A mechanism for improved talc pleurodesis via foam delivery

Talcum powder is recognized as the leading drug for pleurodesis, a treatment of choice for malignant pleural effusions. Recently, it was shown that hydrogel foam delivery systems significantly enhanced the number of adhesions between the chest wall and the lung in a New Zealand rabbit model due to the sol-gel transition. However, many questions still remain regarding the cause of improved efficacy, such as: (1) Would only hydrogel foams improve the efficacy of talc pleurodesis? (2) Is it possible to achieve the same efficacy of hydrogels using non-hydrogel foams? 3) What are the physicochemical properties that can be correlated to the efficacy of talc pleurodesis? In this study, we use non-hydrogel foam formulations to determine the efficacy of pleurodesis. Foam stability and rheology of the formulations were correlated to adhesion formation. The results clearly suggest a correlation of pleurodesis efficacy to the viscosity and modulus of the foam delivery system.

Impaired Glucose and Insulin Homeostasis in Moderate-Severe CKD

Kidney disease leads to clinically relevant disturbances in glucose and insulin homeostasis, but the pathophysiology in moderate-severe CKD remains incompletely defined. In a cross-sectional study of 59 participants with nondiabetic CKD (mean eGFR =37.6 ml/min per 1.73 m(2)) and 39 healthy control subjects, we quantified insulin sensitivity, clearance, and secretion and glucose tolerance using hyperinsulinemic-euglycemic clamp and intravenous and oral glucose tolerance tests. Participants with CKD had lower insulin sensitivity than participants without CKD (mean[SD] 3.9[2.0] versus 5.0 [2.0] mg/min per µU/ml; P<0.01). Insulin clearance correlated with insulin sensitivity (r=0.72; P<0.001) and was also lower in participants with CKD than controls (876 [226] versus 998 [212] ml/min; P<0.01). Adjustment for physical activity, diet, fat mass, and fatfree mass in addition to demographics and smoking partially attenuated associations of CKD with insulin sensitivity (adjusted difference, -0.7; 95% confidence interval, -1.4 to 0.0 mg/min per µU/ml) and insulin clearance (adjusted difference, -85; 95% confidence interval, -160 to -10 ml/min). Among participants with CKD, eGFR did not significantly correlate with insulin sensitivity or clearance. Insulin secretion and glucose tolerance did not differ significantly between groups, but 65% of participants with CKD had impaired glucose tolerance. In conclusion, moderate-severe CKD associated with reductions in insulin sensitivity and clearance that are explained, in part, by differences in lifestyle and body composition. We did not observe a CKD-specific deficit in insulin secretion, but the combination of insulin resistance and inadequate augmentation of insulin secretion led to a high prevalence of impaired glucose tolerance.

Dietary Acid Load is Associated With Serum Bicarbonate but not Insulin Sensitivity in Chronic Kidney Disease

OBJECTIVE

In chronic kidney disease (CKD), dietary acid may promote metabolic acidosis and insulin resistance, which in turn may contribute to adverse clinical health outcomes. We examined associations between dietary acid load, serum bicarbonate, and insulin sensitivity in CKD.

DESIGN

In a cross-sectional study, we collected 3-day prospective food diaries to quantify dietary acid load as net endogenous acid production (NEAP, the nonvolatile acid load produced by the diet's acid balance) and potential renal acid load (PRAL). We measured urine net acid excretion (NAE) in 24-hour urine samples. Insulin sensitivity was measured by hyperinsulinemic euglycemic clamp.

SUBJECTS

Forty-two patients with CKD Stages 3 to 5 attending nephrology clinics in the Pacific Northwest and 21 control subjects (estimated glomerular filtration rate [eGFR] ≥ 60 mL/minute/1.73 m(2)).

MAIN OUTCOME MEASURES

Serum bicarbonate and insulin sensitivity (SIclamp).

RESULTS

Mean age was 60.8 ± 13.6 years, and 54% of participants were men. Mean eGFR and serum bicarbonate concentrations were 34.4 ± 13.1 mL/minute/1.73 m(2) and 24.1 ± 2.9 mEq/L for participants with CKD and 88.6 ± 14.5 mL/minute/1.73 m(2) and 26.3 ± 1.8 mEq/L for control subjects, respectively. Mean NEAP, PRAL, and NAE were 58.2 ± 24.3, 9.7 ± 18.4, and 32.1 ± 19.8 mEq/day, respectively. Considering all participants, dietary acid load was significantly, inversely associated with serum bicarbonate, adjusting for age, gender, race, eGFR, body mass index, and diuretic use: -1.2 mEq/L per standard deviation (SD) NEAP (95% confidence interval [CI] -1.8 to -0.6, P < .0001); -0.9 mEq/L bicarbonate per SD PRAL (95% CI -1.5 to -0.4, P = .0005); -0.7 mEq/L bicarbonate per SD NAE (95% CI -1.2 to -0.1, P = .01). These associations were similar in participants with and without CKD. However, neither NEAP and PRAL nor NAE was significantly associated with SIclamp. Serum bicarbonate was also not significantly associated with SIclamp.

CONCLUSIONS

In CKD, dietary acid load is associated with serum bicarbonate, suggesting that acidosis may be improved by dietary changes, but not with insulin sensitivity.

Psychological, nutritional, and energy expenditure differences in college females with anorexia nervosa vs. comparable-mass controls

This is the first study to examine psychological and behavioral variables in nonhospitalized college females with subclinical anorexia nervosa (AN) as compared to healthy college females of comparable body mass (i.e., body mass index (BMI)<19). Participants who met all DSM-IV [Diagnostic and statistical manual of mental disorders, 4th ed. (1994). Washington, DC: APA.] criteria for AN-restrictive type (except for BMI<17.5; n=11) and control participants (n=15) with comparable body mass completed psychological, nutritional, and exercise assessments. Results suggested that those with AN evidenced more general psychopathology, more eating disorder symptoms, more dieting, more compulsive exercise, and less consumption of calories compared to participants in the control group. There was no difference in macronutrient consumption. There was no significant difference in expenditure of energy, despite differences in reports of compulsive exercise. Given similar body mass, this suggests that the women with AN were experiencing an energy deficit consistent with the disorder's defining features of "fear of gaining weight or becoming fat" and provides us with more understanding of individuals with AN in their natural environment.

Evaluation of a cognitive-behavioral therapy intervention to improve body image and decrease dieting in college women

This two-group experimental study evaluated the effectiveness of a cognitive-behavioral body image intervention, adapted from an effective clinical intervention, with normal college females. Participants included nonclinical, freshman college women who were assigned randomly to either the experimental intervention or the control group (brief educational session). Participants were assessed prior to the intervention and again 1 month later on dieting behavior, body image, fear of fat, and anxiety concerning physical appearance. Although it was hypothesized that each of these variables would be lower in the experimental group, none of these results, except for a trend for decreased dieting, were found. Overall these results of slightly reduced dieting behavior are consistent with other research targeting primary and secondary prevention. This intervention's failure to impact body image and eating behaviors of college students illustrates the continuing challenge of eating disorders prevention.

Comparison of extended versus brief treatments for marijuana use

Adult marijuana users (N = 291) seeking treatment were randomly assigned to an extended 14-session cognitive-behavioral group treatment (relapse prevention support group; RPSG), a brief 2-session individual treatment using motivational interviewing (individualized assessment and intervention; IAI), or a 4-month delayed treatment control (DTC) condition. Results indicated that marijuana use, dependence symptoms, and negative consequences were reduced significantly in relation to pretreatment levels at 1-, 4-, 7-, 13-, and 16-month follow-ups. Participants in the RPSG and IAI treatments showed significantly and substantially greater improvement than DTC participants at the 4-month follow-up. There were no significant differences between RPSG and IAI outcomes at any follow-up. The relative efficacy of brief versus extended interventions for chronic marijuana-using adults is discussed.

Determinants of attrition from cessation treatment in smokers with a history of major depressive disorder

Attrition from smoking cessation treatment by individuals with a history of major depression was investigated. An investigation of preinclusion attrition examined differences between eligible smokers who did (n = 258) and did not (n = 100) attend an initial assessment session. Postinclusion attrition was investigated by comparing early dropouts (n = 33), late dropouts (n = 27), and treatment completers (n = 117). Those who failed to attend the assessment session were more likely to be female, to smoke cigarettes with higher nicotine content, and to have a history of psychotropic medication use. Early-treatment dropouts reported a higher smoking rate than late-treatment dropouts and endorsed more symptoms of depression than late dropouts and treatment completers. Results are compared with previous investigations of smoking cessation attrition, and implications for treatment and attrition prevention are discussed.

Determinants of attrition from cessation treatment in smokers with a history of major depressive disorder

Attrition from smoking cessation treatment by individuals with a history of major depression was investigated. An investigation of preinclusion attrition examined differences between eligible smokers who did (n = 258) and did not (n = 100) attend an initial assessment session. Postinclusion attrition was investigated by comparing early dropouts (n = 33), late dropouts (n = 27), and treatment completers (n = 117). Those who failed to attend the assessment session were more likely to be female, to smoke cigarettes with higher nicotine content, and to have a history of psychotropic medication use. Early-treatment dropouts reported a higher smoking rate than late-treatment dropouts and endorsed more symptoms of depression than late dropouts and treatment completers. Results are compared with previous investigations of smoking cessation attrition, and implications for treatment and attrition prevention are discussed.

On Being a Person of Integrity...Or Ethics and Other Liabilities

The emergence of managed care and the health industry's response to it has precipitated a moral crisis for many health care professionals. Caught between the patients' best interests and the employers' and payers' restrictions, professionals find their good intentions tested. In this article, the author distinguishes moral from ethical problems and suggests that self-examination and self-diagnosis of the mindsets and conditions that contribute to moral malfunctioning in the workplace--self-management at the individual level--is essential for maintaining the ethical stance of the profession and the integrity of the professional.

Relapse prevention as an interventive model for HIV risk reduction in gay and bisexual men

Despite considerable self-initiated HIV risk reduction among men who have sex with men, little is known about how to design interventions that will effectively assist individuals from this population in maintaining safer sex behaviors over time. The present study evaluated the effectiveness of a 17-session group counseling intervention that incorporated components based on a cognitive-behavioral model of relapse. Differential behavioral outcomes following treatment included an increase in the percentage of sexual activities that were protected and a decrease in unprotected oral sex. However, considerable risk reduction (e.g., increased condom use, decreased unprotected sex, and decreases in the number of male partners and in the total number of sexual acts) occurred in both treated and untreated participants. Measures of mediating attitudinal variables drawn from relapse prevention theory largely predicted behavioral changes. Over time, several of the risk reduction behaviors achieved at posttreatment were not maintained, suggesting the importance of further developing effective strategies for supporting behavior change maintenance.

The ethics of managed care: Part 3--Toward a common vision

A common set of values is one of the primary unifying elements of any systematized group. The moral crisis in health care today has more to do with value dis-integration than economic dis-array. The use of resource allocation mechanisms like managed care expand the needs of conscience with those of man-willed choice. If health professionals are to meet the ethical challenges of "managed care," they must start by reminding themselves of what the scientific and ethical commitments both promise and imply.

25 years: a slightly irreverent retrospective

From 1970 when room rates soared to 50 dollars a day, to the reorganization occasioned by DRGs, and restructuring for healthcare reform in the 1990s; from the gleaming white supervisory nurse of yesteryear, through nursing's image crisis, to the vice presidents and case managers of today; from the rise of critical care units to the development of ethics committees, Nursing Management's editor chronicles and comments on the major (and sometimes minor) events of the last 25 years of nursing.

Testing the abstinence violation effect construct with marijuana cessation

It has been proposed that internal, stable, and global attributions for the cause of a lapse following a period of abstinence and concomitant feelings of guilt and loss of control increased the probability of a return to regular substance use. The Abstinence Violation Effect (AVE) hypotheses were tested in a sample of 75 adult marijuana users who reported a lapse into marijuana use following completion of either a relapse prevention (RP) or social support group treatment aimed at abstinence. Results showed that more internal, stable, and global attributions for the cause of the lapse and perceived loss of control were related significantly to concurrently reported relapse. Further, internal and global attributions predicted marijuana use during the subsequent 6 months. Results are discussed in terms of support for the AVE construct, treatment implications, and the failure of the RP treatment to modify reactions to a lapse.

Perception of male drinkers as a function of their alcoholic beverage preference

The present study examined perception of a man's likelihood of driving after drinking and his ability to do so as a function of his choice of beverage. Perceptions of his social characteristics were also examined. The sample was composed of 200 volunteer undergraduate psychology students. Equal numbers of male and female subjects read one of four vignettes which varied only in the male protagonist's choice of beverage: beer, wine, shots of distilled spirits, or cola. After reading the story, subjects answered multiple-choice questions about the character, tapping social judgments, situational judgments and drinking and driving judgments. Subject drinking habits were also assessed. The most notable result was the consistently positive perception of the protagonist portrayed as an abstainer. The lack of a consistent alcoholic beverage distinction implies that the beer-spirits double standard is far from a clear-cut discrimination. Possible explanations for results are discussed. This study questions the robustness of the alcoholic beverage type bias and reflects the need for future research.

Health reform: the shape of things to come

To understand the various legislative initiatives at state and national levels, one must know what questions to ask and what issues are raised by each question. The questions are: (1) How much shall we reform the system? (2) How quickly shall we reform the system? (3) How shall we fund the system? and (4) How shall we organize or reorganize the system? If the complex issues these questions raise are dealt with quickly, boldly and fairly, meaningful health reform will be passed in 1993 and phased in over the next five to seven years.

Complete recovery after massive ethylene glycol ingestion

We treated a 64-year-old man who recovered completely from a massive antifreeze ingestion with ethylene glycol levels well above those of previously described survivors. Rapid and aggressive treatment of the patient with recognized methods, including hemodialysis, resulted in the favorable outcome.