Dissociative Identity Disorder in Schools Part II

Dissociation is a well-established outcome of early life trauma, but school nurses may not be aware of resources and recommendations available to support students who experience it. If dissociation or behaviors consistent with dissociation are present, trauma-informed care (TIC) principles can guide individualized care of the student. Part I of this two-part article provided a pertinent background on dissociation, dissociative identity disorder (DID), the effects of social media, and TIC. Part II offers specific recommendations for implementing these principles in school nursing practice and follows the student vignette through the school year. Due to their holistic approach to care and long-standing leadership in providing TIC, nurses can significantly affect health, safety, and access to learning for students expressing dissociative experiences at school.

Dissociative Identity Disorder in Schools Part I

Dissociation is a normal life adaptation that can become pronounced and disruptive in the setting of repeated or extreme exposure to trauma. Children and adolescents may experience dissociation due to a trauma or stressor-related disorder, anxiety, or depressive disorders. Children and adolescents also may mimic behavior they see online as a way of expressing internally painful and intolerable experiences. Myth and misinformation surround the diagnosis of dissociative identity disorder (DID), formerly multiple personality disorder. The purpose of this article is to provide school nurses with evidence-based information on DID and resources for practice regarding how to provide a secure, consistent approach to students who are being traumatized, misunderstood, or excluded at home or at school. Part 1 of this two-part series describes DID foundations and DID in school-aged children, reviews controversy spurred by social media representation, and presents the Trauma-Informed Care (TIC) model. TIC offers useful perspectives regardless of a student's presentation or diagnostic status. Part 2 will discuss recommendations for managing dissociative presentations using a team-based approach, focusing on the school nurse's roles and responsibilities.

Discussion of “Attitude of Physi -cians Towards Automatic Alerting in Computerized Physician Order Entry Systems”

With these comments on the paper “Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems”, written by Martin Jung and co authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physi cian order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Bipolar mood state reflected in cortico-amygdala resting state connectivity: A cohort and longitudinal study

BACKGROUND

Using resting-state functional magnetic resonance imaging (rsfMRI), we previously compared cohorts of bipolar I subjects in a manic state to those in a euthymic state to identify mood state-specific patterns of cortico-amygdala connectivity. Our results suggested that mania is reflected in the disruption of emotion regulation circuits. We sought to replicate this finding in a group of subjects with bipolar disorder imaged longitudinally across states of mania and euthymia METHODS: We divided our subjects into three groups: 26 subjects imaged in a manic state, 21 subjects imaged in a euthymic state, and 10 subjects imaged longitudinally across both mood states. We measured differences in amygdala connectivity between the mania and euthymia cohorts. We then used these regions of altered connectivity to examine connectivity in the longitudinal bipolar group using a within-subjects design.

RESULTS

Our findings in the mania vs euthymia cohort comparison were replicated in the longitudinal analysis. Bipolar mania was differentiated from euthymia by decreased connectivity between the amygdala and pre-genual anterior cingulate cortex. Mania was also characterized by increased connectivity between amygdala and the supplemental motor area, a region normally anti-correlated to the amygdala in emotion regulation tasks.

LIMITATIONS

Stringent controls for movement effects limited the number of subjects in the longitudinal sample.

CONCLUSIONS

In this first report of rsfMRI conducted longitudinally across mood states, we find that previously observed between-group differences in amygdala connectivity are also found longitudinally within subjects. These results suggest resting state cortico-amygdala connectivity is a biomarker of mood state in bipolar disorder.

Differential brain network activity across mood states in bipolar disorder

BACKGROUND

This study aimed to identify how the activity of large-scale brain networks differs between mood states in bipolar disorder. The authors measured spontaneous brain activity in subjects with bipolar disorder in mania and euthymia and compared these states to a healthy comparison population.

METHODS

23 subjects with bipolar disorder type I in a manic episode, 24 euthymic bipolar I subjects, and 23 matched healthy comparison (HC) subjects underwent resting state fMRI scans. Using an existing parcellation of the whole brain, we measured functional connectivity between brain regions and identified significant differences between groups.

RESULTS

In unbiased whole-brain analyses, functional connectivity between parietal, occipital, and frontal nodes within the dorsal attention network (DAN) were significantly greater in mania than euthymia or HC subjects. In the default mode network (DMN), connectivity between dorsal frontal nodes and the rest of the DMN differentiated both mood state and diagnosis.

LIMITATIONS

The bipolar groups were separate cohorts rather than subjects imaged longitudinally across mood states.

CONCLUSIONS

Bipolar mood states are associated with highly significant alterations in connectivity in two large-scale brain networks. These same networks also differentiate bipolar mania and euthymia from a HC population. State related changes in DAN and DMN connectivity suggest a circuit based pathology underlying cognitive dysfunction as well as activity/reactivity in bipolar mania. Altered activities in neural networks may be biomarkers of bipolar disorder diagnosis and mood state that are accessible to neuromodulation and are promising novel targets for scientific investigation and possible clinical intervention.

State dependent cortico-amygdala circuit dysfunction in bipolar disorder

BACKGROUND

Existing models of the pathophysiology of bipolar disorder posit disruption in neural circuits of emotion regulation and reward processing. However, few fMRI studies have compared regional brain activity and connectivity in different mood states in bipolar disorder to determine if manic symptomatology is reflected in specific circuit abnormalities. The purpose of this study was to test the hypothesis that bipolar mania is associated with altered connectivity between cortical regions thought to regulate subcortical structures such as the amygdala and striatum.

METHODS

28 subjects with bipolar disorder in a manic state, 24 different bipolar subjects in a euthymic state, and 23 matched healthy comparison subjects underwent resting state fMRI scans. Several cortical and sub-cortical structures implicated in the pathogenesis of bipolar disorder were selected for study. We conducted a whole-brain analysis of functional connectivity of these regions.

RESULTS

Bipolar mania was differentiated from euthymia by decreased functional connectivity between the amygdala and anterior cingulate cortex (ACC). Mania was also characterized by increased connectivity between amygdala and dorsal frontal cortical structures that are normally anti-correlated in emotion regulation tasks.

LIMITATIONS

Both groups of bipolar subjects were prescribed medications. The study was not longitudinal in design.

CONCLUSIONS

Compared to bipolar subjects in a euthymic state, subjects in the manic state demonstrate disrupted functional connectivity between brain regions involved in the regulation of emotion and the amygdala. This disruption of activity in neural circuits involved in emotion may underlie the emotional dysregulation inherent to a bipolar manic episode.

Discussion of "Attitude of physicians towards automatic alerting in computerized physician order entry systems"

With these comments on the paper "Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems", written by Martin Jung and co-authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physician order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Health Information Systems Training for a Countrywide Implementation in Uruguay

Objectives Health Information systems training is one of the bottlenecks in clinical systems implementation. In this article, a strategy to massively create and train interdisciplinary coordinating teams is described for a project in Uruguay at FEMI, a non-academic setting which includes 23 health care institutions across the country and a tertiary referral center in Montevideo.

Methods A series of educational activities were designed for the local coordinating teams. They included both onsite and online formats, site visits, integrated with some of the project tasks.

Results In total, 128 professionals from all the Institutions participated in one or more of the training sessions (onsite and online) and 87 of them accomplished one of the forms of training.

Conclusions Massive basic health informatics training was possible in Uruguay through collaboration with academic institutions at the country and regional level. Next steps include an active involvement of nurses in the educational events and planning of massive training of end users.

Health information systems training for a countrywide implementation in Uruguay

OBJECTIVES

Health Information systems training is one of the bottlenecks in clinical systems implementation. In this article, a strategy to massively create and train interdisciplinary coordinating teams is described for a project in Uruguay at FEMI, a non-academic setting which includes 23 health care institutions across the country and a tertiary referral center in Montevideo.

METHODS

A series of educational activities were designed for the local coordinating teams. They included both onsite and online formats, site visits, integrated with some of the project tasks.

RESULTS

In total, 128 professionals from all the Institutions participated in one or more of the training sessions (onsite and online) and 87 of them accomplished one of the forms of training.

CONCLUSIONS

Massive basic health informatics training was possible in Uruguay through collaboration with academic institutions at the country and regional level. Next steps include an active involvement of nurses in the educational events and planning of massive training of end users.

A method of reducing the opioid withdrawal intensity using progressively increasing doses of naloxone

We assessed the withdrawal intensity in acutely morphine-dependent mice using a pretreatment with escalating doses of naloxone. All animals received a single dose of morphine (100 mg/kg) for the induction of acute opioid dependency. Group 1 (control) received three injections of normal saline and then naloxone 0.8 mg/kg. Group 2 received increasing pretreatment doses of naloxone (0.1, 0.2, and 0.4 mg/kg) and a challenge dose of 0.8 mg/kg. Group 3 received three injections of naloxone 0.1 mg/kg and a challenge dose of 0.8 mg/kg. Groups 4 and 5 were used to verify whether ED(50) found in previous studies was comparable with values obtained in the current experiments. The withdrawal intensity was determined by the number of jumps. The mice of group 1 exhibited significantly more jumps after 0.8 mg/kg of naloxone as compared with group 2. The number of jumps in response to naloxone between groups 1 and 2 and groups 2 and 3 was not significantly different. The results show that pretreatment with increasing naloxone doses significantly reduced the withdrawal intensity as compared with the control group; whereas pretreatment with repeated low antagonist did not reduce it significantly.

New uses of legacy systems: examples in perinatal care

In this article, new uses of the Perinatal Information System at the Uruguayan Social Security health care facilities are described. The perinatal information system has been in place for over 13 years, with about 40 thousand clinical records on electronic files. A newly created Web interface allows a distributed access to existing perinatal information within the National Social Security Wide Area a Network. Perinatal data is also exported to a management information system, allowing to dynamically answer questions and make managerial decisions, and eventually link these data with other sources. Future steps regarding clinical information systems are outlined.

Dopa reaction of fetal melanocytes before and after skin transplantation on to nude mice

We have previously demonstrated that human fetal epidermal melanocytes are dopa-negative. The present study was conducted to test the hypothesis that human fetal melanocytes can be activated to produce melanin under conditions differing from their natural in utero environment. To address this question, dopa staining activity of fetal epidermal sheets, obtained from seven aborted fetuses with estimated gestational ages of 13-20 weeks, was evaluated before and after engraftment on to nude mice. Dopa staining became positive 7 days post-engraftment. The intensity of the dopa reaction and the mean number of melanocytes increased by day 14 post-engraftment, and these changes were even greater by day 30. These observations indicate that human fetal melanocytes, potentially capable of synthesizing melanin under conditions differing from their normal in utero environment, are either inhibited, or not stimulated to do so.

Computerized practice guidelines for heart failure management: the HeartMan system

In this paper we discuss the initial stages of development and evaluation of the HeartMan system, a set of computerized practice guidelines for heart failure management. The concept of computerized guidelines as a hybrid of expert systems and practice guidelines methodologies and techniques is proposed. We show the results of the initial evaluation of the system, which are very promising, although the sample size is small, and the study is retrospective: Of 177 messages, 90% were considered appropriate, of which 97.5% would have been followed. Eight percent of the messages were classified as neutral, and 2% classified as inappropriate. The errors were correctable by changing the logic. The potential technical and sociological barriers to the complete development and clinical use of the system are discussed.

Warfarin 2.0--a computer program for warfarin management. Design and clinical use

Warfarin 2.0 is a computer program that helps physicians optimize treatment of outpatients with warfarin. The main reason for its development was to achieve a good anticoagulation level, avoiding both undertreatment--which causes thromboembolic complications--and overtreatment--which causes hemorrhagic complications. The program was also designed to help educate the anticoagulated patient, standardize warfarin management and audit results of what had been done. The philosophy of continuous quality improvement was applied. Warfarin 2.0 is in clinical operation in the University Hospital, Montevideo, Uruguay, and it has also been used since the end of 1993 in the Favaloro Foundation, Dept. of Hematology, Buenos Aires, Argentina. The results from the first 15 months of use in Montevideo showed an increase in the number of patients being followed (from 91 to 132) and the average number of visits per patient (from one visit every 10.6 weeks to one every 6.5 weeks): The frequency of visits has been in the internationally accepted ranges since the program was implemented. Better anticoagulation levels were achieved after an adjusting period. Unfortunately, the number of undertreated patients is still large, and a thorough analysis of the data is going to be undertaken to continue improving warfarin management.

The protective efficacy of polyvalent pneumococcal polysaccharide vaccine

BACKGROUND

Although the protective efficacy of pneumococcal polysaccharide vaccine has been demonstrated in randomized trials in young African gold miners, there has been controversy about its efficacy in older Americans at risk for serious pneumococcal infections. To assess the vaccine's protective efficacy against invasive pneumococcal infections, we conducted a hospital-based case-control study of the efficacy of pneumococcal vaccine in adults with a condition recognized to be an indication for receiving the vaccine.

METHODS

From 1984 to 1990, adults in whom Streptococcus pneumoniae was isolated from any normally sterile site were identified by prospective surveillance in the microbiology laboratories of 11 large hospitals; those with an indication for pneumococcal vaccine were enrolled as case patients. For each case patient, one control was matched according to age, underlying illness, and site of hospitalization. We contacted all providers of medical care to ascertain each subject's history of immunization with pneumococcal vaccine. Isolates of S. pneumoniae were serotyped by an investigator unaware of the subject's vaccination history.

RESULTS

Thirteen percent of the 1,054 case patients and 20 percent of the 1,054 matched controls had received pneumococcal vaccine (P less than 0.001). When vaccine was given in either its 14-valent or its 23-valent form, its aggregate protective efficacy (calculated as a percentage: 1 minus the odds ratio of having been vaccinated times 100) against infections caused by the serotypes represented in the vaccine was 56 percent (95 percent confidence interval, 42 percent to 67 percent; P less than 0.00001) for all 983 patients infected with a serotype represented in the vaccine, 61 percent for a subgroup of 808 immunocompetent patients (95 percent confidence interval, 47 percent to 72 percent; P less than 0.00001), and 21 percent for a subgroup of 175 immunocompromised patients (95 percent confidence interval, -55 percent to 60 percent; P = 0.48). The vaccine was not efficacious against infections caused by serotypes not represented in the vaccine (protective efficacy, -73 percent; 95 percent confidence interval, -263 percent to 18 percent; P = 0.15).

CONCLUSIONS

Polyvalent pneumococcal vaccine is efficacious in preventing invasive pneumococcal infections in immunocompetent patients with indications for its administration. This vaccine should be used more widely.

Flavor preexposures in a conditioned taste aversion situation: a dissociation of behavioral and endocrine effects in rats

A series of experiments examined the effects of flavor preexposures on pituitary-adrenal/behavior relations in a conditioned taste aversion paradigm. It was found that reexposure to a novel milk solution paired earlier with lithium chloride (LiCl) elicited conditioned activation of the pituitary-adrenal system (Experiment 1). The unconditioned response to LiCl (measured by changes in plasma levels of corticosterone) did not vary as a function of prior (2 and 5 vs. 10) exposures to the milk solution (Experiment 2). Increased familiarity with the substance (resulting from 10 prior exposures) rendered the conditioning of a taste aversion to this substance less effective. Further, reexposure to this familiar substance after its pairing with LiCl was not accompanied by the characteristic conditioned pituitary-adrenal activation (Experiment 3). By titrating the number of conditioned stimulus (CS) preexposures (Experiment 4) it was found that within the range of preexposures manipulated (5-10), subjects exhibited (a) a coupling of behavioral and pituitary-adrenocortical responses when the conditioned taste aversion to the milk solution was paralleled by elevated plasma corticosterone (5-6 preexposures), (b) a coupling of these two response systems when flavor consumption was accompanied by suppressed plasma titers of corticoids (9-10 preexposures), or (c) a dissociation of the two system when the conditioned taste aversion was not accompanied by conditioned adrenocortical activity (7-8 preexposures). These data are discussed in terms of a dissociation in the effects of CS preexposures on conditioned adrenocortical and behavioral response systems.

Intestinal calcium-binding protein 3 months after massive small bowel resection in the piglet

Changes in intestinal calcium-binding protein and calcium binding activity were studied at resection and 3 months after 90% small bowel resection in piglets and one adult pig. A calcium-binding protein (MW congruent to 11.000) with calcium-dependent eletrophoretic mobility was partially purified from mucosal extract of proximal jejunum, mid-gut, and ileum. The concentration of calcium-binding protein and the calcium-binding activity of the intact animals were found highest in the proximal jejunal segment, lowest in the ileal segment. After resection in the four surviving animals out of nine, a significant increase in calcium-binding activity was observed in the proximal jejunum and in the distal ileal segment. The change in calcium-binding activity was much more marked in the ileum than the jejunum. These data demonstrate that pig intestinal mucosa possesses an adaptive capacity to increase the synthesis of calcium-binding protein after massive small bowel resection.

Effects of 25-hydroxycholecalciferol on bone lesions of children with terminal renal failure

Quantitative histology was performed on serial iliac crest biopsies obtained from 14 children with terminal renal failure. A long-term study on the comparative effects of vitamin D2 and 25-hydroxycholecalciferol [25-(OH)D3], in five patients with severe lesions of osteomalacia and/or osteitis fibrosa, demonstrated the efficiency of 25 to 200 mug/day of 25-(OH)D3 and the lack of therapeutic action of 345 to 685 mug/day of vitamin D2. In nine subjects with normal roentgenograms or minimal skeletal alterations, the first biopsy taken at the beginning of intermittent hemodialysis showed evidence of defective mineralization and/or lesions of resorption. Four of these children were treated with 25-(OH)D3 (25 to 50 mug/day) and calcium supplementation orally (0.5 to 1.5 g/day); five children received calcium orally (0.5 to 0.75 g/day) alone. Aggravation of bone lesions during intermittent hemodialysis was observed in patients treated with calcium supplements alone. In subjects who were given 25-(OH)D3, mineralization improved and marrow fibrosis disappeared. However, as the two groups of patients were different in composition and in the manner in which they were treated, it is difficult to state whether the beneficial effects observed were solely attributable to 25-(OH)D3 administration. 25-(OH)D3 therapy induced severe intoxication in two patients. A rise in plasma calcium concentration to 11.0 to 11.5 mg/100 ml was observed in two other patients. It is concluded that: a) pharmacologic doses of 25-(OH)D3 are highly effective in healing bone lesions of children with terminal renal failure; b) such treatment requires strict clinical surveillance as 25-(OH)D3 intoxication may occur even in anephric patients.