Risk factors and possible mechanisms of intravenous port catheter migration.

OBJECTIVE: To identify the risk factors for catheter migration and demonstrate possible mechanisms of this migration. DESIGN: Retrospective study. SETTING: Chang Gung Memorial Hospital, a tertiary medical centre in Taiwan. PATIENTS: Patients who underwent implantation of intravenous ports via the superior vena cava (SVC). INTERVENTIONS: Procedures involving catheter placement and re-intervention for catheter migration. MAIN OUTCOME MEASURES: The anatomic location of the catheter tip was confirmed by plain chest X-rays (postero-anterior view). From these plain radiographs, the distance (in cm) between the carina and catheter tip and the angle (in degrees) between the locking nut and catheter were measured. METHODS: A total of 1542 procedures related to intravenous port implantation were retrospectively reviewed but only procedures involving implantation via the SVC were included in the analysis. The study group was composed of 31 interventions because of catheter migration, while the control group consisted of 1475 implantation and re-intervention procedures except those involving catheter migrations. RESULTS: Shallow catheter-tip location (p < 0.0001) and the presence of lung cancer (p = 0.006) were risk factors for catheter migration. CONCLUSIONS: Shallow catheter-tip location and the presence of lung cancer are risk factors for catheter migration. Strategies that ensure low catheter-tip location and avoid increased thoracic pressure may be useful preventive measures.

Blood-brain barrier impairment with enhanced SP, NK-1R, GFAP and claudin-5 expressions in experimental cerebral toxocariasis.

Infection by Toxocara canis in humans may cause cerebral toxocariasis (CT). Appreciable numbers of T. canis larvae cross the blood-brain barrier (BBB) to invade the brain thus causing CT. In the present studies, we evaluated the BBB permeability and BBB injury as assessed by the cerebral Evans blue (EB) concentration as well as by pathological changes and glial fibrillary acidic protein (GFAP) expression in T. canis -infected mice monitored from 3 days (dpi) to 8 weeks post-infection (wpi). The vasodilation neuropeptides, the expressions of substance P (SP) and its preferred binding neurokinin-1 receptor (NK-1R) as well as claudin-5 of tight-junction proteins associated with BBB impairment were also assessed by Western blotting and reverse-transcriptase polymerase chain reaction. Results revealed that BBB permeability increased as evidenced by a significantly elevated EB concentration in brains of infected mice. BBB injury appeared due to enhanced GFAP protein and mRNA expressions from 4 to 8 wpi. Leukocytes might have been unrelated to BBB impairment because there was no inflammatory cell infiltration despite T. canis larvae having invaded the brain; whereas markedly elevated SP protein and NK-1R mRNA expressions concomitant with enhanced claudin-5 expression seemed to be associated with persistent BBB impairment in this experimental CT model.

Administration of 5-androstenediol to mice: pharmacokinetics and cytokine gene expression.

The development of an effective pharmacological countermeasure is needed to reduce the morbidity and mortality in military and civilian populations associated with possible exposure to ionizing radiation. Previous studies in mice have shown that a single subcutaneous (sc) injection of the natural steroid androst-5-ene-3beta,17beta-diol (5-androstenediol, 5-AED), 24-48 h prior to a lethal dose of whole-body (60)Co gamma radiation, stimulated hematopoiesis and enhanced survival. These effects are consistent with our previous observation of 5-AED-induced elevations in circulating G-CSF in normal and irradiated mice. The purpose of this study was to obtain data on the pharmacokinetics of 5-AED after sc and buccal administration to mice, and to determine whether cytokine genes are induced by sc 5-AED in hematopoietic tissues (bone marrow, spleen). We studied effects on serum cytokines and chemokines, and also analyzed the pharmacokinetics of 5-AED after sc administration and compared it with buccal delivery. 5-AED was administered 24 h before irradiation or sham-irradiation. Cytokine mRNAs were quantified by quantitative real-time PCR (QRT-PCR), and cytokine levels in serum by multiplex Luminex. 5-AED administration was associated with elevation of message for GM-CSF, IL-2, IL-3, IL-6, and IL-10 in spleen, and GM-CSF and IL-2 in bone marrow. Irradiation enhanced G-CSF, GM-CSF, IFN-gamma, TPO, IL-2, IL-3, IL-6, IL-10, and IL-12 in spleen, and GM-CSF, IFN-gamma, TPO, IL-3, and IL-10 in bone marrow. Serum levels of G-CSF were significantly elevated in 5-AED-treated mice 4 h after irradiation or sham-irradiation. Serum macrophage inflammatory protein-1gamma (MIP-1gamma) was significantly elevated 4 h after irradiation in 5-AED-treated mice. Plasma 5-AED peaked 2 h after sc injection (30 mg/kg), and remained significantly above control after 4 days, but not 8 days. The time course of plasma 5-AED after buccal delivery (60 mg/kg) was similar, but levels were significantly lower compared to sc delivery. Plasma 5-AED 24 h after administration was not significantly different between sc and buccal delivery. However, in contrast to many studies showing enhanced survival after sc administration of 5-AED, we found no effect on survival of buccal 5-AED. The results suggest that radioprotection is not dependent on the 5-AED concentration at the time of irradiation, but rather on events triggered during the first few hours after administration. The current results suggest that further studies are warranted to directly test the roles of cytokines in the radioprotective effects of 5-AED.

KCNQ channels mediate IKs, a slow K+ current regulating excitability in the rat node of Ranvier.

Mutations that reduce the function of KCNQ2 channels cause neuronal hyperexcitability, manifested as epileptic seizures and myokymia. These channels are present in nodes of Ranvier in rat brain and nerve and have been proposed to mediate the slow nodal potassium current I(Ks). We have used immunocytochemistry, electrophysiology and pharmacology to test this hypothesis and to determine the contribution of KCNQ channels to nerve excitability in the rat. When myelinated nerve fibres of the sciatic nerve were examined by immunofluorescence microscopy using antibodies against KCNQ2 and KCNQ3, all nodes showed strong immunoreactivity for KCNQ2. The nodes of about half the small and intermediate sized fibres showed labelling for both KCNQ2 and KCNQ3, but nodes of large fibres were labelled by KCNQ2 antibodies only. In voltage-clamp experiments using large myelinated fibres, the selective KCNQ channel blockers XE991 (IC50 = 2.2 microm) and linopirdine (IC50 = 5.5 microm) completely inhibited I(Ks), as did TEA (IC50 = 0.22 mm). The KCNQ channel opener retigabine (10 microm) shifted the activation curve to more negative membrane potentials by -24 mV, thereby increasing I(Ks). In isotonic KCl 50% of I(Ks) was activated at -62 mV. The activation curve shifted to more positive potentials as [K+]o was reduced, so that the pharmacological and biophysical properties of I(Ks) were consistent with those of heterologously expressed homomeric KCNQ2 channels. The ability of XE991 to selectively block I(Ks) was further exploited to study I(Ks) function in vivo. In anaesthetized rats, the excitability of tail motor axons was indicated by the stimulus current required to elicit a 40% of maximal compound muscle action potential. XE991 (2.5 mg kg(-1) i.p.) eliminated all nerve excitability functions previously attributed to I(Ks): accommodation to 100 ms subthreshold depolarizing currents, the post-depolarization undershoot in excitability, and the late subexcitability after a single impulse or short trains of impulses. Due to reduced spike-frequency adaptation after XE991 treatment, 100 ms suprathreshold current injections generated long trains of action potentials. We conclude that the nodal I(Ks) current is mediated by KCNQ channels, which in large fibres of rat sciatic nerve appear to be KCNQ2 homomers.

Sero-epidemiology of Toxocara canis infection among aboriginal schoolchildren in the mountainous areas of north-eastern Taiwan.

A sero-epidemiological study of Toxocara canis infection was conducted among Atayal schoolchildren (aged 7-12 years) residing in the mountainous areas of north-eastern Taiwan. The 73 children investigated were each checked for anti-Toxocara IgG, in ELISA based on the larval excretory-secretory antigens of T. canis larvae. A short, self-administered questionnaire was then used to collect relevant information from each subject, including data on the keeping of dogs, playing in soil, eating raw vegetables, and whether the subjects normally washed their hands before eating. Once the seropositive children had been identified, odds ratios (OR), with their corresponding 95% confidence intervals (CI) and P-values, were calculated for each potential risk factor. When diluted 1:64, sera from 42 (57.5%) of the children gave a positive result in the ELISA, indicating that these 42 children were seropositive for T. canis infection. Seropositivity did not appear to be associated with the age or gender of the subject, the eating of raw vegetables, or the regular failure to wash hands prior to a meal. Compared with the other subjects, however, those who admitted living in a household where dogs were kept (OR = 3.79; CI = 1.23-11.69; P = 0.02) or playing in soil (OR = 3.00; CI = 1.10-8.16; P = 0.03) appeared at increased risk of seropositivity.

Late-presenting appendicitis: a laparoscopic approach to a complicated problem.

BACKGROUND: Acute appendicitis is the most common abdominal condition necessitating urgent surgical intervention in the United States. The objective of this study was to determine if interval laparoscopic appendectomy after initial nonoperative treatment for late appendicitis presenting as an appendiceal mass is a safe alternative to immediate appendectomy. METHODS: Thirty two consecutive patients (aged 16-74 years) during a 5-year period presented with appendiceal mass. Seventeen received initial nonsurgical treatment followed by interval laparoscopic appendectomy (aged 16-60 years; group 1). Fifteen underwent immediate appendectomy (aged 16-74 years; group 2). RESULTS: All patients in the interval laparoscopic appendectomy group improved with initial therapy and underwent surgery an average of 4.9 months later. Although the operative time and the complication rate were similar between groups 1 and 2, the time to return to baseline activities was significantly less in group 1 after adjusting for age (p = 0.02 or less). CONCLUSIONS: Interval laparoscopic appendectomy is safe in patients with chronic appendicitis and allows for judicious diagnostic evaluation of the appendiceal mass and planned surgery under controlled conditions.

Toxoplasma gondii infection: relationship between seroprevalence and risk factors among inhabitants in two offshore islands from Taiwan.

A seroepidemiological study of toxoplasmosis among inhabitants of Penghu Island and Kinmen Island offshore of Taiwan was performed using the latex agglutination test from July 1999 to June 2000. In order to determine risk factors for Toxoplasma gondii (T. gondii) infection, the effects of a history of eating raw/undercooked meats and raising pets were focused on using a self-administrated questionnaire. The seroprevalence (28.2%; 190/673) in Kinmen Island was significantly higher than that (2.71%; 8/293) in Penghu Island (P < 0.001). A significant difference in seroprevalence between both sexes was found in Kinmen Island (P < 0.05), but not in Penghu Island. The results of multiple logistic regression analysis showed that the older the age, the higher the OR in both Islands, yet a significant difference in seroprevalence between children and adults or the elderly was observed in Kinmen Island (P < 0.001). Moreover, those who had histories of raising cats or eating raw/undercooked meats seemed to have greater opportunities to become infected with T. gondii (OR = 2.9, 95% CI = 1.9-4.5, P < 0.001; OR = 1.5, 95% CI = 1.1-2.1, P < 0.05). In Penghu Island, a significant association between seroprevalence and a history of raising cats was also observed (OR = 4.6, 95% CI = 1.1-20.1, P < 0.05). Furthermore, workers, farmers, and fishermen seemed to be more susceptible to T. gondii infection than students in Kinmen Island.

Gender differences in posttraumatic stress disorder after motor vehicle accidents.

OBJECTIVE: Women have higher rates of posttraumatic stress disorder (PTSD) than men. The authors examined prior trauma, PTSD, major depression, anxiety disorder not including PTSD, and peritraumatic dissociation; current peritraumatic dissociation; and passenger injury as possible explanations for the different rates of acute PTSD in women and men after a serious motor vehicle accident. METHOD: Subjects age 18-65 years who had been in a serious motor vehicle accident (N=122) were assessed with the Structured Clinical Interview for DSM-III-R and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version 1 month after the accident. RESULTS: Women did not differ from men in meeting the overall reexperiencing criterion for a diagnosis of PTSD (criterion B), but women were at greater risk for the specific reexperiencing symptoms of intense feelings of distress in situations similar to the motor vehicle accident and physical reactivity to memories of the motor vehicle accident. Women were 4.7 times more likely than men to meet the overall avoidance/numbing criterion (criterion C) and 3.8 times more likely to meet the overall arousal criterion (criterion D). Women were more likely than men to report the criterion C symptoms of avoiding thoughts and situations associated with the accident, loss of interest in significant activities, and a sense of foreshortened future and the criterion D symptoms of trouble sleeping, difficulty concentrating, and exaggerated startle response. Multiple logistic regression analysis indicated that the gender differences in acute PTSD were not associated with prior trauma, PTSD, peritraumatic dissociation, major depression, or anxiety disorder not including PTSD or with passenger injury. However, peritraumatic dissociative symptoms at the time of the accident were associated with a significantly higher risk for acute PTSD in women than in men. CONCLUSIONS: Gender differences in peritraumatic dissociation may help explain differences in risk for PTSD and for some PTSD symptoms in women and men.

What constitutes an effective but safe initial dose of lidocaine to test a thoracic epidural catheter?

To investigate the effects of age and dose on the spread of thoracic epidural anesthesia, we placed thoracic epidural catheters in 50 surgical patients divided into groups by age (Group I [young], 18-51 yr; Group II [old], 56-80 yr) and randomly assigned patients to receive either 5 mL (A) or 9 mL (B) of 2% lidocaine (plain) injected via the epidural catheter. Hemodynamic variables were measured (heart rate, mean arterial blood pressure, noninvasive impedance cardiac index) at baseline and every 5 min for 30 min. Detectable blockade occurred within 8 min after injection of 3 + 2 mL or 3 + 6 mL in 48 of 50 patients. Maximum spread of analgesia to pinprick occurred 15-23 min after completion of local anesthetic injection and was significantly different between age and volume groups by two-way analysis of variance (Group IA [young 5], 10.9 +/- 4.0 dermatomes; Group IIB [young 9], 13.9 +/- 4.5 dermatomes; Group IIA [old 5], 14.1 +/- 5.6 dermatomes; and Group IIB [old 9], 17.4 +/- 5.1 dermatomes). Minor decreases in mean arterial blood pressure (8%-17%) and heart rate (4%-11%) were noted. Two patients in the Old 9 group required IV ephedrine or ephedrine/atropine to treat hypotension and bradycardia. We conclude that given the rapid onset (3-8 min), extensive spread (11-14 dermatomal segments), and consistent hemodynamic stability, thoracic epidural anesthesia should be initiated with lidocaine 100 mg (5 mL 2% lidocaine) to establish proper location of the catheter in the epidural space in both younger and older patients.

Peritraumatic dissociation following motor vehicle accidents: relationship to prior trauma and prior major depression.

Individuals who dissociate at the time of a traumatic event (peritraumatic dissociation) are more likely to develop acute and chronic posttraumatic stress disorder (PTSD). However, little is known about who is at risk of peritraumatic dissociation. Motor vehicle accident subjects (N = 122) were systematically recruited and followed over 12 months. We used the Structured Clinical Interview for DSM-III-R (SCID) and the Peritraumatic Dissociative Experiences Questionnaire-Rater Version (PDEQ-RV). Younger subjects were more likely to experience peritraumatic dissociation as were white versus nonwhites, and single versus married subjects. Younger subjects reported a greater number of peritraumatic dissociative symptoms as did subjects with an injured passenger. After adjusting for age and passenger injury, prior major depression was significantly related to more peritraumatic dissociative symptoms. An interaction of age and prior major depression indicated that those who were younger and reported a history of major depression had the greatest number of peritraumatic dissociative symptoms.

Co-occurrence of alcohol, smokeless tobacco, cigarette, and illicit drug use by lower ranking military personnel.

The Worldwide Survey of Health Related Behaviors is administered periodically to a probability sample of military personnel. Earlier reports of these surveys suggested that illicit drug use was highest among the lowest ranking personnel. This paper reports a secondary analysis of the 1992 and 1995 surveys of the lowest ranking personnel. The results suggested that in general illicit drug users tended also to use alcohol, smokeless tobacco, and cigarettes. Heavy drinkers were more likely than light drinkers to use illicit drugs. No such relationship was observed between illicit drug use and the level of use of cigarettes or smokeless tobacco. Moreover, among the heavy drinkers, illicit drug users were especially likely to use cigarettes and among males, smokeless tobacco. The relevance of these results to military policies toward illicit drug use is discussed.

The relationship between heavy alcohol use and work productivity loss in active duty military personnel: a secondary analysis of the 1995 Department of Defense Worldwide Survey.

This cross-sectional study examines the association between heavy alcohol use among active duty military personnel and five work productivity loss events that may have an adverse effect on military performance and readiness. Data for light (N = 3,147) and heavy (N = 2,242) drinkers, categorized by gender and pay grade, were obtained from the 1995 Department of Defense Worldwide Survey. Drinking classification was predefined using a standard algorithm that factored quantity and frequency of wine, beer, and liquor consumed. The relative risks of experiencing a productivity loss event at a particular level and 95% confidence intervals were calculated by applying the Mantel-Haenszel method after adjusting for age. The relative risks for increased self-reported lateness, leaving early, low performance, and on-the-job injury were all higher for heavy drinkers than for light drinkers. This association between the heavy-drinking population and four of five work productivity loss events indicates that prevention programs should target all personnel.

Prevalence of deep venous anomalies in congenital vascular malformations of venous predominance.

PURPOSE: The overall incidence of congenital vascular malformations in the general population is 1.5%. Approximately two thirds of them are malformations of venous predominance. Abnormalities of the deep venous trunks have been observed in association with large superficial compensatory varices in these type of malformations. Knowledge of the integrity of the deep venous system is important in their management because excision of the enlarged superficial veins may be deleterious if there is aplasia or hypoplasia of the deep venous trunks. The objective was to investigate the prevalence and nature of deep venous anomalies that occur in patients with congenital vascular malformations of venous predominance both in our series and in the series from the medical literature. METHODS: From the last 35 years of medical literature, we reviewed seven series of congenital vascular malformations that provided pertinent information on the subject of our study. We also reviewed our own series of 392 patients with congenital vascular malformations studied at Children's Hospital of Mexico City (1963-1983; n = 223 children) and at Walter Reed Army and National Naval Medical Centers (1984-1998; n = 169 children). Of 392 patients, 257 (65.5%) had malformations of venous predominance; these were the subject of our analysis. Prevalence of the following deep venous anomalies was recorded: phlebectasia, aplasia or hypoplasia of venous trunks, aneurysms, and avalvulia. Diagnosis was made by one or more of the following methods: Doppler scanning, duplex scanning, plethysmography, computerized tomography, magnetic resonance imaging, and angiography. RESULTS: At least one anomaly of the deep venous system was present in 47% of the congenital vascular malformations of venous predominance reviewed. Phlebectasia was recorded in 36% of the cases, and aplasia or hypoplasia of deep venous trunks was observed in 8% of the cases. Venous aneurysms also were present in 8% of the cases; avalvulia was recorded in 7% of the cases. CONCLUSION: Anomalies of the deep venous system occur in almost one half of congenital vascular malformations of venous predominance. The most common is the relatively innocuous phlebectasias that occur in over one third of cases. Aplasia/hypoplasia, venous aneurysms, and avalvulia were less frequent, each less than 10%; but failure to detect the latter three anomalies may lead to serious therapeutic errors.

The relative incidence of anterior cruciate ligament injury in men and women at the United States Naval Academy.

The purpose of this study was to evaluate the relative risk of anterior cruciate ligament injury in female versus male midshipmen at the United States Naval Academy. From 1991 to 1997, we recorded the incidence of anterior cruciate ligament injury during intercollegiate athletics, intramural athletics, and military training. The subjects were male and female varsity athletes, coed intramural athletes, and participants in military training consisting of the obstacle course and instructional wrestling. All patient data were collected at the time of injury. Records filed at the intramural sports office, along with a questionnaire completed by coaches and trainers, were used to estimate midshipmen exposures. Results showed that in intercollegiate soccer, basketball, and rugby, women had a relative injury risk of 3.96 compared with men. In coed soccer, basketball, softball, and volleyball, the women's relative injury risk was 1.40 compared with men. In military training, women had a relative injury risk of 9.74 compared with men. In comparing overall annual anterior cruciate ligament injury rates among midshipmen, we found that women had a relative injury risk of 2.44 compared with men. We concluded that female midshipmen have an increased relative risk of anterior cruciate ligament injury as compared with men in intercollegiate athletics, basic military training, and throughout their service academy career. This increase was not statistically significant at the intramural level of athletics.

Multicenter patient self-reporting questionnaire on impotence, incontinence and stricture after radical prostatectomy.

PURPOSE: We determined the incidence of patient self-reported post-prostatectomy incontinence, impotence, bladder neck contracture and/or urethral stricture, sexual function satisfaction, quality of life and willingness to undergo treatment again in a large multicenter group of men who underwent radical prostatectomy. We also determined whether the morbidities of sexual function satisfaction, quality of life and bladder neck contracture and/or urethral stricture are predictable from demographic and postoperative prostate cancer factors. MATERIALS AND METHODS: A self-reporting questionnaire was completed and returned by 1,069 of 1,396 eligible patients (77%) who underwent radical prostatectomy between 1962 and 1997. Of the respondents 868 (85.7%) underwent surgery after 1990 and in all prostatectomy had been done a minimum of 6 months previously. Questionnaire results were independently analyzed by a third party for morbidity tabulation and the association of patient reported satisfaction. RESULTS: The patient self-reported incidence of any degree of post-prostatectomy incontinence, impotence and bladder neck contracture or urethral stricture was 65.6%, 88.4% and 20.5%, respectively. The incidence of incontinence requiring protection was 33% and only 2.8% of respondents had persistent bladder neck contracture or urethral stricture. Although incontinence and impotence significantly affected self-reported sexual function satisfaction, quality of life and willingness to undergo treatment again (p = 0.001), 77.5% of patients would elect surgery again. This finding remained true even after adjusting for demographic variables, and the time between surgery and the survey by multiple logistic regression. CONCLUSIONS: Although radical prostatectomy morbidity is common and affects self-reported overall quality of life, most patients would elect the same treatment again. Impotence and post-prostatectomy incontinence were significantly associated with sexual function satisfaction, quality of life and willingness to undergo treatment again. Bladder neck contracture and/or urethral stricture was associated with willingness to undergo treatment again after adjusting for demographic variables and time from surgery to the survey.

Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents.

OBJECTIVE: This study examined the relation between peritraumatic dissociation and posttraumatic stress disorder (PTSD) in victims of motor vehicle accidents. METHOD: Victims of serious motor vehicle accidents (N = 122) were assessed for peritraumatic dissociation with the Peritraumatic Dissociative Experiences Questionnaire-Rater Version and followed longitudinally to assess acute and chronic PTSD (1 month and 3 months after the accident) with the Structured Clinical Interview for DSM-III-R. RESULTS: The most common peritraumatic dissociative symptom was time distortion (56.6%). Subjects with peritraumatic dissociation were 4.12 times more likely than those without to have acute PTSD and 4.86 times more likely to develop chronic PTSD. The risk was independent of risk associated with the presence of PTSD before the accident. CONCLUSIONS: Peritraumatic dissociation is common following motor vehicle accidents and is a risk factor for acute and chronic PTSD, independent of risk associated with prior PTSD.

Disaster-related bereavement: acute symptoms and subsequent depression.

Despite the large body of literature on bereavement, gaps remain in our current understanding of disaster-related bereavement. We examined acute (1 wk post-disaster) and subsequent (2 mo) bereavement in 71 members of an Air Force community after the loss of 7 crewmembers and 1 passenger in a plane crash. Relative to a comparison group, the subjects had higher levels of acute intrusive and avoidant symptoms, and higher levels of depressive symptoms at 2 mo. High acute intrusive and avoidant symptoms were associated with higher levels of depressive symptoms at 2 mo. Single subjects with significant others had higher intrusive, avoidant, and depressive symptoms at 2 mo than singles without significant others and married subjects. Closer community ties (less transience) predicted higher acute intrusive and avoidant symptoms, and approached significance for depressive symptoms. After controlling for initial symptoms, the best predictors of depression at 2 mo were: low hardiness, being single, and low perceived support from friends.

Acute and chronic posttraumatic stress disorder in motor vehicle accident victims.

OBJECTIVE: This study reports the rates of acute and chronic posttraumatic stress disorder (PTSD) in a suburban community study group of 122 victims of serious motor vehicle accidents and a comparison group of 42 (who had been involved in minor, non-motor-vehicle accidents) followed over 12 months. METHOD: Motor vehicle accident victims were systematically recruited and examined with comparison subjects at 1, 3, 6, 9, and 12 months after the accident. The authors used the Structured Clinical Interview for DSM-III-R to assess DSM-III-R axis I disorders including PTSD. RESULTS: One month after the accident, 34.4% of the motor vehicle accident victims met criteria for PTSD (versus 2.4% of the comparison subjects). Similarly, at 3 and 6 months, rates of PTSD were higher (25.2% and 18.2%) in the motor vehicle accident victims than in the comparison group. Female victims were 4.64 times more likely than male victims to have PTSD at 1 month. Victims with a history of PTSD were 8.02 times more likely at 1 month and 6.81 times more likely at 3 months to have PTSD than those without a history of PTSD. Having an axis II disorder increased the risk for PTSD at 6 months. After adjustment for a history of PTSD and potentially confounding variables, women were 4.39 times more likely than men to develop PTSD at 1 month but did not have a higher risk for chronic PTSD; at 6 months, those with an axis II disorder were at greater risk of PTSD. CONCLUSIONS: Rates of PTSD are high in victims of serious motor vehicle accidents and remain high 9 months later. Female victims have an increased risk of acute but not chronic PTSD. Individuals with a history of PTSD are at risk of acute and chronic PTSD. An axis II disorder increases the risk for chronic but not acute PTSD.

Posttraumatic stress disorder and identification in disaster workers.

OBJECTIVE: Disaster workers who work with deceased victims are at increased risk of posttraumatic stress disorder (PTSD). Identification with the deceased has been proposed as one of the mechanisms in this stress-illness relationship. To examine this hypothesis, this study investigated three types of identification with the dead in a group of disaster workers: identification with the deceased as oneself, identification with the deceased as a friend, and identification with the deceased as a family member. METHOD: Fifty-four volunteer disaster workers who worked with the dead following an explosion on the USS Iowa naval ship were assessed 1, 4, and 13 months after the disaster. PTSD symptoms (measured with the DSMPTSD-IV scale), intrusive and avoidant disaster-related symptoms (measured with the Impact of Event Scale), somatization and general distress (measured with the SCL-90-R), and health care utilization were assessed. RESULTS: Disaster workers who reported identification with the deceased as a friend were more likely than those who did not to have PTSD, more intrusive and avoidant symptoms, and greater levels of other posttraumatic symptoms including somatization. Disaster workers who reported identification with the deceased as a family member had greater intrusive symptoms 1 month after the disaster than those who did not. There were no differences between those who did and did not identify with the deceased as self. Health care utilization was not associated with identification. CONCLUSIONS: Identification with the deceased is a risk factor for PTSD and posttraumatic symptoms in disaster workers exposed to the dead. Identification with the dead as a friend is specifically associated with higher risk for these workers.

The relative increase in skin temperature after stellate ganglion block is predictive of a complete sympathectomy of the hand.

BACKGROUND AND OBJECTIVES: Although an increase in skin temperature of the hand implies sympathetic block after stellate ganglion block (SGB), it does not indicate complete sympathetic block unless accompanied by an absence of sweating because skin temperature may increase even with a partial sympathetic block. This study examined the efficacy of the SGB to block sweating in the hand and to determine if the magnitude of temperature change in the hand is predictive of a negative sweat test. METHODS: Fifty-nine SGBs were performed in 30 patients (15 women and 15 men) for diagnostic or therapeutic indications. Stellate ganglion block was performed via an anterior paratracheal approach at C6 using 15 mL 0.25% bupivacaine. Skin temperature was measured bilaterally on the index finger. A cobalt blue sweat test was performed bilaterally pre- and post-SGB on the middle finger. Successful sympathetic block after SGB was considered present when: (a) (change in ipsilateral temperature (postblock-preblock)] (Di)-[change in contralateral temperature] (Dc) > or = 1.5 degrees C; (b) Horner's syndrome present; and (c) sweat test changed from positive to negative. Logistical regression was applied to determine what value of Di - Dc could be used to predict a negative sweat test. RESULTS: Thirty-six percent (21/59) of blocks met all three criteria. Of the blocks where Di - Dc > or = 1.5 degrees C, 72% (21/29) had a negative sweat test post-SGB. Of the blocks where Di - Dc < 1.5 degrees C, 37% (11/30) had a negative sweat test postblock. If Di - Dc > or = 2.0 degrees C, a negative sweat test could be predicted with 69 +/- 12% sensitivity and 85 +/- 10% specificity. CONCLUSIONS: Stellate ganglion block often fails to increase skin temperature in the ipsilateral more than the contralateral hand. A value of Di - Dc > or = 2.0 degrees C was a good predictor of a sympathetic block, but was not sufficient to guarantee a complete sympathetic block of the hand after SGB in all cases. An apparently successful SGB as measured by "usual" clinical criteria may not result in a complete sympathectomy of the hand as is often assumed. Therefore, if obtaining a sympathectomy is important for diagnostic or therapeutic purposes, performing a sweat test provides important confirmatory evidence of the genuine success of the sympathetic block.