Coatesville Veterans Affairs Medical Center

Abstract The vibrational spectrum of a molecule is considered to be a unique physical property and is characteristic of the molecule. As such, the infrared spectrum can be used as a fingerprint for identification by the comparison of the spectrum from an “unknown” with previously recorded reference spectra. This is the basis of computer‐based spectral searching. In the absence of a suitable reference database, it is possible to effect a basic interpretation of the spectrum from first principles, leading to characterization, and possibly even identification of an unknown sample. This first principles approach is based on the fact that structural features of the molecule, whether they are the backbone of the molecule or the functional groups attached to the molecule, produce characteristic and reproducible absorptions in the spectrum. This information can indicate whether there is backbone to the structure and, if so, whether the backbone consists of linear or branched chains. Next it is possible to determine if there is unsaturation and/or aromatic rings in the structure. Finally, it is possible to deduce whether specific functional groups are present. If detected, one is also able to determine local orientation of the group and its local environment and/or location in the structure. The origins of the sample, its prehistory, and the manner in which the sample is handled all have impact on the final result. Basic rules of interpretation exist and, if followed, a simple, first‐pass interpretation leading to material characterization is possible. This article addresses these issues in a simple, logical fashion. Practical examples are included to help guide the reader through the basic concepts of infrared spectral interpretation.

Benjamin A. Lipsky, Anthony R. Berendt, H. Gunner Deery, John M. Embil, Warren S. Joseph, Adolf W. Karchmer, Jack L. LeFrock, Daniel P. Lew, Jon T. Mader, Carl Norden, and James S. Tan Medical Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Northern Michigan Infectious Diseases, Petoskey, Michigan; Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; Section of Podiatry, Department of Primary Care, Veterans Affairs Medical Center, Coatesville, Pennsylvania; Division of Infectious Diseases, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Dimensional Dosing Systems, Sarasota, Florida; Department of Medicine, Service of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; Department of Internal Medicine, The Marine Biomedical Institute, and Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, Texas; Department of Medicine, New Jersey School of Medicine and Dentistry, and Cooper Hospital, Camden, New Jersey; and Department of Internal Medicine, Summa Health System, and Northeastern Ohio Universities College of Medicine, Akron, Ohio

Ainslie argues that our responses to the threat of our own inconsistency determine the basic fabric of human culture. He suggests that individuals are more like populations of bargaining agents than like the hierarchical command structures envisaged by cognitive psychologists. The forces that create and constrain these populations help us understand so much that is puzzling in human action and interaction: from addictions and other self-defeating behaviors to the experience of willfulness, from pathological over-control and self-deception to subtler forms of behavior such as altruism, sadism, gambling, and the 'social construction' of belief. This book integrates approaches from experimental psychology, philosophy of mind, microeconomics, and decision science to present one of the most profound and expert accounts of human irrationality available. It will be of great interest to philosophers and an important resource for professionals and students in psychology, economics and political science.

Preface 1. The paradox of addiction 2. In search of the two minds 3. Temporary-preference theory 4. The interaction of interests: the effects of short-range interests 5. The interaction of interests 6. Freedom and compulsion 7. Self-generated reward as the basic impulse-control problem 8. The demon at the calliope 9. The texture of experience Appendices Bibliography Indices.

Relative to individuals who do not have addictive disorders, drug abusers exhibit greater devaluation of rewards as a function of their delay ("delay discounting"). The present study sought to extend this finding to methamphetamine (MA) abusers and to help understand its neural basis. MA abusers (n = 12) and control subjects who did not use illicit drugs (n = 17) participated in tests of delay discounting with hypothetical money rewards. We then used a derived estimate of each individual's delay discounting to generate a functional magnetic resonance imaging probe task consisting of three conditions: "hard choices," requiring selections between "smaller, sooner" and "larger, later" alternatives that were similarly valued given the individual's delay discounting; "easy choices," in which alternatives differed dramatically in value; and a "no choice" control condition. MA abusers exhibited more delay discounting than control subjects (P < 0.05). Across groups, the "hard choice > no choice" contrast revealed significant effects in the ventrolateral prefrontal cortex, dorsolateral prefrontal cortex (DLPFC), dorsal anterior cingulate cortex, and areas surrounding the intraparietal sulcus (IPS). With group comparisons limited to these clusters, the "hard choice > easy choice" contrast indicated significant group differences in task-related activity within the left DLPFC and right IPS; qualitatively similar nonsignificant effects were present in the other clusters tested. Whereas control subjects showed less recruitment associated with easy than with hard choices, MA abusers generally did not. Correlational analysis did not indicate a relationship between this anomaly in frontoparietal recruitment and greater degree of delay discounting exhibited by MA abusers. Therefore, while apparent inefficiency of cortical processing related to decision-making in MA abusers may contribute to the neural basis of enhanced delay discounting by this population, other factors remain to be identified.

The Interaural Time Difference for High-Pass Filtered Noise and Its Relationship With Brainstem Dysfunction and Disability in Multiple Sclerosis,

I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. 1,2 The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. "nontrauma" hospital); access to a particular technology at the surgeon's institution; and the surgeon's individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT. II. PROCESS A. Identification of References A MEDLINE search was performed using the key words "abdominal injuries" and the subheading "diagnosis." This search was limited further to (1) clinical research, (2) published in English, and (3) publication dates January 1978 through February 1998. The initial search yielded 742 citations. Case reviews, review articles, meta-analyses, editorials, letters to the editor, technologic reports, pediatric series, and studies involving a significant number of penetrating abdominal injuries were excluded before formal review. Additional references, selected by the individual subcommittee members, were then included to compile the master reference list of 197 citations. B. Quality of the References Articles were distributed among subcommittee members for formal review. A review data sheet was completed for each article reviewed that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services as follows: Class I: Prospective, randomized, double-blinded study Class II: Prospective, randomized, nonblinded trial Class III: Retrospective series, meta-analysis After review by the subcommittee, references were excluded on the basis of poor design or invalid conclusions. An evidentiary table (Table 1) was constructed using the remaining 101 references: Class I, 20 references; Class II, 32 references; and Class III, 49 references. Recommendations were made on the basis of studies included in the evidentiary table (Table 1).Table 1: Euidentiary: Practice Management Guidelines for the Evaluation of Blunt Abdominal TraumaTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedIII. RECOMMENDATIONS A. Level I 1. Exploratory laparotomy is indicated for patients with a positive DPL. 2. FAST may be considered as the initial diagnostic modality to exclude hemoperitoneum. B. Level II 1. When DPL is used, clinical decisions should be made on the basis of the presence of gross blood on initial aspiration (i.e., 10 mL) or microscopic analysis of lavage effluent. 2. Exploratory laparotomy is indicated in hemodynamically unstable patients with a positive FAST. In hemodynamically stable patients with a positive FAST, follow-up CT scan permits nonoperative management of select injuries. 3. Surveillance studies (i.e., DPL, CT scan, repeat FAST) should be considered in hemodynamically stable patients with indeterminate FAST results. 4. CT scanning is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT scan should be admitted for observation. 5. CT scanning is the diagnostic modality of choice for nonoperative management of solid visceral injuries. 6. In hemodynamically stable patients, DPL and CT scanning are complementary diagnostic modalities. C. Level III 1. Objective diagnostic testing (i.e., FAST, DPL, CT scanning) is indicated for patients with abnormal mentation, equivocal findings on physical examination, multiple injuries, concomitant chest injury, or hematuria. 2. Patients with seat belt sign should be admitted for observation and serial physical examination. The presence of intraperitoneal fluid on FAST or CT scan in a patient with seat belt sign suggests the presence of an intra-abdominal injury that may require surgery. 3. CT scanning is indicated for the evaluation of suspected renal injuries. 4. In the patient at high risk for intra-abdominal injury (e.g., multiple orthopedic injuries, severe chest wall trauma, neurologic impairment), a follow-up CT scan should be considered after a negative FAST. 5. In hemodynamically stable patients with a positive DPL, follow-up CT scan should be considered, especially in the presence of pelvic fracture or suspected injuries to the genitourinary tract, diaphragm, or pancreas. IV. SCIENTIFIC FOUNDATION A. Diagnostic Peritoneal Lavage DPL was introduced by Root et al. in 1965 as a rapid and accurate method to identify the presence of intra-abdominal hemorrhage after trauma. 3 Subsequent studies have confirmed the efficacy of DPL in diagnosing abdominal hemorrhage as well as its superiority over physical examination alone. 4 The accuracy of DPL has been reported to be between 92% and 98%. 5–10 The high sensitivity of DPL is because of the significant false-positive rate of the technique. 11–13 Several authors have highlighted the importance of interpreting DPL results in the context of the overall clinical condition of the patient. A positive DPL does not necessarily mandate immediate laparotomy in the hemodynamically stable patient. 12,14–16 DPL has been shown to be more efficient than CT scanning in identifying patients that require surgical exploration. 17 The complication rate associated with DPL is quite low. 18 The incidence of complications is lower for open DPL compared with the closed technique. However, closed DPL can be performed more rapidly. 19–22 Studies designed to examine the ability of physicians to estimate the red blood cell (RBC) count in DPL fluid have demonstrated the poor sensitivity of visual inspection. 23–25 A positive DPL, on the basis of microscopic analysis of lavage fluid, has been defined as > 105 RBCs/mm3. It has been recommended that patients with RBC counts in the equivocal range (i.e., 25,000–75,000 RBCs/mm3) undergo additional diagnostic testing, such as CT scanning. 12 The false-positive rate for DPL is increased in patients with pelvic fractures. 26,27 To avoid sampling the retroperitoneal hematoma, a supraumbilical approach has been recommended, theoretically reducing the chances of a false-positive result. 28 The advantages of DPL for detection of hollow visceral injuries have been clearly demonstrated. 29,30 Two studies that advocate analysis of DPL fluid for amylase and alkaline phosphatase consistent with enteric injuries have been disputed. 31–33 Similarly, the utility of the DPL white blood cell count has been questioned. 34–36 DPL is sensitive for mesenteric injury and, in fact, has been shown to be superior to CT scanning for the diagnosis of this injury. 37 Thus, DPL is a safe, rapid, and accurate method for determining the presence of intraperitoneal blood in victims of BAT. It is more accurate than CT scanning for the early diagnosis of hollow visceral and mesenteric injuries, but it does not reliably exclude significant injuries to retroperitoneal structures. False-positive results may occur in the presence of pelvis fractures. Hemodynamically stable patients with equivocal results are best managed by additional diagnostic testing to avoid unnecessary laparotomies. B. Computed Tomographic Scanning Routine use of CT scanning for the evaluation of BAT was not initially viewed with overwhelming enthusiasm. CT scanning requires a cooperative, hemodynamically stable patient. In addition, the patient must be transported out of the trauma resuscitation area to the radiographic suite. Specialized technicians and the availability of a radiologist for interpretation were also viewed as factors that limited the utility of CT scanning for trauma patients. CT scanners are now available in most trauma centers and, with the advent of helical scanners, scan time has been significantly reduced. As a result, CT scanning has become an accepted part of the traumatologist's armamentarium. The accuracy of CT scanning in hemodynamically stable blunt trauma patients has been well established. Sensitivity between 92% and 97.6% and specificity as high as 98.7% have been reported in patients subjected to emergency CT scanning. 38,39 Most authors recommend admission and observation after a negative CT scan. 40,41 In a recent study of 2,774 patients, the authors concluded that the negative predictive value (99.63%) of CT scanning was sufficiently high to permit safe discharge of BAT patients after a negative CT scan. 42 CT scanning is notoriously inadequate for the diagnosis of mesenteric injuries and may also miss hollow visceral injuries. In patients at risk for mesenteric or hollow visceral injury, DPL is generally felt to be a more appropriate test. 37,43 A negative CT scan in such a patient cannot reliably exclude intra-abdominal injuries. CT scanning has the unique ability to detect clinically unsuspected injuries. In a series of 444 patients in whom CT scanning was performed to evaluate renal injuries, 525 concomitant abdominal and/or retroperitoneal injuries were diagnosed. Another advantage of CT scanning over other diagnostic modalities is its ability to evaluate the retroperitoneal structures. 40 Kane et al. performed CT scanning in 44 hemodynamically stable blunt trauma patients after DPL. In 16 patients, CT scan revealed significant intra-abdominal or retroperitoneal injuries not diagnosed by DPL. Moreover, the findings on CT scan resulted in a modification to the original treatment plan in 58% of the patients. 44 C. Focused Abdominal Sonography for Trauma In recent years, FAST has emerged as a useful diagnostic test in the evaluation of BAT. The advantages of the FAST examination have been clearly established. FAST is noninvasive, may be easily performed, and can be performed concurrently with resuscitation. In addition, the technology is portable and may be easily repeated if necessary. 45–48 In most cases, FAST may be completed within 3 or 4 minutes. 49–51 The test is especially useful for detecting intra-abdominal hemorrhage in the patient with multiple injuries or the pregnant patient. 52 A noted drawback to the FAST examination is the fact that a positive examination relies on the presence of free intraperitoneal fluid. In the hands of most operators, ultrasound will detect a minimum of 200 mL of fluid. 53 Injuries not associated with hemoperitoneum may not be detected by this modality. 49,54,55 Thus, ultrasound is not a reliable method for excluding hollow visceral injury. 47,49,56–58 In addition, the FAST examination cannot be used to reliably grade solid organ injuries. Therefore, in the hemodynamically stable patient, a follow-up CT scan should be obtained if nonoperative management is contemplated. 59 FAST compares favorably with more traditionally used diagnostic tests. In the hemodynamically stable patient with BAT, FAST offers a viable alternative to DPL. 60 DPL may also be used as a complementary examination in the hemodynamically stable patient in the presence of equivocal or negative ultrasound findings with strong clinical suspicion of visceral injury. 61,62 FAST has demonstrated utility in hemodynamically stable patients with BAT. 58,60,63 In addition, ultrasound has been shown to be more cost-effective when compared with DPL or CT scanning. 45,47,60 Overall, FAST has a sensitivity between 73% and 88% and a specificity between 98% and 100%, and is 96% to 98% accurate. 46,50,57,58,64,65 This level of accuracy is independent of the practitioner performing the study. Surgeons, emergency medicine physicians, ultrasound technicians, and radiologists have equivalent results. 46,53,64–66 D. Other Diagnostic Modalities As interest in laparoscopic procedures has increased among general surgeons, there has been speculation regarding the role of diagnostic laparoscopy (DL) in the evaluation of BAT. One of the potential benefits postulated is the reduction of nontherapeutic laparotomies. With modification of the technique to include smaller instruments, portable equipment, and local anesthesia, DL may be a useful tool in the initial evaluation of BAT. Although there are no randomized, controlled studies comparing DL to more commonly used modalities, experience at one institution using minilaparoscopy demonstrated a 25% incidence of positive findings on DL, which were successfully managed nonoperatively and would have resulted in nontherapeutic laparotomies. 67 Although its ultimate role remains unclear, another modality to be considered in the diagnostic evaluation of BAT is visceral angiography. This modality may have diagnostic value when used in conjunction with angiography of the pelvis or chest, or when other diagnostic studies are inconclusive. 68 V. SUMMARY Injury to intra-abdominal viscera must be excluded in all victims of BAT. Physical examination remains the initial step in diagnosis but has limited utility under select circumstances. Thus, various diagnostic modalities have evolved to assist the trauma surgeon in the identification of abdominal injuries. The specific tests are selected on the basis of the clinical stability of the patient, the ability to obtain a reliable physical examination, and the provider's access to a particular modality. It is important to emphasize that many of the diagnostic tests used are complementary rather than exclusionary. On the basis of the above recommendations, a reasonable diagnostic approach to BAT is summarized in Figures 1 and 2. In hemodynamically stable patients with a reliable physical examination, clinical findings may be used to select patients who may be safely observed. In the absence of a reliable physical examination, the main diagnostic choice is between CT scanning or FAST (with CT scanning in a complementary role). Hemodynamically unstable patients may be initially evaluated with FAST or DPL.Fig. 1: Evaluation of BAT: unstable patient.Fig. 2: Evaluation of BAT: stable patient.VI. FUTURE INVESTIGATIONS Recent literature is replete with studies that emphasize the many advantages of ultrasound in the valuation of BAT. Although this technology is becoming more available to trauma surgeons, for a variety of reasons, it has not become universally available in all centers. Continued research addressing the utility of FAST, with emphasis on its advantages specific to resource use, is suggested. In addition, studies should be designed to more closely evaluate the feasibility of FAST as the sole diagnostic test in hemodynamically stable patients. Perhaps safe strategies for nonoperative management of solid visceral injuries could be developed that rely on FAST alone, such that the number of CT scans could be reduced.

CONTEXT: State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group. OBJECTIVE: To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians. DESIGN: Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale. SUBJECTS: All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997. MAIN OUTCOME MEASURES: Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline. RESULTS: A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92). CONCLUSIONS: A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.

Behavioral science has long been puzzled by the experience of temptation, the resulting impulsiveness, and the variably successful control of this impulsiveness. In conventional theories, a governing faculty like the ego evaluates future choices consistently over time, discounting their value for delay exponentially, that is, by a constant rate; impulses arise when this ego is confronted by a conditioned appetite. Breakdown of Will (Ainslie 2001) presents evidence that contradicts this model. Both people and nonhuman animals spontaneously discount the value of expected events in a curve where value is divided approximately by expected delay, a hyperbolic form that is more bowed than the rational, exponential curve. With hyperbolic discounting, options that pay off quickly will be temporarily preferred to richer but slower-paying alternatives, a phenomenon that, over periods from minutes to days, can account for impulsive behaviors, and over periods of fractional seconds can account for involuntary behaviors. Contradictory reward-getting processes can in effect bargain with each other, and stable preferences can be established by the perception of recurrent choices as test cases (precedents) in recurrent intertemporal prisoner's dilemmas. The resulting motivational pattern resembles traditional descriptions of the will, as well as of compulsive phenomena that can now be seen as side-effects of will: over-concern with precedent, intractable but circumscribed failures of self-control, a motivated ("dynamic") unconscious, and an inability to exploit emotional rewards. Hyperbolic curves also suggest a means of reducing classical conditioning to motivated choice, the last necessary step for modeling many involuntary processes like emotion and appetite as reward-seeking behaviors; such modeling, in turn, provides a rationale for empathic reward and the "construction" of reality.

DBA/2J (D2) and C57BL/6J (B6) mice exhibit differential sensitivity to seizures induced by various chemical and physical methods, with D2 mice being relatively sensitive and B6 mice relatively resistant. We conducted studies in mature D2, B6, F1, and F2 intercross mice to investigate behavioral seizure responses to pentylenetetrazol (PTZ) and to map the location of genes that influence this trait. Mice were injected with PTZ and observed for 45 min. Seizure parameters included latencies to focal clonus, generalized clonus, and maximal seizure. Latencies were used to calculate a seizure score that was used for quantitative mapping. F2 mice (n = 511) exhibited a wide range of latencies with two-thirds of the group expressing maximal seizure. Complementary statistical analyses identified loci on proximal (near D1Mit11) and distal chromosome 1 (near D1Mit17) as having the strongest and most significant effects in this model. Another locus of significant effect was detected on chromosome 5 (near D5Mit398). Suggestive evidence for additional PTZ seizure-related loci was detected on chromosomes 3, 4, and 6. Of the seizure-related loci identified in this study, those on chromosomes 1 (distal), 4, and 5 map close to loci previously identified in a similar F2 population tested with kainic acid. Results document that the complex genetic influences controlling seizure response in B6 and D2 mice are partially independent of the nature of the chemoconvulsant stimulus with a locus on distal chromosome 1 being of fundamental importance.

Endosymbiosis of bacteria by eukaryotes is a defining feature of cellular evolution. In addition to well-known bacterial origins for mitochondria and chloroplasts, multiple origins of bacterial endosymbiosis are known within the cells of diverse animals, plants and fungi. Early-diverging lineages of terrestrial fungi harbor endosymbiotic bacteria belonging to the Burkholderiaceae. We sequenced the metagenome of the soil-inhabiting fungus Mortierella elongata and assembled the complete circular chromosome of its endosymbiont, Mycoavidus cysteinexigens, which we place within a lineage of endofungal symbionts that are sister clade to Burkholderia. The genome of M. elongata strain AG77 features a core set of primary metabolic pathways for degradation of simple carbohydrates and lipid biosynthesis, while the M. cysteinexigens (AG77) genome is reduced in size and function. Experiments using antibiotics to cure the endobacterium from the host demonstrate that the fungal host metabolism is highly modulated by presence/absence of M. cysteinexigens. Independent comparative phylogenomic analyses of fungal and bacterial genomes are consistent with an ancient origin for M. elongata - M. cysteinexigens symbiosis, most likely over 350 million years ago and concomitant with the terrestrialization of Earth and diversification of land fungi and plants.

A subjective disturbance of sleep, including the occurrence of repetitive, stereotypical anxiety dreams, is characteristic of posttraumatic stress disorder (PTSD). The phenomenology of the PTSD anxiety dream has seemed most consistent with an underlying rapid eye movement (REM) sleep dysfunction. However, motor behavior reportedly can accompany PTSD dreams, and normal REM sleep typically involves a nearly total paralysis of the body musculature. As a means of understanding this discrepancy, anterior tibialis muscle activity during sleep was studied in a group of Vietnam combat veterans with current PTSD and in an age-matched normal control group. The PTSD subjects had a higher percentage of REM sleep epochs with at least one prolonged twitch burst; they also were more likely to have periodic limb movements in sleep, during nonrapid eye movement sleep. Both these forms of muscle activation also have been observed in REM behavior disorder (RBD), a parasomnia characterized by the actual enactment of dream sequences during REM sleep. The identification of RBD-like signs in PTSD adds to the evidence for a fundamental disturbance of REM sleep phasic mechanisms in PTSD.

Although considerable research effort has been spent in documenting the beneficial effects of social support to individual well-being, little is known about the determinants of this resource or its distribution across sociocultural groups. The present study assessed the influence among college students of sex and sex role on three levels of social support resources: network characteristics, availability of several modes of support, and perceived supportiveness of family and friends. On a composite measure of overall support resources, females were superior to males, and feminine and androgynous individuals were superior to masculine and undifferentiated individuals. Only some specific social support variables differed across these groups specifically, network size and homogeneity, emotional support, and perceived supportiveness of family for sex role.

INTEREST in the action of monoamine oxidase inhibitors has focused attention on the effects that metabolites of naturally occurring amino acids may have on the function of the central nervous system. Lauer et al.1 found that combined therapy with tryptophan and iproniazid had more therapeutic effect on psychotic patients than iproniazid alone. Oates and Sjoerdsma2 showed that administration of tryptophan to subjects receiving monoamine oxidase inhibitors produced hyperreflexia, clonus and euphoria. Pollin, Cardon and Kety3 observed hyporeflexia and extensive mood changes in schizophrenic patients who received tryptophan, or methionine in addition to a monoamine oxidase inhibitor.In conjunction with preliminary . . .

In the past, addiction has been viewed as a sui generis phenomenon (Baker 1988). Recent theories of addiction, however, draw implicit or explicit parallels between addiction and a wide range of other behavioral phenomena. The “disease theory,” for example, highlights similarities between addiction and infectious disease (e.g., Frawley [1988], Vaillant [1983]). Becker and Murphy's rational-choice model of addiction draws a parallel between drug addictions and “endogenous taste” phenomena, such as listening to classical music to attempt to acquire a taste for it, in which current consumption affects the utility of future consumption (Becker and Murphy 1988). Herrnstein and Prelec's “garden path” theory sees addiction as analogous to bad habits, such as workaholism or compulsive lying, that can be acquired gradually due to a failure to notice a deterioration in one's conduct or situation (Herrnstein and Prelec 1992).

Inhibition of mitochondrial respiratory chain function may contribute to dopaminergic neurodegeneration in the substantia nigra (SN) of patients with Parkinson disease (PD). Since large-scale structural changes (e.g. deletions and rearrangements in mitochondrial DNA [mtDNA]) have been associated with mitochondrial dysfunction, we tested the hypothesis that increased total mtDNA deletions/rearrangements are associated with neurodegeneration in PD. This study employed a well-established technique, long-extension polymerase chain reaction (LX-PCR), to detect the multiple mtDNA deletions/rearrangements in the SN of patients with PD, multiple system atrophy (MSA), dementia with Lewy bodies (DLB), Alzheimer disease (AD), and age-matched controls. We also compared the total mtDNA deletions/rearrangements in different brain regions of PD patients. The results demonstrated that both the number and variety of mtDNA deletions/rearrangements were selectively increased in the SN of PD patients compared to patients with other movement disorders as well as patients with AD and age-matched controls. In addition, increased mtDNA deletions/rearrangements were observed in other brain regions in PD patients, indicating that mitochondrial dysfunction is not just limited to the SN of PD patients. These data suggest that accumulation of total mtDNA deletions/rearrangements is a relatively specific characteristic of PD and may be one of the contributing factors leading to mitochondrial dysfunction and neurodegeneration in PD.

We compared the effectiveness and costs of day hospital (DH) versus inpatient (INP) rehabilitation for cocaine dependence. The research subjects were 111 inner city, lower socioeconomic, primarily African-American male veterans who qualified for a diagnosis of cocaine dependence and presented no acute medical or psychiatric conditions requiring inpatient treatment. Fifty-six men were randomly assigned to 1 month of DH rehabilitation (27 hours of weekday treatment weekly), and 55 were assigned to 1-month INP rehabilitation (48 hours of scheduled treatment weekly). Treatment outcome was evaluated 7 months after admission into treatment (92% of the subjects), and a cost analysis was performed. A significantly greater proportion of INP subjects (89.1%) completed treatment than did DH subjects (53.6%). Significant improvements in substance use, psychosocial functioning, and health status were found 7 months postadmission for both groups, but there was little evidence of differential improvement between groups. Urine toxicology findings were consistent with the self-report data in showing improvement from baseline, but no group differences in cocaine use. The groups did not differ significantly in post-rehabilitation aftercare participation or in relapse to additional treatment. DH treatment costs were 40% to 60% of INP treatment costs, depending upon the measure used.

A number of reports suggest that schizophrenia and coeliac disease (gluten enteropathy) occur in the same individual more often than expected by chance. The latter is an hereditary disease, with marked psychic and somatic symptoms which usually improve when wheat gluten and its analogues in other cereals are not eaten. This possible relationship, and the high correlation of the per cent. changes in wheat plus rye consumption with first admissions for schizophrenia during World War II (unrelated to availability of work, hospital beds and physicians or wartime status of the country), suggest that cereals may also be involved in the pathogenesis of schizophrenia (Dohan, 1, 2).

OBJECTIVE: Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied. DESIGN: Retrospective review. METHODS: Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied. RESULTS: A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CP[Pos]) in 365 resuscitations (85.7%); no command-physician was identified (CP[NEG]) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CP(POS) group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CP(POS) group. In the CP(POS) resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations. CONCLUSIONS: An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.

This article presents the well established theoretical base and clinical practice of exposure therapy for trauma. Necessary requirements for positive treatment results and contraindicated procedures are reviewed. EMDR is contrasted with these requirements and procedures. By the definitions and clinical practice of exposure therapy, the classification of EMDR poses some problems. As seen from the exposure therapy paradigm, its lack of physiological habituation and use of spontaneous association should result in negligible or negative effects rather than the well researched positive outcomes. Possible reasons for the effectiveness of EMDR are discussed, ranging from the fundamental nature of trauma reactions to the nonexposure mechanisms utilized in information processing models.