Together JUN and DDIT3 (CHOP) control retinal ganglion cell death after axonal injury

BACKGROUND

Optic nerve injury is an important pathological component in neurodegenerative diseases such as traumatic optic neuropathies and glaucoma. The molecular signaling pathway(s) critical for retinal ganglion cell (RGC) death after axonal insult, however, is/are not fully defined. RGC death after axonal injury is known to occur by BAX-dependent apoptosis. Two transcription factors JUN (the canonical target of JNK) and DDIT3 (CHOP; a key mediator of the endoplasmic reticulum stress response) are known to be important apoptotic signaling molecules after axonal injury, including in RGCs. However, neither Jun nor Ddit3 deficiency provide complete protection to RGCs after injury. Since Jun and Ddit3 are important apoptotic signaling molecules, we sought to determine if their combined deficiency might provide additive protection to RGCs after axonal injury.

METHODS

To determine if DDIT3 regulated the expression of JUN after an axonal insult, mice deficient for Ddit3 were examined after optic nerve crush (ONC). In order to critically test the importance of these genes in RGC death after axonal injury, RGC survival was assessed at multiple time-points after ONC (14, 35, 60, and 120 days after injury) in Jun, Ddit3, and combined Jun/Ddit3 deficient mice. Finally, to directly assess the role of JUN and DDIT3 in axonal degeneration, compound actions potentials were recorded from Jun, Ddit3, and Jun/Ddit3 deficient mice after ONC.

RESULTS

Single and combined deficiency of Jun and Ddit3 did not appear to alter gross retinal morphology. Ddit3 deficiency did not alter expression of JUN after axonal injury. Deletion of both Jun and Ddit3 provided significantly greater long-term protection to RGCs as compared to Jun or Ddit3 deficiency alone. Finally, despite the profound protection to RGC somas provided by the deficiency of Jun plus Ddit3, their combined loss did not lessen axonal degeneration.

CONCLUSIONS

These results suggest JUN and DDIT3 are independently regulated pro-death signaling molecules in RGCs and together account for the vast majority of apoptotic signaling in RGCs after axonal injury. Thus, JUN and DDIT3 may represent key molecular hubs that integrate upstream signaling events triggered by axonal injury with downstream transcriptional events that ultimately culminate in RGC apoptosis.

Oral Medication for Agitation of Psychiatric Origin: A Scoping Review of Randomized Controlled Trials

BACKGROUND

Understanding more about the efficacy and safety of oral second-generation antipsychotic medications in reducing the symptoms of acute agitation could improve the treatment of psychiatric emergencies.

OBJECTIVE

The objective of this scoping review was to examine the evidence base underlying expert consensus panel recommendations for the use of oral second-generation antipsychotics to treat acute agitation in mentally ill patients.

METHODS

The Cochrane Schizophrenia Group's Study-Based Register was searched for randomized controlled trials comparing oral second-generation antipsychotics, benzodiazepines, or first-generation antipsychotics with or without adjunctive benzodiazepines, irrespective of route of administration of the drug being compared. Six articles were included in the final review.

RESULTS

Two oral second-generation antipsychotic medications were studied across the six included trials. While the studies had relatively small sample sizes, oral second-generation antipsychotics were similarly effective to intramuscular first-generation antipsychotics in treating symptoms of acute agitation and had similar side-effect profiles.

CONCLUSIONS

This scoping review identified six randomized trials investigating the use of oral second-generation antipsychotic medications in the reduction of acute agitation among patients experiencing psychiatric emergencies. Further research will be necessary to make clinical recommendations due to the overall dearth of randomized trials, as well as the small sample sizes of the included studies.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations

Introduction

The emergency medical evaluation of psychiatric patients presenting to United States emergency departments (ED), usually termed “medical clearance,” often varies between EDs. A task force of the American Association for Emergency Psychiatry (AAEP), consisting of physicians from emergency medicine, physicians from psychiatry and a psychologist, was convened to form consensus recommendations for the medical evaluation of psychiatric patients presenting to U.S.EDs.

Methods

The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED and then combined this with expert consensus. Consensus was achieved by group discussion as well as iterative revisions of the written document. The document was reviewed and approved by the AAEP Board of Directors.

Results

Eight recommendations were formulated. These recommendations cover various topics in emergency medical examination of psychiatric patients, including goals of medical screening in the ED, the identification of patients at low risk for co-existing medical disease, key elements in the ED evaluation of psychiatric patients including those with cognitive disorders, specific language replacing the term “medical clearance,” and the need for better science in this area.

Conclusion

The evidence indicates that a thorough history and physical examination, including vital signs and mental status examination, are the minimum necessary elements in the evaluation of psychiatric patients. With respect to laboratory testing, the picture is less clear and much more controversial.

Engaging Adults With Chronic Disease in Online Depressive Symptom Self-Management

The main purpose of this study was to evaluate participant engagement and effects of an Internet-based, self-directed program for depressive symptoms piloted among adults with a chronic disease. Eligible participants ( N = 47) were randomly assigned to either the "Think Clearly About Depression" online depression self-management program or the control group. The Patient Health Questionnaire-8 and Chronic Disease Self-Efficacy Scales were administered at baseline and at Weeks 4 and 8 after initiating the intervention. Number Needed to Treat analysis indicated that one in every three treatment group participants found clinically significant reductions in depressive symptoms by Week 8. Paired-sample t tests showed that depressive symptoms and self-efficacy in management of depressive symptoms improved over time for those in the treatment group and not for those in the control group. Participants' engagement and satisfaction with the online program were favorable.

American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines

Introduction

In the United States, the number of patients presenting to the emergency department (ED) for a mental health concern is significant and expected to grow. The breadth of the medical evaluation of these patients is controversial. Attempts have been made to establish a standard evaluation for these patients, but to date no nationally accepted standards exist. A task force of the American Association of Emergency Psychiatry, consisting of physicians from emergency medicine and psychiatry, and a psychologist was convened to form consensus recommendations on the medical evaluation of psychiatric patients presenting to EDs.

Methods

The task force reviewed existing literature on the topic of medical evaluation of psychiatric patients in the ED (Part I) and then combined this with expert consensus (Part II).

Results

In Part I, we discuss terminological issues and existing evidence on medical exams and laboratory studies of psychiatric patients in the ED.

Conclusion

Emergency physicians should work cooperatively with psychiatric receiving facilities to decrease unnecessary testing while increasing the quality of medical screening exams for psychiatric patients who present to EDs.

Emergency department utilization among frequent users with psychiatric visits

OBJECTIVES

The objective was to assess the incidence of psychiatric visits among frequent emergency department (ED) users and utilization among frequent psychiatric users.

METHODS

This was a multicenter retrospective longitudinal study of 1.76 million adult ED visits from acute care hospitals serving the metropolitan San Diego region (2008 through 2010) using nonpublic data submitted to the Office of Statewide Health Planning and Development. Frequent users were defined as having at least four ED visits within 12 consecutive months and were further classified into three groups based on the number of primary psychiatric visits in the same period, as defined by the primary discharge diagnosis (zero, one to three, and four or more visits). Descriptive, univariate, and logistic regression analyses are reported.

RESULTS

Patients with at least one primary psychiatric visit were 4.6 (95% confidence interval [CI] = 4.5 to 4.7) times more likely to be frequent ED users compared to patients with none. However, the majority of frequent ED users (80.1%) did not have any primary psychiatric visits; 16.6% of frequent ED users were classified as occasional psychiatric users, and only 3.3% were classified as frequent psychiatric users. Compared to frequent users without primary psychiatric visits, frequent psychiatric users were more likely to be male, non-Hispanic white, and without private insurance and visited the ED more frequently. Frequent psychiatric users also suffered from psychiatric, medical, and substance abuse comorbidity.

CONCLUSIONS

While patients with primary psychiatric visits were more likely to be frequent users of the ED, only a small percentage of frequent ED users were seen primarily and repeatedly for psychiatric care. However, this small group of frequent psychiatric users visited the ED at a much higher rate than other frequent users and was burdened with both chronic medical and psychiatric conditions.

Oxytocin and psychotherapy: a pilot study of its physiological, behavioral and subjective effects in males with depression

Individual psychotherapy is an important treatment for a number of psychiatric conditions and involves a unique form of human attachment. This raises the question of whether oxytocin (OT), the paradigmatic "attachment hormone", may have benefits in this context. In this randomized, double-blind, crossover trial, we gave male psychiatric outpatients with major depressive disorder 40 IU intranasal OT or placebo before a videotaped session with a therapist and measured a number of subjective, physiological, and behavioral parameters. We report three main findings. Surprisingly - in contrast to prior reports of OT's anxiolytic properties - we found OT caused an increase in anxiety over the course of the therapy session. Secondly, though it had no main effect on cortisol, eye contact, or overall behavior, we did find that OT caused a decrease in nonverbal behaviors that cut off social contact, after controlling for level of depressive symptoms. Lastly, we replicated prior findings that OT improves social cognition (performance on the reading the mind in the eyes test (RMET)), albeit in a depressed patient group. These results inform future studies of oxytocin and psychotherapy and suggest that in certain clinical populations and contexts, OT has heterogeneous subjective effects which may include acute anxiogenesis. Moreover, the similarity of some of these acute effects to those of single-dose serotonergic antidepressants raises interesting questions about the potential antidepressant benefits of chronic OT administration.

Common hand sanitizer may distort readings of breathalyzer tests in the absence of acute intoxication

OBJECTIVES

The use of alcohol-based hand sanitizers has recently become widespread. To the authors' knowledge, no previous study has examined whether application of ethanol-based hand sanitizers by the person operating a common breathalyzer machine will affect the accuracy of the readings. This was a prospective study investigating whether the use of hand sanitizer applied according to manufacturer's recommendations (Group I), applied improperly at standard doses (Group II), or applied improperly at high doses (Group III) had an effect on breathalyzer readings of individuals who had not ingested alcohol.

METHODS

The participants of the prospective study were divided into three groups to assess the effect of hand sanitizer on breathalyzer readings. Group I used one pump (1.5 mL) of hand sanitizer (Purell), allowing the hands to dry per manufacturer's recommendations; Group II used one pump (1.5 mL), without allowing the hands to dry; and Group III used two pumps (3 mL), without allowing the hands to dry. Breathalyzer measures for each group are presented as medians with interquartile ranges (IQR) and ranges. Differences between each sequential group (I vs. II and II vs. III) were assessed using a Mann-Whitney U-test (p < 0.05 significant).

RESULTS

There were 25 study participants in each group for a total of 75 participants. The initial breathalyzer readings of all study participants were 0.000 g/dL. The median breathalyzer reading was 0.004 g/dL in Group I (IQR = 0.001 to 0.008 g/dL), 0.051 g/dL in Group II (IQR = 0.043 to 0.064 g/dL), and 0.119 g/dL in Group III (IQR = 0.089 to 0.134 g/dL). Measures between each subsequent group were all statistically different (p < 0.001).

CONCLUSIONS

The use of common alcohol-based hand sanitizer may cause false-positive readings with a standard hospital breathalyzer when the operator uses the hand sanitizer correctly. The breathalyzer readings are further elevated if more sanitizer is used or if it is not allowed to dry appropriately.

Emergency Physicians Research Common Problems in Proportion to their Frequency

Introduction:

Emergency medicine (EM) organizations such as the Society for Academic Emergency Medicine and the Institute of Medicine have called for more clinical research as a way of addressing the scarcity of research in EM. Previous investigations have examined funding and productivity in EM research, but whether EM researchers preferentially concentrate on certain patient-related topics is not known. We hypothesized that at least part of the scarcity of EM research is from the tendency of EM researchers, like researchers in other fields, to focus on rarer conditions with higher morbidity or mortality instead of on more common conditions with less acuity. This study compared the frequency of specific medical conditions presenting to emergency departments nationwide with the frequency of emergency physician research on those same conditions.

Methods:

This study is a structured retrospective review and comparison of 2 databases during an 11-year span. Principal diagnoses made by emergency physicians as reported by the National Hospital Ambulatory Medical Care Survey were compared to all first-author publications by emergency physicians as reported in PubMed between 1996 and 2006. Statistics included correlations and linear regression with the number of emergency department (ED) visits per diagnosis as the independent variable and the number of articles published as the dependent variable.

Results:

During the study period, there was significant concordance between the frequency of presenting conditions in the emergency department and the frequency of research being performed on those conditions, with a high correlation of 0.85 (P < 0.01). More common ED diagnoses such as injury/poisoning, symptoms/ill-defined conditions, and diseases of the respiratory system accounted for 60.9% of ED principal diagnoses and 50.2% of the total research published in PubMed.

Conclusion:

Unlike researchers in other fields, emergency physicians investigate clinical problems in almost the exact proportion as those conditions are encountered in the emergency department. The scarcity of EM research does not have to do with a skewed focus toward less common patient problems.

Literature-based recommendations for suicide assessment in the emergency department: a review

BACKGROUND

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

OBJECTIVES

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

METHODS

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

RESULTS

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

CONCLUSION

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.