previous studies, the MP dose used in our present study appears to be optimal with high efficacy. MP pulse therapy represents a safe and efficient treatment in GO, which can easily be performed in outpatients.

A 50-year longitudinal study of defense use among inner city men: a validation of the DSM-IV defense axis.

The patterns of use of defense mechanisms by 306 inner-city men were rated from interviews at age 47 and these ratings were analyzed by cluster analysis. Five clusters resulted. The correlates of cluster membership were examined using data from the 50-year longitudinal study of these men. One cluster exhibited the greatest use of mature defenses; the men in this cluster functioned best on all psychosocial and health variables. Two clusters of men used primarily neurotic defenses; these men functioned at an intermediate level on all outcomes. The men in two clusters primarily used immature defenses. The men in one of these clusters used primarily action defenses, whereas the men in the other cluster were the greatest users of projection and fantasy. In general, the men in both these clusters functioned worse than those in the other three. However, the users of action defenses exhibited greater sociopathy, alcohol problems, and marital instability. The findings provide general support for the DSM-IV hierarchy for nonpsychotic defenses, with mature defenses at the top, neurotic defenses in the middle, and action defenses toward the bottom. In particular, the study supports the DSM-IV distinction of action defenses from other immature defenses.

Natural history of male psychological health, XIV: Relationship of mood disorder vulnerability to physical health.

OBJECTIVE: A 55-year prospective study attempted to determine the antecedents and consequences of positive mental and physical health in adult men. A substudy was conducted to look at the late-life physical health of men selected to be as unlike men with major depressive disorder as possible. METHOD: Of 237 men selected for health and followed since college, 64 undistressed men had never used mood-altering drugs or consulted a psychiatrist before the age of 50. The health at age 70 of these 64 men was compared with that of 20 men classified as depressed at age 70, 109 men classified as neither healthy nor depressed at age 70, and 44 men classified as having alcohol dependence or abuse at age 70. RESULTS: At age 70, the 64 undistressed men enjoyed significantly better health than the 109 men in the intermediate group. Only three (5%) of the 64 undistressed men were dead or disabled by age 70, compared with 30 (28%) of the 109 men in the intermediate group and nine (45%) of the 20 depressed men. The mean age of the subjects' maternal grandfathers at death also significantly differentiated the three groups. The differences in longevity among the three groups could not be explained by personality disorder, by cigarette, dietary, or alcohol abuse, or by longevity of the subjects' other first-degree ancestors. CONCLUSIONS: These findings lend support to the hypothesis that risk of affective disorder may lie along a continuum. At one extreme may be men with stable lifestyles, a lifelong resistance to mood disorder, and unusually good physical health in late life. At the other extreme of the continuum may be men with vulnerability to mood disorder and accelerated physical aging.

Hypertriglyceridaemia and Lewis (A-B-) phenotype in non-insulin-dependent diabetic patients.

A relationship between Lewis (a-b-) phenotype and the metabolic syndrome X has been suggested. We studied the frequency of Lewis (a-b-) phenotype in subjects with non-insulin-dependent diabetes mellitus (NIDDM) as well as the relationship between Lewis phenotype and lipid concentration in NIDDM patients. Lewis red blood cell phenotyping was done in 207 NIDDM subjects and 345 non-diabetic control subjects by immuno-agglutination with anti-Lewis a and b monoclonal antibodies. Among NIDDM patients, the proportion with the Lewis (a-b-) phenotype was significantly increased (23.6% vs 14.3%, p = 0.01), and this phenotype was associated with higher levels of triglycerides (2.40 +/- 2.58 vs 1.97 +/- 1.25, p = 0.03). This study shows a relationship between NIDDM and Lewis (a-b-) phenotype. Hypertriglyceridaemia in Lewis-negative NIDDM could suggest an increased risk of ischaemic heart disease for these subjects.

[False positive scintigraphic images in the surveillance of differentiated thyroid cancers]. / Faux positifs scintigraphiques à l'iode 131 dans la surveillance des cancers thyroïdiens différenciés.

Iodine-131 whole body imaging and serum thyroglobulin are used in the follow-up evaluation of differentiated thyroid carcinomas. Iodine 131 is used to detect and treat functioning lesions. Iodine 131 activity detected outside the normal thyroid bed is usually attributed to metastatic disease. False-positive localization of radioiodine has been described, and may be a potential pitfall. We report here six personal cases of false-positive localisations of radioiodine du to body secretions, pathologic exudate, activity in nonlactating breast, salivary gland inflammation, ovarian teratoma. Some of these false-positive can be ruled out easily by removing of clothes, removing of nozzle in patients with tracheostomy, or by ingestion of water in subjects with abnormal mediastinal hyperfixation. Recognition of false-positive radioiodine images is very important to prevent costly additional investigation and possibly inappropriate therapy.

Macrovascular disease is associated with increased plasma apolipoprotein A-IV levels in NIDDM.

Apolipoprotein A-IV (apoA-IV) might play an important role in lipoprotein metabolism, including modulation of triglyceride-rich lipoprotein catabolism, reverse cholesterol transport and cholesteryl ester transfer protein (CETP) activity. Increased apoA-IV levels have been reported in plasma from NIDDM patients. The aim of the present study was to look for a possible association between plasma apoA-IV level and prevalence of macrovascular disease in NIDDM. One hundred and thirty-six NIDDM patients were studied (71 men, 65 women). Macrovascular disease was assessed in each patient by a standardized questionnaire, physical examination, resting electrocardiogram (ECG), and laboratory evaluation (ankle/arm blood pressure ratio, continuous wave Doppler velocimetry). Moreover, patients without any history of coronary heart disease and showing a normal resting ECG underwent a bicycle exercise test or a dipyridamole thallium scintigraphy to detect possible silent myocardial ischemia. Among the 136 NIDDM patients, 56 had macrovascular disease. ApoA-IV levels were significantly higher in NIDDM patients with macrovascular disease than in NIDDM patients without macrovascular disease (20.9 +/- 8.6 vs. 13.3 +/- 5.3 mg/dl; P < 0.001). The influence of different factors, such as age, BMI, cigarette smoking, hypertension, total cholesterol, triglycerides, HDL cholesterol, apoA-IV level, apoA-IV phenotype, fasting glycemia, fasting C-peptide, and microalbuminuria, on the prevalence of macrovascular disease was analyzed using a logistic regression model. In the univariate analysis, apoA-IV level (P < 0.00001), age (P = 0.0087), hypertension (P = 0.012), microalbuminuria (P = 0.018), triglycerides (P = 0.02), and fasting C-peptide (P = 0.03) were positively associated with macrovascular disease. In the multivariate analysis, macrovascular disease was positively associated only with apoA-IV (P < 0.0001) and age (P = 0.003) and negatively associated with HDL cholesterol (P = 0.013). These results indicate that increased plasma apoA-IV level is associated with an increased prevalence of macrovascular disease in NIDDM. Moreover, apoA-IV, in NIDDM patients, appears to be a better marker for macrovascular disease than triglycerides.

[Thymic carcinoid tumor causing paraneoplastic Cushing syndrome. Diagnostic value of double-labelled tomoscintigraphy]. / Tumeur carcinoïde thymique responsable d'un syndrome de Cushing paranéoplasique. Intérêt diagnostique de la tomoscintigraphie en double marquage.

Cushing's syndromes caused by ectopic corticotropin secretion represent 10 to 15% in the causes of Cushing's syndrome. Somatostatin receptor scientigraphy can be successful in the localization of ACTH-secreting neuroendocrine tumors. We report a case of Cushing's syndrome caused by ectopic corticotropin secretion from a thymic carcinoid tumor. Conventional localization techniques failed but the tumor was detected by a double binding thoracic scintigraphy using 111Indium-octreotide and 99mTechnetium-albumine macroagregates.

Natural history of male psychological health, XIII: Who develops high blood pressure and who responds to treatment.

OBJECTIVE: This study was an effort to clarify both the psychological contributions to and the long-term consequences of uncomplicated essential hypertension. METHOD: The subjects were 193 healthy college students selected as sophomores and prospectively followed for over 50 years. Independent assessments of physical and mental health were made. RESULTS: Although objective indices of psychopathology predicted both physical morbidity and mortality, they did not predict hypertension. When pyknic somatotype, college diastolic blood pressure, and well-integrated personality in college were controlled, no other preadult variable predicted hypertension. As expected, heart disease, obesity, and alcohol abuse were each correlated with hypertension. After roughly 20 years, 14 of the 41 men with treated hypertension were in stable remission, and 13 men had developed cardiac complications. No differences between these groups could be discerned. CONCLUSIONS: Over time, hypertension appeared to be more a product of biological than of psychosomatic variables. Good psychological health did not diminish the risk of hypertension.

[Food-dependent Cushing syndrome: a new entity of organic hypercorticism]. / Le syndrome de Cushing alimentaire: une nouvelle entité d'hypercorticisme organique.

Diagnosis of Cushing's syndrome is quite difficult in endocrinology. Spontaneous Cushing's syndrome is usually divided into two subgroups, one which is dependent on corticotropin (ACTH) and another one which is not. In the first class are Cushing's disease, the ectopic corticotropin syndrome and the rare ectopic corticotropin-releasing hormone (CRH) syndrome; these ACTH-dependent Cushing's syndrome have usually diffusely enlarged adrenal glands. In the second class are cortisol producing unilateral adrenocortical adenomas or carcinomas, and the recent Cushing's syndrome with food dependent periodic hormonogenesis. This food dependent Cushing's syndrome is an ACTH-independent Cushing's syndrome with multinodular enlargement of both adrenal glands. Pathogenesis is an aberrant adrenal sensitivity to physiologic secretion of gastric inhibitory peptide (GIP). Ectopic expression of GIP receptors on adrenal cells involve pathologic food induced cortisol secretion. Food dependent Cushing's syndrome is a new cause of Cushing's syndrome. Food induced cortisol secretion may have to be explored in the ACTH-independent Cushing's syndrome.

1995 IPA/Bayer Research Awards in Psychogeriatrics. Late-life consequences of affective spectrum disorder.

Recent research suggests that affective disorder is associated with increased mortality and physical morbidity, but the reasons for this association remain uncertain. This report describes a 50-year prospective study of 240 men evaluated from the time they were university students in 1940-1942. A family history of mental illness was obtained and the men's habits, psychological adjustment, and marital and occupational satisfaction were followed every 2 years and their objective physical health was tracked every 5 years until age 70. Twenty-five men were identified as having affective spectrum disorder prior to age 53. Of the variables studied, the presence of affective spectrum disorder was the most powerful predictor of poor psychosocial outcome at age 65 and one of the most powerful predictors of poor physical health. Alcohol abuse and cigarette abuse accounted for the observed increased rates of heart disease and cancer. When alcohol abuse, smoking, and suicide were controlled for, affective disorder made a significant contribution to physical morbidity by age 70, but not to mortality from natural causes. Affective spectrum disorder, even in an educated population without antisocial trends, carries a profound negative risk to late-life physical and social adjustment.