Efficacy of Problem-Solving Intervention to Improve Adherence in Adolescents and Adults with Cystic Fibrosis

BACKGROUND

Adherence to treatment by adolescents and adults with cystic fibrosis (CF) is often poor.

OBJECTIVES

To assess the impact of a focused clinical intervention on adherence in individual patients, including help in problem-solving key barriers to adherence. To implement a patient-centered problem-solving intervention using CF My Way tools. To identify and overcome a selected barrier to adherence.

METHODS

Medication possession ratios (MPRs), number of airway clearance sessions, forced expiratory volume (FEV1), body mass index (BMI), and health-related quality of life (HRQoL) were measured before and after the intervention.

RESULTS

Sixteen patients with CF, aged 23.4 ± 6.7 years, participated. MPR increased for colistimethate sodium and tobramycin inhalations from a median of 21 (range 0-100) to 56 (range 0-100), P = 0.04 and 20 (range 0-100) to 33.3 (range 25-100), P = 0.03, respectively. BMI standard deviation score rose from -0.37 to -0.21, P = 0.05. No significant improvements were found in FEV1, airway clearance, or HRQoL scores.

CONCLUSIONS

The CF My Way problem-solving intervention increased adherence to medical treatments by removing barriers directly related to the needs and goals of young adults with CF.

Human figure drawings in the evaluation of severe adolescent suicidal behavior

OBJECTIVE

To evaluate the reliability of using certain indicators derived from human figure drawings to distinguish between suicidal and nonsuicidal adolescents.

METHOD

Ninety consecutive admissions to an adolescent inpatient unit were assessed. Thirty-nine patients were admitted because of suicidal behavior and 51 for other reasons. All subjects were given the Human Figure Drawing (HFD) test. HFD was evaluated according to the method of Pfeffer and Richman, and the degree of suicidal behavior was rated by the Child Suicide Potential Scale.

RESULTS

The internal reliability was satisfactory. HFD indicators correlated significantly with quantitative measures of suicidal behavior; of these indicators specifically, overall impression of the evaluator enabled the prediction of suicidal behavior and the distinction between suicidal and nonsuicidal inpatients (p < .001). A group of graphic indicators derived from a discriminant analysis formed a function, which was able to identify 84.6% of the suicidal and 76.6% of the nonsuicidal adolescents correctly. Many of the items had a regressive quality.

CONCLUSIONS

The HFD is an example of a simple projective test that may have empirical reliability. It may be useful for the assessment of severe suicidal behavior in adolescents.

Protection of thrombin receptor expression under hypoxia

Thrombin receptor (ThR) plays a significant role in myocyte contractility and hypertrophy. Heart myocyte ischemic damage, caused by insufficient blood supply, is the leading cause of heart infarction. Here we demonstrate that when primary myocyte cultures are subjected to hypoxic stress, ThR mRNA levels are reduced markedly. This takes place also in vivo in a model of ischemic pig heart, exhibiting reduced levels of ThR compared with normal heart sections. Prior activation of ThR however, by either thrombin receptor-activating peptide (TRAP) or by alpha-thrombin resulted in full protection of ThR mRNA levels under hypoxia. The effect appeared specific to ThR because the addition of TRAP did not affect the hypoxic damage as shown by the levels of lactic dehydrogenase release and up-regulated GLUT-1, a glucose transporter gene. This protection effect took place not only in primary myocytes but also in NIH3T3 fibroblasts. ThR protection occurs via specific cell signaling events because activation of the receptor by TRAP, following interruption of the signaling cascade by calphostin C, a protein kinase C inhibitor, resulted in loss of ThR mRNA protection. Because Ras and Src are part of the ThR signaling cascade, the introduction of either dominant ras or src oncogenes to NIH3T3 murine fibroblasts gave rise to similar protection of ThR mRNA levels under hypoxic conditions without the exogenous addition of TRAP. Likewise, ThR mRNA protection was obtained after transfection with proto-oncogene vav. The 95-kDa protein Vav undergoes tyrosine phosphorylation after ThR activation, serving thus as part of the receptor machinery cascade. We therefore conclude that the initiation of the signaling cascades either exogenously by TRAP or within the cell via src or ras, as well as via vav oncogene interconnecting G-binding protein to the tyrosine kinase pathway, ultimately results in ThR protection under hypoxia. We present hereby, a novel concept of activated receptors, which under minimal oxygen tension protect their otherwise decaying mRNA. Maintaining the level of ThR that plays an active role in normal myocyte function may provide a significant repair mechanism in ischemic tissue, assisting in the regaining of normal myocyte functions.

Metabotropic glutamate receptors limit adenylyl cyclase-mediated effects in rat hippocampus via protein kinase C

Glutamate receptors of the metabotropic type (mGluRs) activate protein kinase C in hippocampus, but few physiological functions of this pathway are known. The present data show that mGluRs utilize protein kinase C to inhibit another second messenger system, the adenylyl cyclase pathway, in neurons of the CA1 area of hippocampus. Activation of mGluRs prevented beta-adrenergic receptors, which couple to adenylyl cyclase, from blocking the slow Ca2+-dependent afterhyperpolarization (AHP). Since the afterhyperpolarization modulates neuronal responsiveness, crosstalk between protein kinase C and the adenylyl cyclase pathway is likely to have physiological consequences. Moreover, mGluRs themselves block the afterhyperpolarization, so the observed interference with the beta-adrenergic response constitutes a hierarchical relationship in which mGluRs are dominant over beta-adrenergic receptors.

Synthesis and structure-activity relationships of N-propyl-N-(4-pyridinyl)-1H-indol-1-amine (besipirdine) and related analogs as potential therapeutic agents for Alzheimer's disease

A series of novel N-(4-pyridinyl)-1H-indol-1-amines and other heteroaryl analogs was synthesized and evaluated in tests to determine potential utility for the treatment of Alzheimer's disease. From these compounds, N-propyl-N-(4-pyridinyl)-1H-indol-1-amine (besipirdine, 4c) was selected for clinical development based on in-depth biological evaluation. In addition to cholinomimetic properties based initially on in vitro inhibition of [3H]quinuclidinyl benzilate binding, in vivo reversal of scopolamine-induced behavioral deficits, and subsequently on other results, 4c also displayed enhancement of adrenergic mechanisms as evidenced in vitro by inhibition of [3H] clonidine binding and synaptosomal biogenic amine uptake, and in vivo by reversal of tetrabenazine-induced ptosis. The synthesis, structure-activity relationships for this series, and the biological profile of 4c are reported.

The relationship between alveolar bone loss and proximal caries in children: prevalence and microbiology

The present study describes the prevalence of alveolar bone loss (ABL) in children in relation to caries, contact and space loss. In addition, the microbial composition of the subgingival plaque of 20 sites, from 5 children, is presented. Bite-wing radiographs from 500 children were examined. ABL was evident in: 99 sites from 60 children; > 1 site in 27 children; the maxilla only in 34 children; the mandible only in 17 children; both arches in 9 children; 37 sites with no caries; 4.9 percent of all sites with proximal caries; 15.8 percent of all sites with contact loss; and 20.5 percent of all sites with mesial drift. Anaerobic bacteria were cultured from all 20 sites. No significant differences in the percentages of colony forming units of Actinobacillus actinomycetemcomitans and black pigmented Bacteroides were found among sites with/without bone loss, with/without caries or probing depths smaller/equal or larger than 2.5 mm.

Blood pressure in Ethiopian immigrants: relationship to age and anthropometric factors, and changes during their first year in Israel

Blood pressure was measured in 483 Ethiopian immigrants during the first week following their arrival in Israel. Mean levels of diastolic (DBP) and systolic blood pressures (SBP) were very low compared with known levels in the Israeli population. BPs were elevated in men greater than 20 years old and in women greater than 40 years old. Quetelet index averaged below 2.00 g/cm2. Considerable weight gains were observed in 265 individuals examined after 1 year. Simultaneously, DBP increased by 4 mm Hg on average, whereas the changes in SBP were small. At the end of 1 year, the mean SBP ranged from 107 (age 5-9 and 10-14) to 124 mm Hg (age greater than or equal to 60) and mean DBP from 69 (age 10-14 and 15-19) to 78 mm Hg (age greater than or equal to 60), remaining nevertheless considerably lower than levels observed in diverse Israeli population groups. Covariance analysis revealed that initial BPs, gender, age, and weight gain significantly affected SBP and DBP at the end of the year.

Prevalence of diabetes mellitus in Ethiopian immigrants

The prevalence of diabetes mellitus among 445 new immigrant Ethiopian Jews was studied immediately after their arrival to Israel, and found to be 0.4%. This low prevalence could be attributed to their long trek accompanied by severe malnutrition which caused death to the old, weak and sick, leaving a selectively young and healthy population group.

Fatty acid composition of adipose tissue in Ethiopian immigrants: a prospective study during their first year in Israel

We measured the subcutaneous adipose tissue fatty acid composition in 22 male Ethiopian Jews, aged 17-65, shortly after their immigration to Israel. These subjects showed a concentration of linoleic acid (17.8%), which was relatively low compared with Israeli levels, and a high concentration of palmitic acid (28.5%). The linoleic/saturated (P/S) ratio was 0.52. After 5 months, a repeat measurement indicated increases of the linoleic acid content and of the P/S ratio to 20.1% and 0.62, respectively (P less than 0.05). In another sample from the same immigrant group, levels after 1 year in Israel were 20.9% and 25.1% for linoleic and palmitic acid, respectively, and the P/S ratio was 0.67. These results differed significantly (P less than 0.02) from those obtained in the first sample after immigration. Apart from decreasing plasma triglyceride levels, no pattern of lipid changes was discernible in our limited samples. Changes in subcutaneous fatty acid composition reflect changes in diet over months, suggesting a decreased carbohydrate intake and in increased fat intake. It remains to be seen whether changing fatty acid composition in conjunction with changes in blood lipids or other factors, over a prolonged period of time, will affect the cardiovascular risk in the immigrants.

Gonadotropin-releasing hormone receptor expression in Xenopus oocytes

The rodent GnRH receptor was characterized in Xenopus oocytes injected with RNA isolated from rat pituitary and from a gonadotrope cell line, alpha T3, derived from a transgenic mouse. Three to 4 days after 150-200 ng RNA injection, 93% of the oocytes, which were recorded by voltage clamp, responded to 10(-7) M GnRH. The mean inward currents obtained after RNA injection were 620 +/- 88 nA (n = 22) with pituitary RNA and 1415 +/- 598 (n = 4) with alpha T3 RNA. The threshold GnRH concentration able to evoke the dose dependent current after pituitary RNA injection was 3 x 10(-9) M GnRH. The GnRH receptor response of the oocyte was antagonized by [D-Phe2,6,Pro3] GnRH and [N-Ac-D-Na](2)1, D-alpha D-Me, pCl-Phe2, D-Arg6, D-Ala10-NH2]GnRH and could be elicited by D-Ser(But)6,Pro9-N-ethylamide GnRH (buserelin). The reversal potential of the GnRH generated current as determined by voltage-ramp was -22.5 +/- 1.0 mV (n = 7) and -25.6 +/- 3.3 mV (n = 3) in pituitary and cell line RNA-injected oocytes respectively, consistent with the chloride reversal potential. The GnRH receptor response was virtually eliminated by intracellular EGTA injection but was unaffected by ligand application in calcium-free perfusate. The GnRH-evoked response is mimicked by intracellular injection of inositol 1,4,5-trisphosphate. To determine the size of the GnRH receptor mRNA, alpha T3 RNA was size fractionated through a sucrose gradient. The maximal GnRH response was induced by a fraction larger than the 28S ribosomal peak. Thus we find that oocytes injected with RNA from an appropriate source develop an electrophysiological response to GnRH which is dependent on intracellular calcium mobilization, is independent of extracellular calcium, and may be mediated by inositol 1,4,5-trisphosphate.

Lipids and lipoproteins in new immigrant Ethiopian Jews in Israel

In an investigation of lipid levels following a period of deprivation and prolonged travel, 206 male and 272 female Ethiopian Jewish immigrants to Israel were evaluated at the end of 1984. This ethnic group, most of whom are lean persons who had apparently consumed a high simple carbohydrate diet, revealed distinct (cross-sectionally evaluated) age and sex patterns of lipid distribution. Total cholesterol in the Ethiopians resembled that in Israeli-born adolescents or adult resident Israelis at ages 8 years through 20-29 years, but mean levels were considerably lower in Ethiopians at ages 30-39 years through 60 years, where they do not exceed 175 mg/dl for males and 190 mg/dl for females. Mean triglyceride levels were higher for Ethiopian females than in Israeli females up to age range 40-49 years. While the levels in Israelis increase steadily with age, no clear age pattern was discernible in the levels in the Ethiopians (at least cross-sectionally). Among the Ethiopian males, levels were considerably higher than those among Israeli males in childhood and adolescence. In Ethiopian adults, the triglyceride levels appeared to be slightly lower than those in resident Israelis. The Ethiopian immigrants displayed markedly reduced high density cholesterol (38 mg/dl for males, 39 mg/dl for females) compared with levels of between 50 and 53 mg/dl for Israelis at age 8-9 years. These differences diminished with age, until, at around age 20-29 years, mean levels became comparable (around 42 mg/dl for males and 50 mg/dl for females) and remained so at older ages. The distinct lipid patterns in the Ethiopian Jewish immigrants to Israel are subject to ongoing follow-up to investigate the effect of a quasi-western diet and a western lifestyle on this ethnic group.

More rapid relief of pain with isosorbide dinitrate oral spray than with sublingual tablets in elderly patients with angina pectoris

To evaluate the possibility of improving clinical practice in the treatment of angina pectoris, the duration of relief of pain with isosorbide dinitrate (ISDN) oral spray and sublingual tablets were compared in elderly patients with chronic stable angina pectoris. Nine patients (mean age 67 years) were studied in a randomized crossover trial. The patients underwent bicycle ergometry, which resulted in typical chest pain associated with electrocardiographic ST-segment depression in all 9. The patients received ISDN oral spray or sublingual tablets immediately on termination of exercise. At least 6 hours later another ergometry test was performed and the patients were crossed over to the other drug. ISDN spray relieved pain in all patients at a mean duration of 61.6 +/- 24.4 seconds after administration, whereas the duration of relief of pain by ISDN sublingual tablets was 112.4 +/- 70 seconds. The difference was highly significant (p less than 0.0005). It is concluded that clinical practice of treatment of angina pectoris in the elderly can be improved by using ISDN oral spray rather than sublingual tablets. The spray is effective at twice the rapidity of the sublingual tablet.

Calcific constrictive pericarditis in pregnancy. A case report

A woman developed congestive heart failure after a normal delivery. The underlying disease was diagnosed as calcific constrictive pericarditis, and the patient underwent pericardiectomy.

Acute myocardial infarction in a young woman taking oral contraceptives. A case report

Acute myocardial infarction occurred in a 25-year-old woman. Coronary angiography performed one month after the acute illness was normal. An ergonovine test was negative. The patient's acute myocardial infarction most probably was induced by the use of oral contraceptives in combination with heavy smoking. Oral contraceptives, with their known influence on the blood coagulation system, must be considered a risk factor in precipitating coronary artery disease.