Baseline Level Of Function Research Articles

Cancer Prehabilitation

Cancer prehabilitation, a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient's health to reduce the incidence and the severity of current and future impairments. There is a growing body of scientific evidence that supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments. This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen. More recent research shows that opportunities exist to use other unimodal or multimodal prehabilitation interventions to decrease morbidity, improve physical and psychological health outcomes, increase the number of potential treatment options, decrease hospital readmissions, and reduce both direct and indirect healthcare costs attributed to cancer. Future research may demonstrate increased compliance with acute cancer treatment protocols and, therefore, improved survival outcomes. New studies suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other. In an impairment-driven cancer rehabilitation model, identifying current and anticipating future impairments are the critical first steps in improving healthcare outcomes and decreasing costs. More research is urgently needed to evaluate the most effective prehabilitation interventions, and combinations thereof, for survivors of all types of cancer.

Effectiveness and neural mechanisms associated with tDCS delivered to premotor cortex in stroke rehabilitation: study protocol for a randomized controlled trial

BackgroundMore than 60% of stroke survivors experience residual deficits of the paretic upper limb/hand. Standard rehabilitation generates modest gains. Stimulation delivered to the surviving Primary Motor Cortex in the stroke-affected hemisphere has been considered a promising adjunct. However, recent trials challenge its advantage. We discuss our pilot clinical trial that aims to address factors implicated in divergent success of the approach. We assess safety, feasibility and efficacy of targeting an alternate locus during rehabilitation- the premotor cortex. In anticipating variance across patients, we measure neural markers differentiating response from non-response.Methods/DesignIn a randomized, sham-controlled, double-blinded pilot clinical study, patients with chronic stroke (n = 20) are assigned to receive transcranial direct current stimulation delivered to the premotor cortex or sham during rehabilitation of the paretic arm/hand. Patients receive the designated intervention for 30 min, twice a day for 3 days a week for 5 weeks. We assess hand function and patients’ reports of use of paretic hand. A general linear mixed methods model will analyze changes from pre- to post-intervention. Responders and non-responders will be compared upon baseline level of function, and neural substrates, including function and integrity of output tracts, bi-hemispheric balance, and lesion profile. Incidence of adverse events will be compared using Fisher’s Exact test, while rigor of blinding will be assessed with Chi-square analysis to ascertain feasibility.DiscussionVariable success of cortical stimulation in rehabilitation can be related to gaps in theoretical basis and clinical investigation. Given that most patients with severe deficits have damage to the primary motor cortex or its output pathways, it would be futile to target stimulation to this site. We suggest targeting premotor cortex because it contributes substantially to descending output, a role that is amplified with greater damage to the motor cortex. With regards to clinical investigation, paired cortical stimulation in rehabilitation has been compared to rehabilitation alone in unblinded trials or to unconvincing sham conditions. Transcranial direct current stimulation, a noninvasive technique of brain stimulation, which offers a more effective placebo and has a favorable safety-feasibility profile, may improve scientific rigor. Neural markers of response would help inform patient selection for future clinical trials so we can address limitations of recent negative studies.Trial registrationNCT01539096

It Takes a Family

It Takes a Family

Functional Recovery in Hospitalized Elderly Adults

To the Editor: We read with much interest the study by Baztán et al., 1 which identified the predictors of functional recovery during hospitalization for acute medical diseases in elderly adults. This observation is of substantial value because it confirms, clarifies, and summarizes the results of two recent studies, one in Italy2 and the other in Australia.3 While investigating the predictors of in-hospital functional recovery after a preadmission acute decline, Baztán et al.1 properly performed separate analyses for complete in-hospital recovery (being discharged with baseline functional level of 15 days before admission) and partial recovery (functional improvement not great enough to allow the individual to be discharged at the baseline, premorbid level). For complete in-hospital recovery, the association between the extent of preadmission decline and inability to achieve complete functional recovery during hospitalization is somewhat obvious, because if an individual experiences a large preadmission decline, he or she is unlikely to fully regain his or her premorbid functionality during the limited time of hospital stay.3 Partial in-hospital recovery deserves, in our opinion, more consideration. Similar to the results of one of the previous studies,2 in the observation by Baztán et al.,1 individuals with partial functional improvement had two distinctive and seemingly contrasting features: they had greater preadmission decline, but also higher baseline functional level. Thus, although greater preadmission decline is negatively associated with complete recovery, it is positively associated with partial recovery.1-3 A large pre-admission decline reflects greater vulnerability to the stress of the acute illness and predicts negative outcomes,4 but when the coexistence of high premorbid function mitigates this condition of “frailty,” then there is a “resilient” effect during hospitalization (functional improvement proportional to the previous preadmission decline).1, 2 In the Progetto Dimissioni in Geriatria Study, 35.9% of participants who experienced a preadmission functional decline had fully regained baseline functional status at hospital discharge, 23.1% improved partially but did not fully recover, 39.7% remained stable, and only 1.3% declined further during hospitalization.2 A full recovery to baseline level is typical of individuals with good premorbid characteristics (younger age, baseline independence, low comorbidity, limited preadmission decline)5 and is supposed to occur independently of the quality of hospital management; to the contrary, individuals with dramatic preadmission decline but high baseline level of function may represent an intermediate category between “frail” and “fit” individuals, who may undergo only partial, yet precious, improvements during hospitalization. These individuals are presumably those who may benefit more from specific geriatric interventions aimed at improving functional outcomes during the hospital stay. Thus, if acute illnesses and subsequent hospitalization account for nearly half of all new cases of disability in elderly persons,6 “resilience” should be emphasized much more than “frailty,” with the aim of identifying phenotypes of individuals who may be most likely to recover in response to geriatric interventions during hospitalization. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed equally to the preparation of this manuscript. Sponsor's Role: None.

Randomized trial of a broad preventive intervention for Mexican American adolescents.

This randomized trial of a family-focused preventive intervention for Mexican American (MA) adolescents evaluated intervention effects on adolescent substance use, internalizing and externalizing symptoms, and school discipline and grade records in 8th grade, 1 year after completion of the intervention. The study also examined hypothesized mediators and moderators of intervention effects. Stratified by language of program delivery (English vs. Spanish), the trial included a sample of 516 MA adolescents (50.8% female; M = 12.3 years, SD = 0.54) and at least one caregiver that were randomized to receive a low-dosage control group workshop or the 9-week group intervention that included parenting, adolescent coping, and conjoint family sessions. Positive program effects were found on all 5 outcomes at 1-year posttest but varied depending on whether adolescents, parents, or teachers reported on the outcome. Intervention effects were mediated by posttest changes in effective parenting, adolescent coping efficacy, adolescent school engagement, and family cohesion. The majority of intervention effects were moderated by language, with a larger number of significant effects for families who participated in Spanish. Intervention effects also were moderated by baseline levels of mediators and outcomes, with the majority showing stronger effects for families with poorer functioning at baseline. Findings not only support the efficacy of the intervention to decrease multiple problem outcomes for MA adolescents but also demonstrate differential effects for parents and adolescents receiving the intervention in Spanish vs. English, and depending on their baseline levels of functioning.

Motor Rehabilitation after Stroke

Stroke is one of the most common conditions in adults that may cause impairment and disability. Motor impairments often persistently affect the daily function and quality of life among stroke survivors. Recently, a few novel interventions to improve motor impairment have evolved that make use of advances in neuroscience and neurobehavioral knowledge. These theory-driven approaches attempt to translate basic science research into novel clinical practice and build on methods to manipulate favorable plasticity changes within the brain in response to task-related training to augment motor recovery. Developing a new clinical intervention may consist of four phases [1]: consideration of concept, development of concept, demonstration of concept, and proof of concept. The value of a phase I study is to learn how well an intervention can be applied, how patients respond to the intervention, to whom it ought to be given, what outcomes should be measured, and how its safety can be assured. Phase II studies aim to standardize the new treatment, compare efficacy against alternative treatments, and ensure that outcomes can be measured objectively and reliably. Phase III studies aim to optimize the treatment (dosage optimization) and enhance its practicality. Most of the papers published in this special issue are Phase I studies. An increase in Phase II and III studies is needed to improve stroke rehabilitation research and practice. Among the five Phase I studies presented here, two assessed how well the intervention could be applied in patients with stroke. A. Reinthal and colleagues evaluated the effects of a novel activity-based gaming exercise that involved highly repetitive practice in stroke rehabilitation. S. B. Badia and M. S. Cameirao used 10 healthy individuals to test a neurorehabilitation training toolkit designed for stroke survivors in the home environment. Three papers in this special issue addressed appropriate treatments for specific types of patients, for example, the degree of impairments or type of symptoms. This information can be used to maximize the benefits of specific interventions. Among these studies, C. Schuster and colleagues' study involved a qualitative, patient-centered study to address where, when, what, how, and why motor imagery can be used for stroke rehabilitation. F. Malouin and colleagues investigated the effect of the side of hemispheric lesion on temporal congruence between real and imagined movements and its link with working memory deficits in persons with chronic stroke. B. Langhammer and B. Lindmark demonstrated immediate and follow-up improvements after functional exercise between groups with high and low baseline functional level for a period of 36 months after stroke. L. Chuang and colleagues' study of instrument evaluation examined the reliability of Myoton-3 myometer, a tool used to quantify muscle tone, elasticity, and stiffness in stroke patients. This study provided evidence for the psychometric soundness of myotonometric measurement. Also included in this special issue are two systematic reviews of optimal dosage of stroke motor rehabilitation. To advance stroke motor rehabilitation, future research may translate concepts from basic sciences to clinical trials and heath care of patients with stroke. Issues relevant for study may include, but are not limited to, the following. What are the most beneficial interventions for specific types of patients under specific circumstances [2]? What are the factors (e.g., the time for delivering a specific intervention, patient characteristics) that may affect treatment outcomes [3, 4]? What are the fundamental mechanisms (neurophysiologic and biomechanical) that may underlie motor improvements? How can bioengineered or robotic devices be optimally used to effectively manage motor impairment and disabilities? What are the optimal dosages for specific rehabilitation regimens [5]? Continued research on these issues will lead to improved knowledge and practice guidelines for stroke rehabilitation. Ching-yi Wu Keh-chung Lin Steven L. Wolf Agne`s Roby-Brami

Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity

Automaticity is integral to expert performance, but experts must be able to transition from an automatic mode into a more effortful state when required. In this study, the authors identified and characterized the manifestations of the phenomenon of "slowing down when you should" to stay out of trouble in operative practice. The authors interviewed 28 surgeons (60-minute, semistructured format) from various specialties at four academic medical centers and observed 5 hepatopancreatobiliary surgeons in the operating room (29 cases, 147 hours) during 2007-2009. Using a grounded theory qualitative methodology, they conducted a thematic analysis of transcripts and field notes in an iterative manner. Data collection continued until saturation. They adopted a reflexive approach throughout. Surgeons described and the authors observed four phenomenological manifestations of the transition to a more effortful state. In the most extreme manifestation, "stopping," surgeons actually stopped the procedure, whereas in the most subtle manifestation, "fine-tuning," surgeons were able to continue the procedure and focus on minor events simultaneously. A separate phenomenon of "drifting" represented surgeons' failure to transition out of the automatic mode when appropriate, resulting in surgical errors or near misses. The manifestations of the slowing down phenomenon represent acts of cognitive refocusing during the potentially more-critical moments of operative practice. Further, the authors challenge the conception of automaticity as effortless, arguing that automatic behavior can be attentive (fine-tuning) as well as inattentive (drifting).

Remediation of Facial Emotion Recognition in Schizophrenia: Functional Predictors, Generalizability, and Durability

Impaired recognition of facial emotion in schizophrenia is associated with poor social functioning. Evidence shows that targeted emotion recognition training (ERT) can improve perception of facial emotions in schizophrenia for up to 1 week after training. This study investigated whether (a) improved recognition generalizes to novel faces, (b) training effects are durable over 1 month, and (c) baseline functioning levels predict the extent of improvement. Thirty-nine participants with schizophrenia received ERT using Ekman's Micro-Expression Training Tool (METT; 2003 Ekman , P. ( 2003 ). Emotions revealed: Recognizing faces and feelings to improve communication and emotional life, , 2nd ed. New York : Henry Holt and Company, LLC . [Google Scholar]). Emotion recognition was assessed using METT face stimuli and other face stimuli not used in training (static faces shown at 100% and 50% intensity and dynamic stimuli). Baseline ratings of interpersonal and cognitive functioning were collected; a subgroup of 10 participants was followed up at 1 month posttraining. Post-METT training, participants showed improved perception of METT faces and novel faces. The subgroup followed over 1 month showed improved recognition of novel faces and dynamic stimuli 1 month after training, but not immediately after training. Baseline measures of interpersonal and social functioning and general face processing and working memory abilities (50% intensity expressions only) predicted improvement in facial affect recognition immediately after METT training. These findings suggest that the effectiveness of ERT in schizophrenia is influenced by pretraining levels of social functioning and that general face processing abilities and working memory may affect the ability to accurately process subtle facial expressions. Furthermore, improved recognition generalizes to novel faces but only over time, which might indicate an increasing awareness of facial emotion after ERT, at least in people with better baseline social functioning.

RECOVERY AND ITS RELATION TO SYMPTOMATIC AND FUNCTIONAL REMISSION IN FIRST EPISODE PSYCHOSIS

Introduction: Generally agreed outcome criteria in psychosis are required to evaluate the effectiveness of new treatment strategies and surmount therapeutic pessimism. The aim of this study is to explore recovery and its relation to symptomatic and functional remission in first episode patients and to find predictors of recovery. Methods: In a sample of first episode patients (N = 125) symptomatic and functional remission during the last nine months of a two years follow-up period were examined, as well as recovery and its predictors. Recovery was clinically defined by the two dimensions of symptomatic and functional remission. Results: Half the patients (52.0%) showed symptomatic remission, a quarter (26.4%) showed functional remission, while one fifth (19.2%) met both criteria-sets and were considered recovered. Functionally remitted patients recovered in 72.7% (OR = 2.7), symptomatically remitted patients in 36.9% (OR = 0.6). Recovery was significantly associated with short duration of untreated psychosis (OR = 0.531, df = 1, p = 0.008). No recovery occurred in patients with long duration of untreated psychosis (>6 months). Another significant predictor of recovery was better baseline functioning (OR = 0.858, df = 1, p = 0.021). Conclusions: Functional remission is more selectively associated with recovery than symptomatic remission. Treatment delay reduces chance of recovery. Baseline functioning levels also significantly predict recovery. Our results clearly show that social functioning is an important parameter in schizophrenia outcome research, both as a predictor of future course characteristics, and as a more selective index of recovery than symptom remission.

Operative management of periprosthetic femur fractures in the elderly using biological fracture reduction and fixation techniques

Treatment of periprosthetic femur fractures often requires deviation from standard fixation techniques due to the presence of associated arthroplasty components, however, the use of adjuvant bone grafts and bone graft substitutes remain controversial. 59 patients (average age, 74 years) with either a periprosthetic femoral shaft about an arthroplasty stem (n=29) or supracondylar fracture above a total knee arthroplasty (n=30) were treated with biological open-reduction internal-fixation techniques without the use of bone grafts or bone-graft substitutes. All except one patient healed after the index procedure. Three patients had progressive malalignment associated with failed screw fixation but all healed without further surgical intervention. 49 out of the 59 patients returned to their baseline level of function. These results indicate that use of adjuvant bone graft materials may not be routinely necessary when treating periprosthetic femur fractures using lateral plates and biological reduction and fixation techniques.

Predictors of long‐term work disability in Major Depressive Disorder: a prospective study

Major Depressive Disorder (MDD) is a major cause of long-term work disability. However, factors predicting this are not well known. In the Vantaa Depression Study, predictors for being granted a disability pension during an 18-month follow-up were examined among the 186 psychiatric MDD in- and out-patients belonging to the labour force at baseline. The 21 patients (11.3%) granted a disability pension were significantly older, more hopeless, had worse social and occupational functioning, and spent more time depressed during follow-up. After adjusting for these predictors, being on sick leave at baseline still strongly predicted disability pension during follow-up. Disability pension is predicted by multiple sociodemographic and clinical factors. Baseline level of functioning and duration of depressive episodes are key clinical predictors. The positive and negative consequences of sick leave warrant closer attention.

Subcortical vascular lesions and functional recovery in older patients with gait disorders

This study aimed to assess whether subcortical vascular lesions (SVLs) predict functional recovery after rehabilitation in elderly patients with gait disorders (GD) due to multiple etiology (GD-ME). All patients consecutively admitted with GD-ME ( n = 103) in our Rehabilitation and Aged Care Unit (RACU) underwent a standardized rehabilitative program. The outcome measure was the Barthel Index (BI) Relative Functional Gain (RFG), a measure of improvement adjusting for baseline functional level. Potential predictors included cognition, depression, functional and nutritional status, physical health, occurrence of adverse clinical events during hospital stay, and SVLs, assessed with a validated visual rating scale based on brain CT scans. Predictors were divided into quartiles and the association with RFG was assessed. In a multivariate linear regression model, SVLs maintained its predictive power on RFG after adjustment for age, gender, and adverse clinical events, which was the only variable associated to RFG in the bivariate model (adjusted p = 0.002 for trend). The study shows that SVLs is a predictor of functional recovery in elderly patients with GD-ME.

Ten year longitudinal study of neuropsychological functioning subsequent to a first episode of schizophrenia

We previously reported relative stability in neuropsychological functions over a 4- to 5-year period after the onset of a first episode of schizophrenia, with patients demonstrating less improvement than controls on some functions [Hoff, A.L., Sakuma, M., Wieneke, M., Horon, R., Kushner, M., DeLisi, L.E., 1999. A longitudinal follow-up study of neuropsychological functioning subsequent to a first-episode of schizophrenia. American Journal of Psychiatry 156, 1336–1341.]. The current study was conducted to extend follow-up evaluations through 10 years of illness to determine whether neuropsychological functions remain stable or deteriorate over a longer time period. Twenty-one first episode patients and 8 controls were re-evaluated 10 years after an initial evaluation on neuropsychological and clinical measures. Repeated measures analyses demonstrated no differences between patients and controls in degree of change over this time period nor was change in symptoms reliably associated with improvement or deterioration in cognitive abilities. However, baseline level of cognitive functioning was correlated with the degree of change. Thus, when the baseline level of functioning was controlled for in the analyses, less or lack of improvement was seen in the patients compared with controls in verbal intellectual functioning, delayed verbal and nonverbal recall, and cognitive inhibition (Stroop Color Word Test). In no test did patients deteriorate significantly more than controls. We conclude that most first episode patients have had considerable cognitive decline by the time of their first hospitalization and that it remains relatively stable through at least 10 years of illness. Most cognitive change takes place early in this illness, prior to the first hospitalization, but its exact timing still remains unknown.

Increase of mild disability in Japanese elders: A seven year follow-up cohort study

BackgroundJapan has the highest life expectancy in the world. In a 2002 census government report, 18.5% of Japanese were 65 years old and over and 7.9% were over 75 years old. In this ageing population, the increase in the number of dependent older persons, especially those with mild levels of disability, has had a significant impact on the insurance budget. This study examines the increase of mild disability and its related factors.MethodsAll community-dwelling residents aged 65 and over and without functional decline (n = 1560), of Omishima town, Japan, were assessed in 1996 using a simple illustrative measure, "the Typology of the Aged with Illustrations" to establish a baseline level of function and were followed annually until 2002. The prevalence and incidence of low to severe disability, and their association with chronic conditions present at the commencement of the study, was analyzed. A polychotomous logistic regression model was constructed to estimate the association of each chronic condition with two levels of disability.ResultsAn increase in mild functional decline was more prevalent than severe functional decline. The accumulation of mild disability was more prominent in women. The major chronic conditions associated with mild disability were chronic arthritis and diabetes in women, and cerebrovascular accident and malignancy in men.ConclusionThis study showed a tendency for mild disability prevalence to increase in Japanese elders, and some risk factors were identified. As mild disability increasingly prevalent, these findings will help determine priorities for its prevention in Japanese elders.

The impact of adjuvant therapy for breast cancer on cognitive function: current evidence and directions for research

Available evidence supports the hypothesis that adjuvant chemotherapy for breast cancer can produce cognitive deficits, and that these deficits may have a significant impact on patients’ quality of life. Studies have generally compared the results of a variety of cognitive measures performed following treatment to standardized population-based norms or to cancer patients who received local therapy, rather than to the individual’s baseline level of functioning. Several longitudinal studies are in progress or in the planning stages to better quantify and understand the incidence and impact of cognitive effects of adjuvant chemotherapy, and to identify possible susceptibility factors in subgroups. Although the neurocognitive changes appear to be subtle, there may be enough data to consider discussing the possibility of cognitive dysfunction as an adverse effect when assessing the risks and benefits of adjuvant chemotherapy. Likewise, as the aromatase inhibitors are increasingly given to larger numbers of women in the adjuvant setting, it will be important to understand the cognitive impact of estrogen deprivation. Finally, there is interest in examining supportive pharmacologic or behavioral measures that might prevent or decrease cognitive effects in this setting. Herein, the data on cognitive changes associated with chemotherapy for breast cancer, current and future research directions, as well as possible treatments are reviewed.

WHEN STUDY DESIGNS CONTROL FOR REGRESSION TO THE MEAN

Dear Editor-in-Chief: In a recent article, we demonstrated that baseline level of function is an important variable to consider when studying the relationship between exercise therapy and subsequent improvement in physical function (3). Dr. Shephard argues that the results remain suspect due to the possible confounding influence of regression to the mean (RM). He stated that the apparent effect of initial physical function should have been evaluated relative to either a zero-treatment control group or that potential effects for RM should have been estimated using standard statistical techniques. We appreciate the opportunity to clarify this point for Dr. Shephard and others who may have had a similar concern. First, simply having a zero-order control group would not control for RM unless participants had been randomized to all treatment conditions (2). There are numerous examples in the literature of quasi-experimental designs that include a zero-treatment control condition and falsely conclude that the results are not confounded by threats to internal validity such as RM (1). The key to controlling for threats to internal validity such as RM is the existence of multiple treatment groups where participants are randomized to conditions. As stated by Campbell and Kenny (1) (p. 51): “Randomized experiments have much to recommend them because they eliminate RM as a plausible rival hypothesis.” In our study, we employed a four-group randomized controlled clinical trial that was stratified by gender. Thus, we were able to make sound conclusions about the effect of baseline physical function on changes in function because the interpretations were made relative to other randomized treatment conditions where this effect was not observed. Parenthetically, the use of a zero-order control comparison in our design as opposed to a standard of care that is usually positive would have been careless and misleading on our part. With respect to Dr. Shephard’s second option—statistical adjustment—we are uncertain as to what he had in mind. First, we would point out that the common approach to controlling for baseline physical function scores on change in physical function over time in a statistical model is to covary baseline values. A careful read of our statistical analysis will reveal that, in fact, this is what we did. It was the significant baseline by treatment interaction that led us to our interpretation. Thus, we employed very rigorous methods both in design and analysis that support the integrity of our original conclusion. As for estimating RM in a nonexperimental design, we would point the reader to Campbell and Kenny’s primer on regression artifacts (1). A discussion of this topic is far beyond the scope of a letter to the editor. However, it is important to remember that the potential bias caused by RM increases as reliability of measurement decreases, where true-score estimation is computed as follows (one of the most important formulas in psychometrics for understanding biases due to RM): X'T = rX(X - MX) + MX, where X'T is the predicted true score, rX is the reliability of X, and MX is the mean of X (1). W. Jack Rejeski, Ph.D. Lawrence R. Brawley, Ph.D. James L. Norris, Ph.D.

Gender and functional outcome after coronary artery bypass

Background: Female gender is an established risk factor for increased mortality and morbidity after coronary artery bypass graft (CABG) surgery. However, the impact of gender on functional outcome after CABG is not well established. Methods: Functional status was assessed at baseline and at 6 months with the Duke Activity Status Index (DASI) in 196 consecutive patients undergoing isolated primary CABG. Follow-up data were complete in 158 (81%) patients. The functional status of the 54 (34%) female and the 104 (66%) male patients was compared. Results: The mean DASI score was significantly lower in women at baseline (19.3 ± 13.8 vs 28.3 ± 16.8, P = .001) and at 6 months (22.7 ± 16.3 vs 32.8 ± 18.2, P = .0007); however, the 6-month change in DASI score (3.3 ± 16.9 vs 4.5 ± 20.0, P = .7) was comparable. A similar proportion of women and men (54% vs 53%) had improved above their baseline functional level at 6 months. Conclusions: These data demonstrate that women undergo CABG at a significantly lower functional level than men; however, the functional improvement after CABG is similar across genders. (Surgery 1999;126:184-90.)

Cognitive behavioral treatment of posttraumatic stress disorder subsequent to a motor vehicle accident: A case example

A high-functioning 27-year-old male with no prior psychiatric history developed posttraumatic stress disorder and marital problems subsequent to a motor vehicle accident. His treatment with exposure-based behavior therapy was augmented by involving his wife in exposure homework assignments. The additional inclusion of marital sessions that focused on increasing intimacy levels appeared to facilitate recovery. Upon completion of treatment, the patient returned to baseline levels of functioning. At 16-week follow-up, the patient remained asymptomatic. Treatment implications for the interconnection between PTSD symptoms and relationship difficulties are discussed.

Social Skills Training for Schizophrenia

Article AbstractThe enhancement of social skills may be pivotal in our patients with schizophrenia, raising their baseline level of function and allowing achievement of their goals, thereby reducing rehospitalizations. Social Skills Training for Schizophrenia provides the formula to achieve this end. It is one of the volumes in the "Treatment Manuals for Practitioners" series, which is edited by David H. Barlow. This volume is a collaborative product of 4 clinicians who distill the learning of the past 30 years in the field along with the recent neurocognitive research, resulting in an up-to-date integration for this modality of psychiatric rehabilitation.

Protein Kinase Cδ Mediates Ethanol-induced Up-regulation of L-type Calcium Channels

Brief ethanol exposure inhibits L-type, voltage-gated calcium channels in neural cells, whereas chronic exposure increases the number of functional channels. In PC12 cells, this adaptive response is mediated by protein kinase C (PKC), but the PKC isozyme responsible is unknown. Since chronic ethanol exposure increases expression of PKCdelta and PKCepsilon, we investigated the role these isozymes play in up-regulation of L-type channels by ethanol. Incubation with the PKC inhibitor GF 109203X or expression of a PKCdelta fragment that inhibits phorbol ester-induced PKCdelta translocation largely prevented ethanol-induced increases in dihydropyridine binding and K+-stimulated 45Ca2+ uptake. A corresponding PKCepsilon fragment had no effect on this response. These findings indicate that PKCdelta mediates up-regulation of L-type channels by ethanol. Remaining responses to ethanol in cells expressing the PKCdelta fragment were not inhibited by GF 109203X, indicating that PKCdelta-independent mechanisms also contribute. PKCdelta overexpression increased binding sites for dihydropyridine and L-channel antagonists, but did not increase K+-stimulated 45Ca2+ uptake, possibly because of homeostatic responses that maintain base-line levels of channel function. Since L-type channels modulate drinking behavior and contribute to neuronal hyperexcitability during alcohol withdrawal, these findings suggest an important role for PKCdelta in alcohol consumption and dependence.