Relationship between C-reactive protein and arterial stiffness in an asymptomatic population

Plasma concentration of high sensitive C-reactive protein (hsCRP) is used as a marker for inflammatory states and is directly correlated with the risk for coronary heart disease. Evidence concerning the role of inflammation in atheroma formation has been derived from several models of atherosclerosis. Inflammation should exert its adverse vascular effects by structural changes in the artery wall and consequently alterations in arterial elasticity, which could be detected already in asymptomatic early vascular disease. We hypothesized that CRP is related to large artery elasticity, but not to small artery elasticity in early vascular disease. Therefore, we examined the association between arterial stiffness of large and small arteries and inflammation in an asymptomatic population referred for primary prevention cardiovascular screening. Studies were performed in 391 subjects (age 21-82 years; 254 men, 137 women) who underwent screening at the Cardiovascular Disease Prevention Center. Large artery (C1) and small artery (C2) elasticity indices were obtained by the CVProfiler 2000 (HDI, Eagan, MN, USA). After overnight fasting, venous samples were taken for measurement of hsCRP, lipids, glucose. There was a significant inverse correlation between hsCRP (0.29 +/- 0.40 mg/dl) and C1 (16.7 +/- 5.8 ml/mmHg), r = -0.133, P = 0.01; there was no significant correlation between hsCRP and C2 (6.6 +/- 3.2 ml/mmHg). C2, but not hsCRP, was inversely correlated with age, abnormal lipids and glucose, whereas C1, but not hsCRP, was inversely correlated with age and systolic blood pressure (SBP). In multiple regression analysis, the relationship between hsCRP and C1 was not affected by age, body mass index, SBP, serum glucose or lipids. In conclusion, these findings support the hypothesis that hsCRP, a marker for acute and low-grade inflammation, is associated with large artery but not with small artery elasticity in asymptomatic individuals undergoing primary prevention cardiovascular screening.

From cognitive information to shared meaning: healing principles in prevention intervention

Families with parental affective disorder participated in a large-scale longitudinal study which involved participation in a standardized, short-term, psychoeducational preventive intervention. These families were followed for at least 3 years. An analysis of clinical material from the first 12 families to complete the intervention identified specific healing principles that contributed to positive changes in behavior and attitude. The healing elements of the intervention included demystification of the illness, modulation of shame and guilt, increase in the capacity for perspective taking, and development of a hopeful perspective and belief in one's own competence. Therapeutic effectiveness evolved in a process that linked cognitive information and presented depression as an illness that could be understood with the acknowledgement of family members' individual and collective experience. In this way, families developed a shared understanding of the illness that was useful over time. This article discusses the ways in which the healing principles promoted changes in family members' behavior and attitude, which, in turn, enhanced resiliency in children.

OR management

Market forces throughout the US, especially in specific geographic areas, have brought about profound changes in health care delivery. One of the most significant is the move to managed and capitated care with the resulting impact on hospital reimbursement. As these forces gain momentum, continually moving further from fee for-service, the hospital portion of the healthcare dollar continues to contract. In response, healthcare delivery organizations are developing innovative strategies to ensure the continual provision of cost effective care. Emphasis is placed upon keeping resources close to the point-of-care delivery. Necessary savings, reductions, and efficiencies must come from structural change, reengineering, best practice development, and more cost effective care delivery with highly standardized use of resources. Healthcare is in a transitionary stage. The transition has been from providing acute inpatient care to managing the continuum of care, from treating illness in individuals to providing education and maintaining wellness in the defined population. Revenue centers are no longer recognized; rather, in this increasingly capitated market, all, including operating rooms, are cost centers. The focus is no longer on filling beds, ORs, radiology suites, etc. The challenge is to find effective methods to minimize the needed resources to deliver high quality, cost effective care while maintaining and increasing patient and physician satisfaction. This article focuses on surgery in a large integrated system, Sharp Health care (San Diego, CA), a network of organizations providing, or arranging to provide, a coordinated continuum of services to a defined population.

Comparison of preventive interventions for families with parental affective disorder

Twenty families participated in a random assignment trial of two cognitive psychoeducational preventive interventions for families with parental affective disorder. Twelve families were assigned to a clinician-based intervention and eight to a lecture-based intervention, with assessment prior to intervention and an average of 18 weeks following intervention. Both groups were satisfied and believed they received help from the intervention. The clinician-based group was significantly more satisfied overall, and reported significantly more changes in both behaviors and attitudes about their illness from pre- to postintervention. Both groups showed significant decrease in degree of upset over issues of concern from pre- to postintervention. The clinician-based group reported receiving significantly more help with their primary concern. The implications of these findings are discussed.

Initial findings on preventive intervention for families with parental affective disorders

OBJECTIVE

The purpose of this study was to develop a clinician-based cognitive, psychoeducational, preventive intervention for families with parental affective disorder that would be suitable to widespread use, test its feasibility and safety, and define the areas affected by the intervention. The intervention was designed to increase understanding of parental illness and resilience in the children.

METHOD

The authors studied the first seven families (14 parents) to receive the intervention. Enrollment criteria included affective disorder during the preceding year in at least one parent, presence of at least one child between the ages of 8 and 14 years who was not psychiatrically ill at the time of participation, and willingness to participate in the research study. The intervention consisted of parent, child, and family sessions. Assessment included semistructured interviews with parents about affective disorders, standard ratings of marital satisfaction and therapeutic alliance, and a recently developed semistructured interview to assess response to the intervention.

RESULTS

Overall satisfaction with the intervention was rated moderate to high by parents. No harm was reported. Ten of 14 parent subjects reported five or more behavior and attitude changes that they attributed to the intervention. The most frequent behavior and attitudinal changes reported were increased discussion of the illness and related issues and increased understanding of information about affective illness.

CONCLUSIONS

The authors conclude that the intervention is safe and feasible in families with parental affective disorder.

The relationship between thought disorder and psychotic symptoms in borderline personality disorder

Often patients with personality and affective disorder are troubled by psychotic and psychotic-like symptoms. Predicting a course that includes such symptoms, and subsequently adjusting treatment to take into consideration the added difficulties presented by psychosis, is clinically important. In the current study, a measure of thought disorder, the Thought Disorder Index (TDI), significantly predicted prospective psychotic and psychotic-like symptoms in a sample of 49 personality and affective disorder patients. Multiple regressions demonstrated that the TDI had predictive value above and beyond that of a clinical interview. The high prevalence of psychotic symptoms was most striking in patients with borderline personality disorder.

A Markov model for predicting levels of psychiatric service use in borderline and antisocial personality disorders and bipolar type II affective disorder

This study examines the relationship between borderline personality disorder (BPD) and the use of psychiatric services in a naturalistic follow-up comparison with antisocial personality disorder and bipolar type II affective disorder. In the first follow-up series, borderline psychopathology was associated with higher levels of psychiatric service use (emergency, daycare, and inpatient). Markov analyses indicated that the transition between levels of psychiatric service use followed a stationary, second order process (i.e. the immediate past and current service use, predicted use on the next follow-up, and the relationship did not depend on the point in time examined in the follow-up series). Further, the transition probabilities generated from this model did not depend significantly on diagnosis. Predictions from the Markov model about the cumulative probability that subjects would use the highest level of psychiatric services were tested on a second series of follow-ups on the same subjects 20 months later. The model-based predictions (starting from the observed levels in the first two follow-ups of the second series) clustered into three groups, of high, middle, and low predicted probabilities. The subject group with the lowest predicted likelihood had a cumulative probability of 0.19 for using emergency, daycare, or inpatient hospitalization by 22 months of follow-up, whereas the group with the highest likelihood (containing a disproportionate number of BPD subjects) had a cumulative observed probability of 0.80. The Markov model generated from this second series supported the stationarity of the transition process. BPD subjects began using high levels of psychiatric services, but their transition from one level to another over time followed a process similar to that of non-BPD subjects.