Posttraumatic stress disorder as a risk factor for obesity among male military veterans.

OBJECTIVE: Obesity is a significant public health problem in the United States, particularly among military veterans with multiple risk factors. Heretofore, posttraumatic stress disorder (PTSD) has not clearly been identified as a risk factor for this condition. METHOD: We accessed both a national and local database of PTSD veterans. RESULTS: Body mass index (BMI) was greater (P < 0.0001) among male military veterans (n = 1819) with PTSD (29.28 +/- 6.09 kg/m(2)) than those veterans (n = 44 959) without PTSD (27.61 +/- 5.99 kg/m(2)) in a sample of randomly selected veterans from the national database. In the local database of male military veterans with PTSD, mean BMI was in the obese range (30.00 +/- 5.65) and did not vary by decade of life (P = 0.242). CONCLUSION: Posttraumatic stress disorder may be a risk factor for overweight and obesity among male military veterans.

Increased disorderliness and amplified basal and pulsatile aldosterone secretion in patients with primary aldosteronism.

To investigate the pathophysiology of altered aldosterone secretion in patients with primary aldosteronism, the pulsatile mode of in vivo aldosterone and cortisol release was examined by quantitative deconvolution analysis in 5 normal subjects (controls) and 10 patients with aldosterone-producing adenomas (APA) under conditions of sodium (150 meq/day) balance. Episodic release of aldosterone and cortisol was assessed by sampling blood at 10-min intervals for 24 h. A waveform-independent deconvolution algorithm was used to calculate endogenous aldosterone and cortisol secretion rates on a sample by sample basis in each subject. There were no differences in the number of aldosterone or cortisol secretory bursts per day or their mean interpulse intervals between normal subjects and patients with primary aldosteronism. A 24-h rhythmicity in serum aldosterone concentrations was maintained in APA patients. Patients with primary aldosteronism had significantly higher (P < 0.01) aldosterone mean secretory rates, mean mass of aldosterone secreted per burst, maximal aldosterone secretion rates attained within each burst, and mean basal (nadir) aldosterone secretion rates. A recently introduced regularity statistic, approximate entropy (ApEn), was used to test for orderliness (small ApEn) vs. randomness (large ApEn) in the aldosterone time series. ApEn was significantly larger for the APA patients (1.433 +/- 0.148) than for normal subjects (0.306 +/- 0.098; P < 0.001), with complete group segmentation yielding 100% sensitivity and specificity. In contrast, a scale-invariant form of this measure, normalized ApEn, showed no significant distinction between tumoral and normal aldosterone release patterns. These ApEn findings taken together are consistent with the deconvolution results from an entirely distinct perspective, reinforcing an amplitude difference, but no frequency difference, between normal subjects and APA patients. Unexpectedly, patients with APA had significantly lower mean cortisol secretory rates, reduced cortisol secretory burst mass, and attenuated maximal cortisol secretory rates than normal subjects (P < 0.01). Plasma cortisol and aldosterone concentrations in patients remained positively correlated over short time lags. In summary, the present findings demonstrate that in normal subjects and patients with APA, both aldosterone and cortisol are secreted in a burst-like mode. The presence of substantial basal aldosterone release and increased irregularity of serial aldosterone concentrations distinguishes APA from normal subjects.(ABSTRACT TRUNCATED AT 400 WORDS)

Diurnal variation of urinary excretion for patients with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome).

Ten patients [8 men and 2 women, mean age (SD) 37.6 +/- 6.5 years] with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent serial determinations at 6:00 AM, 12 noon, 6:00 PM, and 12 midnight of levels of urinary creatinine concentration (UCR), urinary specific gravity (SPGR), and urinary osmolality (UOSM) on 8 consecutive Thursdays. Diurnal variation (p less than 0.015) was present in the case of each parameter of urinary excretion (UCR, SPGR, and UOSM). These three parameters remained very low throughout the day (mean UCR 19.0 mg/dl, mean SPGR 1.0033, and mean UOSM 112.6 mosmol/kg), which is consistent with severe and persistent hyposthenuria, and each parameter correlated well with the other two parameters (r between 0.78 and 0.93, p less than 0.001). The 6:00 PM (UC6PM) value for UCR correlated best with the daily mean UCR (UCM), providing the simple linear regression UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) for the 10 PIP patients. Twenty-four-hour urinary volume (24UV) could then be estimated using UCM and values of 17.5 and 12.5 mg creatinine/kg body weight for male and female PIP patients, respectively, to calculate the daily urinary excretion of urinary creatinine. The group mean 24UV was 6963 ml, with a range of 4934-9884 ml. We hope that information about the diurnal variation of urinary excretion (21.6%, 20.5%, 27.4%, and 30.4% of 24UV excreted in consecutive quartiles commencing with the 12 midnight to 6:00 AM quartile), coupled with the utilization of the equation UCM = 0.7615 X UC6PM + 6.1503 (r = 0.912, p = 0.0005) to estimate UCM as an index of 24UV in the PIP syndrome, will provide tools to better elucidate the relationship between psychosis and water dysregulation.

Treatment of psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) using lithium and phenytoin.

Six patients [5 men and 1 woman, mean age 37.3 +/- 8.2 (SD) years] with psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome) underwent a sequence of treatments in an effort to normalize basal serum sodium levels and thereby protect the patients against complications, including hyponatremic seizures and coma. The morning baseline group mean basal serum sodium value was 132.5 +/- 3.8 meq/liter. Over a 20-month period, the sequence of treatments was salt-added diet, lithium and phenytoin, and lithium alone. Each treatment program yielded morning group mean basal serum sodium determinations superior to baseline values, except for the program of lithium alone, which could not be tolerated. The combination of lithium and phenytoin provided a morning group mean basal serum sodium level of 140.6 +/- 3.2 meq/liter, which was superior (p less than 0.01) to all other treatment modalities. Early morning hyposthenuria persisted throughout the 20-month period of observation.

Development of water dysregulation during Arieti's third stage of schizophrenia?

We found abnormal diurnal weight gain among 25% of acutely psychotic patients with schizophrenia and 68% of chronically psychotic patients with schizophrenia. They were weighed at 7:00 AM and 4:00 PM weekly for 3 weeks. We normalized the diurnal weight gain (NDWG) as a percentage by subtracting the 7:00 AM weight from the 4:00 PM weight, multiplying the difference by 100, and dividing the result by the 7:00 AM weight, NDWG was 0.93% +/- 0.89% for the 36 acutely psychotic patients and 2.2% +/- 1.5% for the 68 chronically psychotic patients (F = 25.297, p less than 0.0001). Drugs did not explain this difference. Our data, though preliminary, suggest that water dysregulation, as manifested by abnormal diurnal weight gain, develops in schizophrenia as patients progress into Arieti's third stage of this disorder. A longitudinal study design, rather than our cross-sectional one, would be necessary to assess developmental changes in schizophrenia.

Psychogenic polydipsia and water intoxication--concepts that have failed.

Ten patients (8 men, 2 women; mean age 38.7 +/- 8.1 years), 7 of whom had schizophrenic disorders and 3 of whom had bipolar disorder (manic-depressive illness), manifested psychosis, intermittent hyponatremia, and polydipsia (PIP syndrome). The relationship between serum sodium and urinary water excretion among the 10 PIP patients is described in detail. The success of lithium in improving serum sodium levels and in decreasing urinary water excretion among the three PIP patients with bipolar disorder and the failure of changes in urinary water excretion to explain changes in serum sodium levels among the 10 PIP patients argue against "psychogenesis" as the explanation for the polydipsia and excessive water intake as the sole explanation for hyponatremia or complications ascribed to water intoxication.

Marked sinus tachycardia resulting from the synergistic effects of marijuana and nortriptyline.

A young patient experienced marked sinus tachycardia while smoking marijuana and receiving therapeutic doses of nortriptyline. The authors discuss the potential synergistic effects of these drugs and recommend treatment with propranolol.

Myocardial infarction before age 36: risk factor and arteriographic analysis.

One-hundred consecutive patients who were 35 years of age of younger underwent coronary arteriography after clinical myocardial infarction. Ninety-two percent were men. Four distinct subgroups were identified: Ninety-four patients (78 percent) had significant coronary artery disease (greater than 50 percent diameter narrowing of at least one major coronary artery), 20 (17 percent) had normal coronary arteries, 5 (4 percent) had major coronary arterial anomalies and 1 patient had coronary arteritis. Of the patients with obstructive coronary disease, risk factors were smoking in 89 percent, positive family history of coronary artery disease in 48 percent, hypertension in 21 percent and a history of lipid abnormality in 20 percent. Risk factors were distinctly less frequent in the groups without coronary atherosclerosis. In the group with coronary artery disease, the prevalence rate of one, two and three vessel disease was 32, 26 and 42 percent, respectively. Coronary arterial anomalies included anomalous origin of the left coronary artery from the pulmonary artery (three patients) and single right and single left coronary artery (one patient each). It is concluded that myocardial infarction before age 36 is a disease of men who smoke and who often have a family history of premature coronary artery disease. Twenty-two percent of patients will have normal coronary arteries, coronary arterial anomalies or coronary vasculitis. Coronary arteriography should be considered for patients who sustain a myocardial infarction before age 36 for purposes of diagnosis, management and prognosis.

Clinical correlates in hypertensive patients with left ventricular hypertrophy diagnosed with echocardiography.

Seventy-three hypertensive patients were evaluated with M mode and two dimensional echocardiography. Left ventricular hypertrophy was found in 37 patients (51 percent); 29 had concentric hypertrophy and the remaining 8 had disproportionate septal thickening. Factors that did not influence the distribution of patients in the group with left ventricular hypertrophy and normal subjects included (1) duration of hypertension, (2) level of blood pressure, (3) age, (4) body surface area, and (5) race. More of the patients who had a normal left ventricular mass (32 or 89 percent) than of those who had hypertrophy (22 or 59 percent) were receiving two or more antihypertensive drugs. Electrocardiography was very insensitive in identifying left ventricular hypertrophy in these patients. The presence of increased left ventricular mass was associated with a greater incidence of other target organ disease.

Semiautomated method for evaluation of left ventricular regional wall motion in coronary artery disease.

Regional left ventricular wall motion was independently assessed in 436 patients using both subjective visual inspection of ventriculograms and objective computer-determined percent change in the square root of the area between systolic and diastolic outlines. Agreement between subjective and objective techniques was greatest at the ventricular apex and least at the base and partly dependent on the number of abnormal segments present. Objective analysis of regional wall motion provides a permanent quantitative record of wall motion and shows good agreement with meticulous subjective inspection of ventriculograms. As such, it has potential as an adjunct to ventriculography.

Selective coronary arteriography in congenitally corrected transposition of the great arteries.

Three cases of congenitally corrected transposition of the great arteries in adults who underwent selective coronary arteriography are presented. The morphologic features of the epicardial coronary anatomy are distinctive and are identifiable angiographically as morphologically right and left coronary arteries that are specifically concordant with the morphologically right and left ventricles. This relation is constant in the presented cases, in previously published coronary arteriograms of congenitally corrected transposition of the great arteries and in a review of the anatomic studies of congenitally corrected transposition of the great arteries that identify the coronary arterial pattern. Thus the angiographic characteristics of the epicardial coronary arterial pattern permit identification of the morphologic features of the underlying ventricle regardless of other spatial relations.

Treatment strategies in the polydipsia-hyponatremia syndrome.

The clinician must first identify the patient at risk of developing water intoxication and its complications including seizures, coma, and death. In the polydipsic patient, behavioral approaches correcting or limiting polydipsia may prevent progression to dilutional hyponatremia. Drugs that oppose the central release or renal action of antidiuretic hormone will usually normalize morning serum sodium concentration in patients with the polydipsia-hyponatremia syndrome. The clinician can monitor such patients by observing diurnal changes in body weight. Specific interventions derive from specific weight changes. For the symptomatic patient suffering from water intoxication, intravenous administration of saline raising the serum sodium concentration to the 120-mmol/L range, followed by fluid restriction to further correct hyponatremia, will almost always successfully correct hyponatremia and protect against central pontine myelinolysis.

Tricyclic antidepressant use in a patient with bundle branch blocks and ventricular ectopy.

Amoxapine, a dibenzoxapine tricyclic antidepressant, was used successfully to treat a depressed elderly woman with left anterior hemiblock, right bundle branch block, and ventricular ectopy. This case highlights the importance of serial electrocardiographic monitoring in depressed patients with cardiac abnormalities treated with tricyclic antidepressants. The apparent reduction of ectopy in this case indicates a possible quinidine-like action of amoxapine.

Oral sodium chloride in the management of schizophrenic patients with self-induced water intoxication.

Hyponatremia is always present in patients with water intoxication and accounts for many of the life-threatening symptoms and signs found in this population. In schizophrenic patients, water restriction, a cornerstone in the treatment of water intoxication, may be impossible to implement over the course of long-term management. The use of oral sodium chloride administration in such patients and its short-term efficacy in preventing major motor seizures are described.

Dressler's syndrome and angina pectoris relieved by surgery.

A 49-year-old woman with progressive angina pectoris developed chronic Dressler's syndrome following a second myocardial infarction. Control of the chronic pericarditis required long-term steroid therapy. Because of multiple complications generated by the steroid administration, she underwent coronary angiography followed by pericardiectomy and coronary artery bypass surgery. The patient remains asymptomatic without steroid or antianginal medication five years after surgery.

Myocardial infarction in a young woman with isolated coronary arteritis.

A 26-year-old black woman presented with a febrile illness and subsequently sustained an inferior myocardial infarction with chest pain. CPK-MB elevation and ECG changes. Left ventriculography revealed inferior wall hypokinesis, and coronary angiography demonstrated multiple aneurysms of the coronary arteries. Findings on visceral angiography of multiple organs was normal. Various etiologies were considered; however, her clinical course was felt to be most consistent with periarteritis nodosa and steroid therapy was instituted.

Historic and angiographic features of young adults surviving myocardial infarction.

Sixty-eight survivors of myocardial infarction occurring before the age of 36 years were studied using selective coronary cinearteriograms, regardless of symptoms. Three groups of patients were delineated; 56 patients (82 percent) had obstructive coronary arterial disease, nine (13 percent) had normal coronary arteries, and three (4 percent) had congenital coronary arterial anomalies. Because the prognosis in these three groups is different, all young patients with myocardial infarction should undergo coronary arteriographic studies after a suitable period of convalescence. Myocardial infarction in the young differs from that in the elderly by virtue of a more heterogeneous underlying coronary anatomy, an overwhelming preponderance of male patients, and a better reported prognosis.

Saphenous vein graft from aorta to coronary vein with production of continuous murmur. A complication of coronary artery bypass surgery.

A saphenous vein graft was inadvertently placed from the aorta to the coronary vein adjacent to the proximal left anterior descending coronary artery in a 53-year-old man with symptomatic coronary artery disease. The post-operative finding of a continuous murmur led to cardiac catheterization and successful surgical correction. The postoperative finding of a continuous murmur must alert the clinician to this possible technical error.

Evaluation of the in vivo function of the Hancock porcine xenograft in the aortic position.

We evaluated the vivo hemodynamic function of the stent-mounted glutaraldehyde-fixed porcine xenograft in 23 patients who had undergone aortic valve replacement from 2 days to 24 months prior to the study. Functional aortic valve orifice areas for the porcine xenograft ranged from 0.58 to 3.0 sq. cm., the average area being 1.36 sq. cm. Six patients had calculated prosthetic valve orifice areas less than 1.0 sq. cm. Valve orifice area did not correlate significantly with valve size or the time interval from surgery to postoperative study. Left ventricular stroke volume showed a significant, positive correlation with calculated xenograft orifice area. Systemic thromboembolism was not encountered. One patient required reoperation for xenograft stenosis caused by dense fibrin deposition on the aortic leaflets. We conclude that use of the stent-mounted glutaraldehyde-fixed porcine xenograft can be associated with significant functional stenosis which may be related to annulus size or inertial properties of the valve. These factors should be taken into consideration when considering use of the stent-mounted glutaraldehyde-fixed porcine xenograft in individual patients.