A-TAPER: A Framework for Deprescribing Medications effectively

Inappropriate medication use creates avoidable safety issues for older adults. Deprescribing medications that are high risk and/or of minimal benefit is important for reducing morbidity and adverse effects, especially in this population. A variety of deprescribing resources and algorithms are available, but a singular framework to effectively approach and implement the deprescribing of unnecessary medications in practice does not exist. An interprofessional team of pharmacists, geriatricians, and researchers developed a framework to guide providers in deprescribing medications. This framework is represented by the acronym A-TAPER, which stands for Assess medication use, Talk about risks versus benefits, select Alternatives, Plan next steps, Engage patient, and Reduce dose. Within this framework, comprehensive, medication-specific deprescribing toolkits can be created.

Motivational interviewing for patients with chronic kidney disease

Successful management of chronic kidney disease (CKD) typically involves consideration of several lifestyle changes and treatments that could improve patients' health outcomes. The complexity of behavioral changes and treatment decisions that must be made by patients, with the support of their treatment team, could diminish their motivation to address CKD and lead to poorer treatment outcomes. Hence, motivational enhancement, in the context of patient education and shared decision-making with the treatment team, is a critical issue in CKD patient care. This article describes how motivational interviewing can be used with patients to enhance their motivation to address CKD and participate in treatment.

Supervision and Mentoring of Clinical Psychology Predoctoral Interns and Postdoctoral Residents

In this special issue, we are discussing issues related to evidence-based mentoring across types of training program. We have been asked to focus on topics related to such training at the predoctoral internship and postdoctoral residency levels. At these levels, mentoring primarily takes place in the context of clinical supervision, although it involves many other roles and responsibilities. We begin by placing our discussion in historical context and outlining previous research in supervision at the internship and postdoctoral levels as well as the barriers to the empirical study of supervision and its outcomes. We then describe the training settings in which we work and our approach to the practice and measurement of supervision at our site. In the absence of a body of empirical literature, we have attempted to implement a trainee-focused model of supervision that seems to fit with the overall structure and flow of our training site. We conclude with a call to the training community to advance efforts in the area of empirical investigation of our work to provide high quality supervision to our psychology trainees.

Assessment of rates of overweight and obesity and symptoms of posttraumatic stress disorder and depression in a sample of Operation Enduring Freedom/Operation Iraqi Freedom veterans

OBJECTIVE

We examined rates of overweight and obesity in a sample of Operation Enduring Freedom/Operation Iraqi Freedom Veterans setting up routine care within 1 Veterans Affairs medical center and examined associations between weight and measures of symptoms of posttraumatic stress disorder (PTSD) and depression.

METHODS

Retrospective chart reviews were conducted to collect data on weight and symptoms of PTSD and depression.

RESULTS

Mean body mass index (=27 kg/m2, SD = 4.47) was within the overweight range. Veterans had rates of overweight that were higher than those of national samples of individuals in the same age group, but had lower rates of obesity. Measures of symptoms of PTSD and depression were not associated with weight.

CONCLUSIONS

A high proportion of individuals in this group of Operation Enduring Freedom/Operation Iraqi Freedom Veterans is overweight with rates consistent with the larger active duty population. Overweight was not associated with psychological distress. These data raise concerns for long-term problems with weight in this group of Veterans.

Pain, coping and health care utilization in younger and older adults with sickle cell disease

Sickle cell disease is characterized by acute pain crises. Pain, chronic medical problems, utilization and coping were compared in younger vs older patients using questionnaires and medical record review. Groups reported similar pain intensity and medical conditions. The pattern of utilization differed such that older patients attended outpatient clinic, and younger patients went to the Emergency Department. Younger patients were more likely to cope by ignoring pain, or by using heat, cold or massage. Older patients were more likely to pray and hope. We conclude that age plays an important role in the utilization and coping of sickle cell patients.

Role of components of the phagocytic NADPH oxidase in oxygen sensing

It has been hypothesized that O(2) sensing in type I cells of the carotid body and erythropoietin (EPO)-producing cells of the kidney involves protein components identical to the NADPH oxidase system responsible for the respiratory burst of phagocytes. In the present study, we evaluated O(2) sensing in mice with null mutant genotypes for two components of the phagocytic oxidase. Whole body plethysmography was used to study unanesthetized, unrestrained mice. When exposed to an acute hypoxic stimulus, gp91(phox)-null mutant and wild-type mice increased their minute ventilation by similar amounts. In contrast, p47(phox)-null mutant mice demonstrated increases in minute ventilation in response to hypoxia that exceeded that of their wild-type counterparts: 98.0 +/- 18.0 vs. 20.0 +/- 13.0% (n = 11, P = 0.003). In vitro recordings of carotid sinus nerve (CSN) activity demonstrated that resting (basal) neural activity was marginally elevated in p47(phox)-null mutant mice. With hypoxic challenge, mean CSN discharge was 1.5-fold greater in p47(phox)-null mutant than in wild-type mice: 109.61 +/- 13.29 vs. 72.54 +/- 7.65 impulses/s (n = 8 and 7, respectively, P = 0.026). Consequently, the hypoxia-evoked CSN discharge (stimulus-basal) was approximately 58% larger in p47(phox)-null mutant mice. Quantities of EPO mRNA in kidney were similar in gp91(phox)- and p47(phox)-null mutant mice and their respective wild-type controls exposed to hypobaric hypoxia for 72 h. These findings confirm the previous observation that absence of the gp91(phox) component of the phagocytic NADPH oxidase does not alter the O(2)-sensing mechanism of the carotid body. However, absence of the p47(phox) component significantly potentiates ventilatory and chemoreceptor responses to hypoxia. O(2) sensing in EPO-producing cells of the kidney appears to be independent of the gp91(phox) and p47(phox) components of the phagocytic NADPH oxidase.

Stroke awareness among Georgia adults: epidemiology and considerations regarding measurement

BACKGROUND

To design and evaluate interventions for reducing the impact of stroke in Georgia, we assessed knowledge of signs, risk factors, and burden of stroke.

METHODS

Adults in Georgia were studied with a random digit dial telephone survey.

RESULTS

Answering an unaided question, 39% of 602 respondents named > or =1 stroke warning sign. Awareness was considerably greater when assessed with prompted questions. Most respondents (70%) said they would call 911 if someone had a stroke; almost all (95%) considered stroke an emergency. Risk factor awareness ranged from 97% (previous stroke) to 69% (diabetes). Altogether, 6% reported having had a stroke; 48% reported a stroke in their family.

CONCLUSIONS

Georgia adults have low awareness of stroke warning signs. Our findings underscore the importance of conducting an effective educational campaign. Furthermore, a need exists for questions on stroke awareness that approximate more closely the situation in which a person must identify a potential stroke.

Incidence and duration of romantic attraction in students progressing from secondary to tertiary education

There is increasing interest in the nature and biological significance of romantic love but few quantitative data are available for testing specific hypotheses. This paper describes the use of a survey instrument to assess incidence and duration of romantic attractions over a 2-year period amongst students (121 male; 162 female) progressing from school to university education. The results for males and females were similar and schooling single-sex or co-educational--had little effect. Students averaged 1.45 romantic episodes per year and 93% of students reported at least one episode over the survey period. Duration of attraction was around 9 weeks if never reciprocated and around 12 weeks if reciprocated. There was seasonal variation of onset of episodes with peak incidence over the summer or early autumn seasons. Collectively the results accord with the view that frequent, short-duration romantic episodes could have a role in selection of appropriate long-term reproductive partnerships.

Psychosocial stress and the menstrual cycle

The relationship between mood states, urinary stress hormone output (adrenaline, noradrenaline and cortisol) and adequacy of the menstrual cycle was examined in 120 recorded non-conception cycles from 34 women. It was hypothesized that women with higher stress levels would be more likely to experience abnormal cycles and that within women higher stress levels would positively relate to follicular phase length and inversely relate to luteal phase length. There was a non-significant trend for women to report higher stress levels during oligomenorrhoeic and unclear cycles compared with normal cycles. Analysis of covariance indicated that there was no consistent relationship between the measures of stress used here and follicular or luteal phase length within women. There was also no consistent pattern of relationship between reported mood states and stress hormone excretion within women. Further research is warranted to understand the role of stress and subtle menstrual cycle abnormalities in female fertility.

Psychosocial stress and treatment outcome following assisted reproductive technology

This study investigated the association between psychosocial stress and outcome of in-vitro fertilization and gamete intra-Fallopian transfer treatment. Ninety women, enrolled for treatment at a private infertility clinic, completed two self-administered psychometric tests (Bi-polar Profile of Mood States, POMS; and State-Trait Anxiety Inventory, STAI) and a questionnaire to ascertain demographic and lifestyle characteristics before the start of treatment. Approximately 12 months later an outcome measure was determined for each participant in terms of whether she was pregnant or not pregnant and the number of treatment cycles undertaken to achieve clinical pregnancy. The women's scores on the psychological tests were similar to published normative scores. On univariate analysis, history of a previous pregnancy was positively related to the probability of pregnancy and full-time employment, a more 'hostile' mood state and higher trait anxiety were associated with a lower cumulative pregnancy rate. A Cox multiple regression model found previous pregnancy history, trait anxiety, and the POMS agreeable-hostile and elated-depressed scales to be the most important lifestyle and stress variables predictive of pregnancy. The results emphasize the importance of psychosocial stress in treatment outcome but indicate that the relationships are complex. Further studies are required to validate whether these findings can be generalized to other populations.

Lung injury and oxidoreductases

Acute lung injury represents a wide spectrum of pathologic processes, the most severe end of the spectrum being the acute respiratory distress syndrome. Reactive oxygen intermediates have been implicated as important in the pathobiochemistry of acute lung injury. The endogenous sources that contribute to the generation of reactive oxygen intermediates in acute lung injury are poorly defined but probably include the molybdenum hydroxylases, NAD(P)H oxidoreductases, the mitochondrial electron transport chain, and arachidonic acid-metabolizing enzymes. Our laboratory has focused, in particular, on the regulation of two of these enzyme systems, xanthine oxidoreductase (XDH/XO) and NAD(P)H oxidase. We observe that gene expression of XDH/XO is regulatory in a cell-specific manner and is markedly affected by inflammatory cytokines, steroids, and physiologic events such as hypoxia. Posttranslational processing is also important in regulating XDH/XO activity. More recently, the laboratory has characterized an NAD(P)H oxidase in vascular cells. The cytochrome components of the oxidase, gp91 and p22, appear similar to the components present in phagocytic cells that contribute to their respiratory burst. In human vascular endothelial and smooth muscle cells, oncostatin M potently induces gp91 expression. We believe that regulation of gp91 is a central controlling factor in expression of the vascular NAD(P)H oxidase. In summary, the studies support the concept that the oxidoreductases of vascular cells are expressed in a highly regulated and self-specific fashion.

A prospective study of psychosocial stress and fertility in women

The objective of this study was to compare average stress levels during the month of conception to those of previous infertile months. We postulated that stress level during the actual month of conception would be lower than that during previous non-conception cycles. Thirteen normal women from the general community, who were attempting pregnancy, kept daily records of coital activity and basal body temperature, and twice a month completed self-administered questionnaires and provided a 12 h overnight urine sample. On average, women reported significantly more favourable mood states on standard psychometric tests, during the month of conception than during the previous non-conception cycles. In addition, they felt significantly less 'hassled' during the month of conception. However, mean urinary hormone excretion of adrenaline, noradrenaline and cortisol did not significantly differ between conception and non-conception cycles and there was little relationship between the psychological measures of mood state and excretion of adrenaline and cortisol. There was no evidence of increased coital frequency during the month of conception when mood states were improved, suggesting that stress effects on libido were unlikely to account for the findings. The results support the conclusion that psychosocial stress influences fertility in females but as yet mechanisms remain unclear.

Early recognition of risk factors for persistent effects of vecuronium

Renal failure and hepatic failure are important risk factors for persistent effects of vecuronium. We report a case in which vecuronium therapy after cardiac arrest led to prolonged paralysis due to severe renal and hepatic dysfunction not apparent until after vecuronium therapy. Biochemical and electrophysiologic examinations confirmed that neuromuscular blockade due to accumulation of one active metabolite of vecuronium was the primary cause of the patient's paralysis. This case highlights the importance of recognizing progressive renal and hepatic dysfunction after cardiac arrest when contemplating treatment with vecuronium.

Motor neuron diseases and amyotrophic lateral sclerosis: GM1 antibodies and paraproteinemia

Six of 110 patients (5.5%) with forms of motor neuron disease had abnormal titers of GM1 antibodies of 1:1,600 or higher. Four others came with previously known high titers. Three patients with upper motor neuron (UMN) signs had titers of 1,600; those with probable or no UMN signs had higher titers. Nine patients had conduction block; six of them had abnormal antibody titers, four with 6,400 or higher. Therefore, patients with motor neuron disease and abnormal anti-GM1 titers may have UMN signs or conduction block.

Mononeuritis multiplex associated with cryoglobulinemia in HIV infection

We describe a patient with human immunodeficiency virus (HIV) infection who developed mononeuritis multiplex associated with polyclonal (type III) cryoglobulinemia. The patient's symptoms stabilized following treatment with plasmapheresis and removal of the cryoglobulin. Our case represents the first report of polyclonal cryoglobulinemia in HIV disease and suggests that cryoglobulinemia may play an etiologic role in some patients with HIV-associated neuropathy.

Gadolinium-MRI in acute transverse myelopathy

A patient with acute transverse myelopathy (ATM) had serial magnetic resonance imaging (MRI) studies before and after administration of gadolinium (Gd-DTPA). Gd-DTPA-MRI was useful in estimating the pathologic extent and residual deficit expected in ATM.