Homocysteine, Alzheimer genes and proteins, and measures of cognition and depression in older men.

The epsilon4 allele of apolipoprotein E (APOE), and the plasma levels of APOE, amyloid beta-protein precursor, amyloid beta1-40 (Abeta40) and homocysteine (Hcy) have all been correlated with the presence of dementia. Mutations in the methylnetetrahydrofolate reductase enzyme (MTHFR) have been associated with elevated levels of Hcy. This study explored the association of these factors with cognition and depression in community dwelling older men. Two hundred and ninety-nine men, mean age 78.9 years (SD 2.8), were studied in this cross-sectional survey. Mean plasma Hcy was 13.5 (SD 5.3) micromol/L. The MTHFR genotype had no obvious impact on Hcy levels. Ln Hcy and Ln Abeta40 were both inversely correlated with calculated glomerular filtration rate (cGFR), r = -0.41 (p < 0.001) and r = -0.28 (p < 0.001), respectively. There was a positive correlation between Ln Hcy and Ln Abeta40, r = 0.19 (p < 0.001), which remained significant after adjusting for cGFR, with a doubling of Hcy associated with a 24% increase of Abeta40. The e4 allele was associated with increased depressive symptoms as measured by the Geriatric Depression Scale-15, Odds ratio (OR) = 2.59 (95%CI 1.06-6.34) and poorer performance on the Clock Drawing Test, OR = 2.32 (95% CI: 1.25-4.29). There was a positive association between Abeta40 and Hcy, even after adjustment for cGFR in this sample of well, community dwelling older men. This association may help elucidate the link between elevated levels of Hcy and Alzheimer's disease.

A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project.

Using data from a nationwide project on young people in Australia aimed at assessing suicidality in general health settings, we present a brief screening tool for suicidality (the depressive symptom index suicidality subscale). Two thousand eight hundred and fifty-one (15-24 year old) patients presenting to 247 Australian general practitioners between 1996 and 1998 were assessed. In addition to the suicide screen, patients completed the general health questionnaire-12 and the Center for Epidemiological Studies depression scale. Patients' chief complaints were taken from the summary sheets completed by their general practitioners. Using inter-item correlational and factor-analytic techniques, as well as a general approach to construct validity, we show that the measure has favorable reliability and validity characteristics. We also provide results on cut-points that may facilitate its use in clinical and research settings. Because the screen is brief, easy to use, reliable, and valid, we encourage its use to combat the vexing international health problem of suicide.

Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people.

OBJECTIVE: To determine the effectiveness of a training program for general practitioners in recognising and responding to psychological distress and suicidal ideation in young people. DESIGN AND SETTING: The study, conducted in general practice surgeries in Tasmania, Victoria and Western Australia in 1996 and 1997, used a pre-/posttest design to audit consecutive young patients presenting in the six weeks before and the six weeks after the GPs' participation in the training program. PARTICIPANTS: Consisted of 23 GPs who attended a youth suicide prevention workshop and 423 patients aged 15-24 years who presented to the GPs' surgeries (203 pre-workshop and 220 post-workshop). INTERVENTION: GPs attended a one-day training workshop designed to enhance their ability to recognise, assess and manage young patients at risk of suicide. MAIN OUTCOME MEASURES: Scores on three patient self-report inventories (General Health Questionnaire-12 [GHQ-12], Center for Epidemiological Studies Depression Scale [CES-D] and Depressive Symptom Inventory--Suicidality Subscale [DSI-SS]); a GP-completed form for each patient summarising presenting complaint(s), psychological assessment and proposed management plan. RESULTS: After training, GPs demonstrated increased recognition rates of psychologically distressed patients scoring above the cut-offs of the GHQ-12 (48% increase; odds ratio [OR], 1.748; 95% CI, 0.904-03.381) and CES-D (39.5% increase; OR, 2.067; 95% CI, 1.031-4.143); enquiry about suicidal ideation increased by 32.5% (OR, 1.483; 95% CI, 0.929-2.366); and identification of suicidal patients (determined by DSI-SS score) increased by 130% (OR, 3.949; 95% CI, 1.577-9.888). Training did not lead to any significant change in GPs' patient management strategies. CONCLUSIONS: A one-day training course can significantly enhance GP detection rates of psychological distress and suicidal ideation in young patients, but higher recognition rates do not necessarily lead to changes in patient management.

The relationship between chief complaints, psychological distress, and suicidal ideation in 15-24-year-old patients presenting to general practitioners.

OBJECTIVES: To determine the prevalence of psychological distress and suicidal ideation among patients aged 15-24 years presenting to general practitioners, and the relationship between these variables and patients' chief complaints. DESIGN AND SETTING: Questionnaire survey of young people presenting to Australian general practitioners between 1996 and 1998. PARTICIPANTS: 247 general practitioners who volunteered to participate in a nationwide project aimed at teaching general practitioners to identify and treat suicidal youth; 3242 consecutive 15-24-year-old patients presenting to participating general practitioners during a specified six-week period. MAIN OUTCOME MEASURES: Patients completed three self-administered questionnaires: the General Health Questionnaire-12, the Center for Epidemiological Studies Depression Scale, and the Depressive Symptom Inventory-Suicidality Subscale. Patients' chief complaints were obtained from summary sheets completed by their general practitioners. RESULTS: While only 12% of patients presented with psychological complaints, about 50% percent had clinically significant levels of psychological distress and 22% had clinically significant levels of suicidal ideation. CONCLUSIONS: Despite presenting with primarily medical complaints, almost half of young people presenting to primary care physicians had high levels of psychological distress and almost a quarter had high levels of suicidal ideation.

Psychological distress and suicidal ideation among 15-24-year-olds presenting to general practice: a pilot study.

OBJECTIVES: The study sought to determine: (i) the prevalence rates of psychological distress and suicidal ideation among 15-24-year-old patients presenting to general practice; and (ii) the relationship between patients' presenting complaints and their levels of psychological distress and suicidal ideation. METHOD: This was a pilot study designed to sample patients aged 15-24 years presenting consecutively to general practitioners during a 4-week period. The study was set among five general practices in the western suburbs of Perth, Western Australia. Participants included five general practitioners and 69 patients aged 15-24 years. Main outcome measures were the General Health Questionnaire (GHQ-12), the Centre for Epidemiological Studies Depression Scale (CES-D) and the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS). RESULTS: One-third of patients scored above the cut-off of the GHQ-12, 31.9% above the cut-off of the CES-D and 20.3% above the cut-off of the DSI-SS. The majority of patients (87.5%) presented with medical complaints. Of these, 26.8%, 23.2% and 21.4% scored above the cut-offs of the GHQ-12, CES-D and DSI-SS, respectively. Patients presenting with psychological complaints (12.5%) were significantly more likely to score above the cut-off of the CES-D. CONCLUSIONS: In this pilot study, patients aged 15-24 presenting to five general practices had relatively high levels of psychological distress and suicidal ideation. Of most concern were those presenting with medical complaints and who also had high levels of unreported psychological distress.

Alternating pressure mattresses: comfort and quality of sleep.

Comfort is particularly important for patients with terminal illness where the priority is to maximize quality of life. Equally important is effective pressure area care, as such patients are at high risk of developing pressure sores because of their poor general condition (Bale and Regnard, 1995). The present randomized controlled study set in a hospice focused on the development of methodology for assessing patient comfort and quality of sleep and used this to compare two widely used, alternating air pressure mattresses (the Nimbus II and the Pegasus Airwave). The Nimbus II mattress performed consistently better than the Pegasus Airwave in terms of patient comfort and quality of sleep. Features of the Nimbus II that may explain its better performance include less extreme changes in pressure, lower peak inflation pressures and the ability to automatically vary the pressure to suit the patient's position and weight.

Protriptyline in obstructive sleep apnea: a double-blind trial.

We evaluated protriptyline, a nonsedating tricyclic antidepressant, as a treatment for obstructive sleep apnea in a double-blind crossover study of five men. After two weeks of treatment, with no change in body weight, daytime somnolence was markedly reduced and nocturnal oxygenation was improved, although apnea duration and frequency were not significantly decreased. Rapid-eye-movement (REM) stage time as a fraction of the total sleep time was reduced during treatment from 0.231 +/- 0.031 to 0.107 +/- 0.013 (mean +/- S.E.M.) (P less than 0.05). REM apnea time as a fraction of total sleep time was reduced from 0.145 +/- 0.022 to 0.054 +/- 0.006 (P less than 0.05). REM reduction during treatment with protriptyline can account for decreased REM apnea time. Similar decreases in REM stage time and REM apnea duration and similar improvement in oxygenation continued after six months of treatment. In addition, body weight, apnea, and arousal frequency were decreased at this time. Although the obstructive sleep apnea was not resolved, it was reduced. Protriptyline can be effective in patients with sleep apnea when the disorder is not life-threatening.

Diagnosis of sleep breathing disorders in a general hospital. Experience and recommendations.

In the 24 months after a sleep breathing laboratory opened in a general hospital, 48 patients thought to have a primary sleep breathing disorder were referred for study. Evaluation of breathing during sleep was most useful in those having excessive daytime sleepiness or unexplained polycythemia. The sleep apnea syndrome was documented in 19 of 24 patients with excessive daytime sleepiness. Of 15 patients with unexplained polycythemia, ten were found to have severe hypoxemia during sleep. This experience suggests that facilities for evaluation of sleep breathing disorders should be available in larger medical centers.

Breathing during sleep in parents of sudden infant death syndrome victims.

Some children with "aborted" sudden infant death syndrome (SIDS) and parents of SIDS victims have abnormal control of ventilation. Because apnea during sleep occurs in some children who go on to die of SIDS, and because the abnormality in ventilatory control may be familial, we examined breathing during sleep in parents of SIDS victims to determine whether breathing pattern abnormalities were common in them. We studied 12 patients (6 couples) of SIDS victims and 12 age-matched control parents with healthy children. We failed to demonstrate significant differences in the incidence of apneas or breathing pattern irregularities between the SIDS and control parents. However, 2 SIDS parents, 1 male and 1 female, had 44 and 31 apneic episodes, respectively, exceeding the number conventionally used to document excessive apneic episodes during sleep. Neither of these parents had the hundreds of apneic episodes usually seen in the sleep apnea syndrome. Although these 2 SIDS parents support the notion that a sleep breathing abnormality may exist in SIDS parents, most of the SIDS parents had normal breathing during sleep. Because the abnormalities in the two SIDS parents were minor, and because the remainder of the subjects were normal, we conclude that polysomnographic recordings fail to reveal a "marker" that might identify potential SIDS parents.

Paralytic shellfish poisoning.

Two cases of paralytic shellfish poisoning after ingestion of mussels occurred in October 1977 in Nova Scotia. The incidence of this type of poisoning is relatively high among persons living on the coast of the Bay of Fundy and the estuary of the St. Lawrence River. The causative organism, Gonyaulax tamarensis, elaborates an endotoxin, saxitoxin, that blocks neuromuscular transmission in the motor axon and muscle membrane while leaving the end-plate unaffected; it also suppresses conduction in the atrioventricular node and inhibits the respiratory centre. The clinical manifestations are unique and include numbness of the lips, tongue and fingertips within minutes of ingestion of the poisoned shellfish, then numbness of the legs, arms and neck, with general muscular incoordination, and finally respiratory distress and muscular paralysis. Treatment is symptomatic and prevention can only occur by public education.