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In this study, a two-step optimisation process for the estimation of the single crystal stiffness tensor from the indentation modulus is presented. This was accomplished by using a 2-dimensional data correlation method for nano-indentation, EBSD and ab initio data, as well as EDS for phase separation in a multi-phase material. Here, a single-phase Fe-24Ni-0.4C austenitic steel and a two-phase Fe-9.5Ni-0.5Co Seymchan meteorite were used as example materials.In a first step, the combination of high-speed nano-indentation mapping data with elemental and orientation distribution maps allowed the estimation of indentation moduli along specific crystal surface planes normal directions, (001), (011) and (111) using a least squares optimisation based on starting values from DFT or experimentally determined stiffness tensors. A second global optimisation step to estimate the single crystal stiffness tensor using pre-solved solution parameters of the Vlassak-Nix equations yielded reasonable correspondence between the experimentally determined stiffness tensors from correlative nano-indentation data and other methods. The presented method demonstrates generally the possibility to derive directionally sensitive elastic properties from high-speed nano-indentation for cubic materials statistically.

In martensitic steels the distribution of C is fundamental for the technological material properties. However, the effect of Si on C segregation is not known in detail. In this study, the impact of Si on the microstructure of martensitic steels is investigated using scanning electron microscopy and the martensite/austenite orientation relationships are determined using electron backscatter diffraction and transmission Kikuchi diffraction. Transmission electron microscopy and selected area diffraction pattern analysis were used to analyse the intragranular substructure of the martensitic phase. Further, the effect of Si on the redistribution of C is investigated by atom probe tomography in combination with transmission Kikuchi diffraction measurements in order to obtain the local C distribution and correlate it with the crystallography. It was found that the Si addition forms a sigmoidal distribution at the phase boundary and functions as a barrier for C segregation, hence reduces C partitioning into the austenite, while a Si free alloy shows clear C partitioning. Further it was observed that stable C cluster formation occurs along fine twin boundaries in the martensite, inhibiting carbide formation and partitioning of the C into the austenite.

The determination of orientation relationships in dual or multi-phase materials is very important in the field of interface engineering for the design of materials with tailored properties. In this work, a code is developed for the automated and statistical analysis of the orientation relationship of electron backscatter diffraction data. The code is applied to the example of Fe-Ni-(Si)-C alloys containing lenticular martensite and retained austenite, and it is shown that the orientation relationship (OR) corresponds to the Greninger–Troiano OR and that a statistically reliable investigation of the OR between the retained austenite and the related martensite variants is feasible using the code developed in this study.

Introduction: Both men and women can be diagnosed with haemophilia and the experience with haemophilia may be different between men and women., Aim: This study aimed to compare patient-reported outcomes in men versus women with haemophilia., Methods: This cross-sectional study is a post-hoc analysis of data collected as part of the Haemophilia-related Distress Questionnaire validation study. Adults aged ≥18 years with haemophilia A or B were recruited from one of two haemophilia treatment centres between July 2017 and December 2019. Outcomes included quality of life, measures of mental and physical health, and overall health. Unadjusted and multivariable linear regression models were used to examine potential mediators of sex-based differences in outcomes., Results: Of the 139 study participants included (21 women, 118 men), the mean age was 36.9 years and most (89.2%) had haemophilia A. Approximately 85.7% and 26.3% of women and men had mild haemophilia, respectively.  PHQ-9 depression and PROMIS-29 Profile anxiety and fatigue scores were significantly higher in women than men in unadjusted and adjusted analyses. There were no statistically significant differences in other outcomes., Conclusions: Women with haemophilia are more likely to experience depression, anxiety, and fatigue than men with haemophilia. This study highlights the need for mental health services to be integrated into the care of women with haemophilia. Future research is needed to understand whether women with haemophilia are more or less likely to experience depression, anxiety, and fatigue than women without haemophilia as well as determine the impact of reduced mental health on clinical outcomes., (© 2024 John Wiley & Sons Ltd.)

Hemophilia-related distress (HRD) has been shown to be higher among those with lower educational attainment, but potential racial/ethnic differences have not been previously described. Thus, we examined HRD according to race/ethnicity. This cross-sectional study was a planned secondary analysis of the hemophilia-related distress questionnaire (HRDq) validation study data. Adults aged ≥ 18 years with Hemophilia A or B were recruited from one of two hemophilia treatment centers between July 2017-December 2019. HRDq scores can range from 0-120, and higher scores indicate higher distress. Self-reported race/ethnicity was grouped as Hispanic, non-Hispanic White (NHW) and non-Hispanic Black (NHB). Unadjusted and multivariable linear regression models were used to examine mediators of race/ethnicity and HRDq scores. Among 149 participants enrolled, 143 completed the HRDq and were included in analyses. Approximately 17.5% of participants were NHB, 9.1% were Hispanic and 72.0% were NHW. HRDq scores ranged from 2 to 83, with a mean of 35.1 [standard deviation (SD) = 16.5]. Average HRDq scores were significantly higher among NHB participants (mean = 42.6,SD = 20.6; p-value = .038) and similar in Hispanic participants (mean = 33.8,SD = 16.7, p-value = .89) compared to NHW (mean = 33.2,SD = 14.9) participants. In multivariable models, differences between NHB vs NHW participants persisted when adjusting for inhibitor status, severity, and target joint. However, after household income was adjusted for, differences in HRDq scores were no longer statistically significant (β = 6.0 SD = 3.7; p-value = .10). NHB participants reported higher HRD than NHW participants. Household income mediated higher distress scores in NHB compared to NHW participants, highlighting the urgent need to understand social determinants of health and financial hardship in persons with hemophilia., (© 2023. W. Montague Cobb-NMA Health Institute.)

Objective: The COVID-19 global pandemic has created severe, long-lasting challenges to college students in the United States (US). In the present study, we assessed mental health symptomatology (depression, anxiety, life stress), academic challenges, and economic stress during the first wave of the Coronavirus pandemic. Method: A total sample of 361 college students ( M age  = 22.26, SD  = 5.56) was gathered from a community college ( N =  134) and mid-size public university ( N =  227) in Southwest US, both designated as Hispanic Serving Institutions. Results: Pearson and point biserial correlations indicated associations between mental health symptomatology, academic challenges, and economic stress, including expected delays in graduation. Multivariate analysis revealed that community college students had statistically significantly higher scores on anxiety F (1, 312) = 5.27, p  = .02, η p 2  = .01 than 4-year university students, as well as key differences with respect to academic challenges. Chi Square analyses revealed that Latinx families experienced greater economic hardships, including job loss or reduced work hours (χ 2 (1, N  = 361) = 28.56, p  = .00) than other ethnic/racial groups. Conclusions/Contributions: Findings revealed that community college students faced disparately negative mental health symptomatology, academic challenges, and economic stress during the first wave of the Coronavirus pandemic. Further, Latinx students' families experienced significant economic hardship that may have impacted students' academic progress and future planning., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Introduction: In chronic diseases, disease-related distress can impact disease outcomes. Distress and haemophilia-related distress has been demonstrated in people with haemophilia (PwH). The association of haemophilia-related distress on disease outcomes among PwH is unknown., Aim: To study the association of haemophilia-related distress with haemophilia specific outcomes, including adherence to prophylactic therapy, the presence of a target joint, healthcare utilization and work-impairment., Methods: In a cross-sectional study, adults with haemophilia A or B were enrolled in a study to validate the haemophilia-related distress questionnaire (HRDq). In this planned analysis, univariate and multivariate associations between the HRDq total score and disease outcomes were explored., Results: The 114 participants in this analysis were male, mostly with haemophilia A (92%) and severe disease (52%) with a median age of 31.9 years. On univariate analysis, HRDq total score (5-point change) was associated with the presence of a target joint (P = .002), high healthcare utilization (P = .011), poor adherence (P = .033) and work-impairment (P ≤ .001). After adjustment for age, race, severity and other potential confounders, adherence (aβ 0.33, 95% CI .17, .49) and work-impairment (aβ 4.69, 95% CI 3.27-6.1) remained statistically significantly associated with HRDq total score., Conclusion: Haemophilia-related distress is associated with poor adherence to factor prophylaxis and work-impairment. The direction of the association (causation) is yet to be determined and requires future study., (© 2023 John Wiley & Sons Ltd.)

Introduction: The Patient-Reported Outcomes Measurement Information System (PROMIS) provides measures of health status that assess physical, mental and social well-being from the patient perspective. PROMIS measures are used in clinical practice and research across various patient populations but are not yet validated among patients with haemophilia., Aim: Evaluate the sensitivity of PROMIS to indicators of haemophilia clinical severity and compare PROMIS measures to those from other PRO instruments., Methods: Male adults with haemophilia (n = 115) completed the PROMIS-29 short form which includes 4 questions for each of 7 domains: depression, anxiety, ability to participate in social roles and activities, physical function, pain interference, fatigue and sleep disturbance. Participant responses for each domain were scored on a T-score metric with a mean of 50 and a standard deviation of 10 based on the original PROMIS reference sample of US adults. Participants also completed other generic and haemophilia-specific health-related quality of life questionnaires., Results: Participants who experienced higher pain and depression levels reported significantly worse health in every PROMIS domain compared with their peers. Those who had recently needed to use crutches, visit an emergency department or were currently unemployed or disabled also reported poor PROMIS scores on most domains. Construct validity was supported by correlations between PROMIS domain scores and domain scores reported using the EQ-5D-5L and Haem-A-QoL., Conclusion: The PROMIS instrument provides a potentially valuable tool to evaluate the impact of haemophilia and suggests usefulness in research and clinical practice., (© 2021 John Wiley & Sons Ltd.)

Social media serves as a key mechanism for sexual minority young adults to connect with peers and to learn about COVID-19. We utilized focus groups to explore how sexual minority gender expansive college women ( N = 28) engage with social media, including alcohol-related content on social networking sites. Two focus groups were held in-person during the month before the campus closed on March 10, 2020 due to a shelter-in-place mandate. Focus groups were then moved online, and also assessed how engagement with social media, including alcohol-related content, changed in response to COVID-19 at one month and two months into shelter-in-place. Using social media to connect with sexual and gender minority (SGM) content and community was a prominent theme across the three cohorts of data collection. Social drinking via social networking sites became increasingly prominent during shelter-in-place as a way to combat isolation, boredom, and the general stress of coping with COVID-19.

Introduction: In patients with haemophilia, general psychological distress as measured by the National Comprehensive Cancer Network (NCCN) distress thermometer has been associated with pain, disability and increased healthcare utilization., Aims: To develop and validate a measure of haemophilia-related distress., Methods: After qualitative interviews, the Hemophilia-Related Distress Questionnaire (HRDq) was developed. To validate the HRDq, adults (≥18 years) with haemophilia were enrolled, reported demographic and clinical information, and completed the HRDq and other questionnaires that measured similar constructs. Analysis included factor analysis and assessment of internal consistency using Cronbach's α, convergent validity using Pearson's correlation coefficient, and discriminant validity by comparing subgroups of patients. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC)., Results: Among 130 enrolled participants, 126 (median age=32.7 years) completed the 24 item HRDq in a median time of 5.4 minutes with overall HRDq scores ranging from 2 to 83 (median score=31.5; higher scores indicating higher distress). Assessment of convergent validity demonstrated a strong correlation (ρ>.60) of the HRDq total score with the NCCN Distress Thermometer, Haem-A-QoL total Score, and PROMIS-29 Profile social role domain and a mild to moderate correlation with all other questionnaire domains (.3-.59, p < .05). Distress was higher among those who had less education, were not employed, and were disabled and was not significantly different among those with severe compared with non-severe disease. Assessment of test-retest reliability demonstrated an ICC value of .84 (95% CI .71-.91) for the total score., Conclusions: The HRDq demonstrates good internal consistency, construct and discriminant validity, and retest reliability with a low responder burden., (© 2020 John Wiley & Sons Ltd.)

Objectives: To describe the health of intersex adults (people with differences of sex development) in the U.S. using community-based research methods., Methods: In July-September 2018, we conducted a national health study of intersex adults aged 18 and older in the U.S., using a survey hosted on Qualtrics. The study describes the physical and mental health experiences of intersex adults, including differences by age (18 to 39 vs. 40 and older). Questions were derived from national (Behavioral Risk Factor Surveillance System) and intersex-related health studies., Results: A non-probability sample of 198 intersex adults completed the survey over three months. Over 43% of participants rated their physical health as fair/poor and 53% reported fair/poor mental health. Prevalent health diagnoses included depression, anxiety, arthritis, and hypertension, with significant differences by age. Nearly a third reported difficulty with everyday tasks and over half reported serious difficulties with cognitive tasks., Conclusions: To our knowledge, this is the first national study of intersex adults in the U.S. Greater understanding of intersex health over the life course is essential. Findings highlight the need for longitudinal studies and further examination of potential health disparities experienced by intersex populations., Competing Interests: The authors have declared that no competing interests exist.

Distress effects are widely examined in cross-sectional studies with less known about effects on future health. This review summarizes distress impacts on health among adults in prospective studies and describes available distress measurement tools. Four inter-disciplinary databases were searched. Effects of distress on mortality and other outcomes were reviewed and estimated in a meta-analysis. A total of 19 studies were assessed which incorporated 10 distress tools. Distress had a detrimental effect on health regardless of the population studied, distress tool used, and health outcome examined. There was an increased mortality risk among those reporting high versus low distress (pooled hazard ratio (95% confidence interval) = 1.29 (1.15-1.46)).

Introduction: Distress related to disease burden has been defined and described among people with chronic diseases including diabetes and cancer. In these populations, disease-specific distress is associated with health outcomes. Haemophilia-related distress is less understood., Aim: To identify qualitative features of haemophilia-related distress among affected adults to ultimately inform the creation of a measurement tool., Methods: Adults with haemophilia A or B associated with a large haemophilia treatment centre in the south-eastern U.S. were recruited to participate in this qualitative study. Fifteen participants completed semi-structured telephone interviews. Interviews lasted 1-2 hours and explored experiences of distress related to various aspects of haemophilia. Interviews were audio taped, transcribed and coded using NVIVO, software for organizing, managing and analysing qualitative data. Coding was deductive and inductive, and the analysis was thematic., Results: Haemophilia-related distress was broadly related to feelings of isolation and vulnerability which incorporated health system factors, physical functioning, caretaker roles and psychological considerations. Specific features associated with haemophilia-related distress included lack of trust in the knowledge of haemophilia and care provided by staff in community healthcare settings, concerns about the future such as health insurance access and ageing/disability, long-standing feelings of being different from others and feeling like an outsider, treatment burdens and fear of acute bleeds. Protective factors included supportive relationships with family, friends and haemophilia care teams through which participants received practical and emotional support., Conclusion: Features of haemophilia-related distress were identified. Results will facilitate distress measurement and intervention efforts to reduce distress in adults with haemophilia., (© 2019 John Wiley & Sons Ltd.)

Adults with chronic bleeding disorders report high distress, but it is unclear how distress varies over time. Patients rated their distress on a 10-point scale at two clinic visits. Of 83 patients, roughly one-quarter reported consistent no/low distress (29%), one-quarter reported consistent distress (22%), and half (49%) reported a change in distress of at least two points. Overall activity levels, depressive symptoms, and non-White race were significantly associated with worsening and consistent distress in adjusted analyses while improvements in activity levels and depressive symptoms during the study period were associated with distress improvement. Our results suggest that distress is modifiable.

Purpose: The study purpose was to examine opinions about a single-item assessment of differences of sex development (DSD) to be used in research., Methods: An online survey was conducted with a convenience sample of 111 adults who self-identified as intersex or having a DSD diagnosis. Participants read and provided feedback on the proposed single-item assessment., Results: The item received general endorsement to represent a population that is often not identified in research; however, participants provided suggestions for improvement., Conclusion: This study represents a first step toward identifying people with DSD conditions in surveys to better understand their needs.

Objectives: Fear of Harm (FOH) is a pediatric onset phenotype of bipolar disorder (BD) characterized by BD plus treatment resistance, separation anxiety, aggressive obsessions, parasomnias, and thermal dysregulation. Intranasal ketamine (InK) in 12 youths with BD-FOH produced marked improvement during a two-week trial. Here we report on the open effectiveness and safety of InK in maintenance treatment of BD-FOH from the private practice of one author., Methods: As part of a chart review, patients 18 years or older and parents of younger children responded to a clinical effectiveness and safety survey. Effectiveness was assessed from analysis of responses to 49 questions on symptomatology plus qualitative content analyses of written reports and chart review. Adverse events (AEs) were analyzed by frequency, duration and severity. Peak InK doses ranged from 20 to 360mg per administration., Results: Surveys were completed on 45 patients treated with InK for 3 months to 6.5 years. Almost all patients were "much" to "very much" improved clinically and in ratings of social function and academic performance. Significant reductions were reported in all symptom categories. There were 13 reports of persistent AEs, none of which resulted in discontinuation. Acute emergence reactions were sporadically observed in up to 75%, but were mild and of brief duration., Limitations: Retrospective review from a single practice without placebo control with potential for response and recall bias., Conclusions: InK every 3-4 days at sub-anesthetic doses appeared to be a beneficial and well-tolerated treatment. Use of InK may be considered as a tertiary alternative in treatment refractory cases. Randomized control trials are warranted., (Copyright © 2017. Published by Elsevier B.V.)

Objectives: Intravenous ketamine, a glutamate N-methyl-d-aspartate (NMDA) receptor antagonist, has been shown to exert a rapid antidepressant effect in adults with treatment resistant depression. Children with bipolar disorder (BD) often respond poorly to pharmacotherapy, including polypharmacy. A pediatric-onset Fear of Harm (FOH) phenotype has been described, and is characterized by severe clinical features and resistance to accepted treatments for BD. The potential efficacy and safety of intranasal ketamine in children with BD with FOH-phenotype were assessed by a systematic retrospective chart review of a case series from the private practice of one of the authors, including cases with clear refractoriness to mood stabilizers, antipsychotics and benzodiazepines., Methods: A comparison was made between routinely collected symptom measures 1-2 weeks prior to and after the administration of ketamine, in 12 treatment-refractory youth, 10 males 2 females ages 6-19years., Results: Ketamine administration was associated with a substantial reduction in measures of mania, fear of harm and aggression. Significant improvement was observed in mood, anxiety and behavioral symptoms, attention/executive functions, insomnia, parasomnias and sleep inertia. Treatment was generally well-tolerated., Conclusions: Intranasal ketamine administration in treatment-resistant youth with BD-FOH produced marked improvement in all symptomatic dimensions. A rapid, substantial therapeutic response, with only minimal side effects was observed. Formal clinical trials to assess safety and efficacy are warranted., (Copyright © 2012 Elsevier B.V. All rights reserved.)

To determine the specificity of suggested endophenotypes of pediatric bipolar disorder (PBD), the performance of 15 euthymic children with PBD was contrasted with that of 20 children with attention-deficit/hyperactivity disorder (ADHD), a population with reportedly similar executive dysfunction, and 18 children with both PBD and ADHD. Children with PBD and PBD+ADHD (ages 8 to 17) demonstrated higher intraindividual variability in reaction time, slower processing speed, and more sluggish motor preparedness than did children with ADHD. The findings support the contention that processing speed, intraindividual variability, and slower and more variable reaction time as interstimulus interval lengthens are likely specific endophenotypes of PBD.

Background: In a prior concordance study of affected sibling pairs with a community diagnosis of pediatric bipolar disorder (PBD) a behavioral phenotype termed Fear of Harm (FOH) was found to have one of the strongest concordance coefficients (rho) between probands and siblings, and the widest contrasts between the rho-estimates for the proband/sibling vs. proband/comparison pairs [Papolos, D., Hennen, J., Cockerham, M.S, Lachman, H., 2007]. A strategy for identifying phenotypic subtypes: concordance of symptom dimensions between sibling pairs who met screening criteria for a genetic linkage study of childhood-onset bipolar disorder using the Child Bipolar Questionnaire (CBQ) was employed. J. Affect. Disord. 99, 27-36.]. We used the Child Bipolar Questionnaire (OUT) (CBQ) to further elucidate this behavioral phenotype of PBD. We hypothesized that selective factors including parent reported symptoms of mania and depression, would be distinguishing features of impairment between groups defined by 1) the magnitude of their score on a continuous measure of FOH, and 2) the high FOH group would have significantly greater levels of severity on course of illness variables. These measures included earlier age of onset of first psychiatric symptoms, first hospitalization, and frequency of psychiatric hospitalizations, as well as, degree of social impairment as determined by exposure to the juvenile justice system and school performance problems., Methods: The sample was comprised of children with community diagnoses of bipolar disorder or at risk for the illness based on enriched family history with multiple first degree relatives diagnosed with BPD (N=5335). Included were all subjects who had >40 positively endorsed CBQ symptom items at frequencies of very often, almost always, and always. This group was divided randomly into two groups, the exploratory group (N=2668) and the hypothesis testing (study) group (N=2666). The exploratory group was used for the development of hypotheses and the study group was used to test these hypotheses on a new set of data. All results reported here derive from the latter group. In subsequent analyses, we classified each child as having a high degree of FOH, low FOH, or no FOH. We examined a subset of the sample for differences in age of onset of first psychiatric symptoms, course of illness and measures of symptom severity. These groups were compared using the chi-square procedure for categorical data and the Analysis of Variance (ANOVA) with Scheffe pair wise tests for continuous variables. The Child Bipolar Questionnaire V.2.0, the Yale-Brown Obsessive Compulsive Scale (YBOCS) and the Overt Aggression Scale (OAS) were the principal instruments used to obtain diagnostic information for this study., Results: We found that children representative of the FOH phenotype when compared to children with PBD who lack this trait had higher indices of severity of mania and depression, as well as other indices that reflect severity and course of illness. Trait factors were derived from a factor analysis of CBQ in a large population of children diagnosed with or at risk for PBD, and used to further elucidate trait features of children with FOH. Children with the FOH traits were also more likely to be defined by six CBQ factors; Sleep/Arousal, Harm to Self and Others, Territorial Aggression, Anxiety, Self-esteem, Psychosis/Parasomnias/Sweet Cravings/Obsessions (PPSO)., Limitations: This data is derived from samples enriched with bipolar disorder cases. Further validation is needed with samples in which childhood-onset BD is rarer and diagnoses more diverse. Clinician diagnosis was not validated via research interview., Conclusions: The FOH phenotype, as defined by a metric derived from combining items from the YBOCS/OAS, is a clinically homogeneous behavioral phenotype of PBD with early age of onset, severe manic and depressive symptoms, and significant social impairment that is strongly associated with 6 CBQ factors and can be easily identified using the CBQ. Through the examination of dimensional features of PBD in an enriched sample of large size, we were able to further refine a phenotype and identify clinical dimensions potentially linked to endophenotypic markers that may prove fruitful in differential diagnosis, treatment and etiological studies of PBD. The nature of the sets of specific symptoms that comprise the FOH factors enabled us to propose a biological model for the phenotype (OUT) that involves a complex orexigenic circuit which links hypothalamic, limbic, and other brain nuclei primarily responsible for the regulation of behavioral and proposed physiological features of the FOH phenotype.

We construct and implement a stochastic model of convergent extension, using a minimal set of assumptions on cell behavior. In addition to the basic assumptions of volume conservation, random cell motion, and cell-cell and cell-ECM adhesion, and a non-standard assumption that cytoskeletal polymerization generates an internal pressure tending to keep cells convex, we find that we need only two conditions for convergent extension. (1) Each cell type has a particular aspect ratio towards which it regulates its geometry. We do not require that cells align in a specific orientation, e.g. to be oriented mediolaterally. (2) The elongating tissue is composed of cells that prefer to be elongated, and these cells must be accompanied by cells which prefer to be round. The latter effectively provide a boundary to capture. In simulations, our model tissue extends and converges to a stacked arrangement of elongated cells one cell wide, an arrangement which is seen in ascidian notochords, but which has not been observed in other models. This arrangement is achieved without any direct mediolateral bias other than that which is provided by the physical edge of the adjacent tissue.

Background: Data are sparse on the incidence of postoperative cognitive, cardiac, and renal complications after deliberate hypotensive anesthesia in elderly patients., Methods: This randomized, controlled clinical trial included 235 older adults with comorbid medical illnesses undergoing elective primary total hip replacement with epidural anesthesia. The patients were randomly assigned to one of two levels of intraoperative mean arterial blood pressure management: either to a markedly hypotensive mean arterial blood pressure range of 45-55 mmHg or to a less hypotensive range of 55-70 mmHg. Cognitive outcome was assessed by within-patient change on 10 neuropsychologic tests assessing memory, psychomotor, and language skills from before surgery to 1 week and 4 months after surgery. Prospective standardized surveillance was performed for cardiovascular and renal outcomes, delirium, thromboembolism, and blood loss and replacement., Results: The two groups were similar at baseline in terms of age (mean, 72 yr), sex (50% women), comorbid conditions, and cognitive function. After operation, no significant differences in the incidence of early or long-term cognitive dysfunction were observed between the two blood pressure management groups. There were no significant differences in the rates of other adverse consequences, including cardiac, renal, and thromboembolic complications. In addition, no differences occurred in the duration of surgery, intraoperative estimated blood loss, or transfusion rates., Conclusions: Elderly patients can safely receive controlled hypotensive epidural anesthesia with this protocol. There was no evidence of greater risks, or early benefits, with the use of the more markedly hypotensive range.

The purpose of this study was to test Nelles and Barlow's (1988) hypothesis that spontaneous panic attacks are rare or nonexistent prior to adolescence as children lack the ability to make the internal, catastrophic attributions (i.e., thoughts of losing control, going crazy, or dying) characteristic of panic according to the cognitive model (Clark, 1986). Conceptions of panic attacks, including the understanding of symptoms and causes, and cognitive interpretations of the somatic symptoms of panic were examined in children from Grades 3, 6, and 9. A significant main effect for grade was found for conceptions of panic attacks, with third graders receiving significantly lower scores than sixth and ninth graders. However, the majority of all children, regardless of age, tended to employ internal (e.g., "I'd think I was scared or nervous") rather than external (e.g., "I'd think I was feeling that way because of the temperature or the weather") explanations of panic attacks. No significant grade differences were found for the tendency to make internal versus external and catastrophic versus noncatastrophic attributions in response to the somatic symptoms of panic. When presented with panic imagery in a panic induction phase, children, regardless of age, made more internal and noncatastrophic attributions. Finally, internal attributional style in response to negative outcomes and anxiety sensitivity were found to be significant predictors of internal, catastrophic attributions. The challenge that these findings pose to Nelles and Barlow's hypothesis, and their relevance for understanding children's cognitive interpretations of panic symptomatology are discussed.

A 65-year-old man with no past history of violent or criminal behavior abruptly strangled his wife after she scratched his face during a domestic argument. He appeared emotionally blunted and lacked insight into the motivations for his violent actions. The presence of left-sided cerebral dysfunction was initially suggested by subtly decreased dexterity of his dominant right hand. A magnetic resonance image (MRI) revealed a large arachnoid cyst centered in his left Sylvian fissure that effaced ventral frontal, anterior temporal and insular cortical gyri. The left middle cerebral artery was displaced relative to an earlier study, providing indirect evidence that the cyst had enlarged during his adult life. Neuropsychological testing indicated generally intact cognitive abilities except for mild impairment on tests of prospective memory and executive functions. He was found to have intermittently decreased EEG amplitude in the left fronto-temporal region. Positron emission tomography (PET) revealed significantly reduced resting glucose metabolism in the left frontal and temporal lobes. He was also found to have pathological diminution of autonomic responses to affectively charged visual stimuli, a phenomenon previously reported in patients with ventromedial frontal lobe injury and acquired disturbances of social conduct. In light of these findings, we suggest that his violent behavior represents stimulus-bound aggression, triggered by a novel physical threat and unchecked by learned social restraints owing to the presence of ventral prefrontal dysfunction.

This case highlights the complexities of evaluating and treating psychiatric symptoms that are concurrent with a seizure disorder. Interictal and postictal psychoses, affective disorders, personality changes, and cognitive deficits are common problems that require modified psychiatric treatments.

Objective: To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults., Design: Randomized controlled clinical trial., Setting: Orthopedic specialty academic hospital., Patients: A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women., Intervention: Random assignment to either epidural or general anesthesia., Main Outcome Measures: A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes., Results: The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall)., Conclusions: The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.

Based on our review of the available data, we conclude that panic attacks are common among adolescents, while both panic attacks and Panic Disorder appear to be present, but less frequent, in children. Furthermore, it is evident that both adolescents and children who report panic attacks describe the occurrence of cognitive symptoms, although with less frequency than physiological ones. Consistent with the cognitive model of panic, it seems that at least some youngsters are capable of experiencing the physiological symptoms of panic accompanied by the requisite catastrophic cognitions. However, a more complete understanding of the cognitive manifestation of panic attacks/disorder among children awaits further investigation. Future research should aim to explore the developmental progression in children's cognitive responses to specific panic symptomatology. Risk factors (e.g. anxiety sensitivity, depression) which may contribute to the likelihood of misinterpreting physiological sensations in a catastrophic manner throughout the course of development should also be assessed: Finally, we are in general agreement with Abelson and Alessi (1992) who argue that we must begin to ask ourselves how panic disorder may be manifested in children. That is, rather than assessing the frequency with which children experience symptoms of adult panic, we should explore what panic would look like in children. They propose that the study of panic in children would be facilitated by a reformulation of separation anxiety as a childhood expression of panic disorder. Although this reformulation makes intuitive sense and is appealing from a developmental perspective, we would insert a strong caveat. Although the research is yet to be conducted, it is probable that childhood separation anxiety is only one of many routes to panic disorder outcome. It is improbable that such direct and continuous pathways are present for the majority of children, adolescents and adults who experience panic disorder. More probably, the pathways are multiple, complex, and discontinuous (Robbins & Rutter, 1990). Much work remains to be done before we are able to ferret out the linkages between developmental processes and clinical outcomes for panic disorder in children and adolescents.

Objective: The goals of this longitudinal investigation were 1) to study the rate of development of irreversible dementia in elderly depressed patients with a dementia syndrome that subsided after improvement of depression and 2) to compare it with that of depressed, never-demented patients., Method: The subjects were 57 elderly patients consecutively hospitalized for major depression. At entry into the study, 23 subjects also met criteria for "reversible dementia," while 34 were without dementia. After a systematic clinical evaluation, the subjects were followed up at approximately yearly intervals for an average of 33.8 months., Results: Irreversible dementia developed significantly more frequently in the depressed group with reversible dementia (43%) than in the group with depression alone (12%). Survival analysis showed that the group with reversible dementia had a 4.69-times higher chance of having developed dementia at follow-up than the patients with depression alone. No clinical characteristics at entry into the study were found to discriminate the subjects who developed irreversible dementia during the follow-up period from those who remained nondemented., Conclusions: These findings suggest that geriatric depression with reversible dementia is a clinical entity that includes a group of patients with early-stage dementing disorders. Therefore, identification of a reversible dementia syndrome is an indication for a thorough diagnostic workup and frequent follow-ups in order to identify treatable neurological disorders.

Pain ratings during the cold pressor test were significantly lower in female inpatients with borderline personality disorder who report that they do not experience pain during self-injury (BPD-NP group, n = 11), compared with similar patients who report that they do experience pain during self-injury (BPD-P group, n = 11), and normal female subjects (n = 6). Pain ratings were not significantly different in the BPD-P and normal control groups. Self-report ratings of depression, anger, anxiety, and confusion were significantly lower, and ratings of vigor significantly higher following the cold pressor test in the BPD-NP group, but not in the BPD-P group. Only anxiety was significantly lower in the normal control group following the cold pressor test. The implications and limitations of these preliminary findings are discussed.