Veteran Beliefs About the Causes of Gulf War Illness and Expectations for Improvement

BACKGROUND

Individuals' beliefs about the etiology of persistent physical symptoms (PPS) are linked to differences in coping style. However, it is unclear which attributions are related to greater expectations for improvement.

METHOD AND RESULTS

A cross-sectional regression analysis (N = 262) indicated that Veterans with Gulf War Illness (GWI) who attributed their GWI to behavior, (e.g., diet and exercise), had greater expectations for improvement (p = .001) than those who attributed their GWI to deployment, physical, or psychological causes (p values > .05).

CONCLUSIONS

Findings support the possible clinical utility of exploring perceived contributing factors of PPS, which may increase perceptions that improvement of PPS is possible.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02161133.

Memory complaints moderate the concordance between self-report and electronically monitored adherence in adults with type 2 diabetes

AIMS

We examined the impact of memory complaints on the concordance between self-report (SR) and electronically monitored (EM) medication adherence, independent of depression symptoms, among adults with type 2 diabetes (T2D).

METHODS

Adults (N = 104, age = 56.6 ± 9.2; 64% female) completed a prospective and retrospective memory questionnaire (PRMQ) and a depression symptom interview at baseline. EM was tracked over 3 months and participants rated adherence using SR. Multiple linear regression evaluated PRMQ as a moderator of the relationship between EM and SR, adjusting for depression and other covariates.

RESULTS

PRMQ was correlated with lower SR (r = -0.31, p = 0.001), but not with EM. PRMQ moderated the relationship between SR and EM, independent of depression symptoms. At low levels of PRMQ, SR and EM were closely related (β = 0.76, p < 0.001); at high levels of PRMQ the relationship was weaker (β = 0.28, p = 0.02). Participants who under-reported their adherence (SR < EM) had higher PRMQ scores than more concordant reporters (p = 0.016).

CONCLUSIONS

SR and EM measures were less concordant among adults with T2D who endorsed higher PRMQ scores. Memory complaints may contribute to under-reporting of medication adherence in adults with T2D.

Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness

OBJECTIVE

Conditions defined by persistent "medically unexplained" physical symptoms and syndromes (MUS) are common and disabling. Veterans from the Gulf War (deployed 1990-1991) have notably high prevalence and disability from MUS conditions. Individuals with MUS report that providers do not recognize their MUS conditions. Our goal was to determine if Veterans with MUS receive an ICD-10 diagnosis for a MUS condition or receive disability benefits available to them for these conditions.

METHODS

A chart review was conducted with US Veterans who met case criteria for Gulf War Illness, a complex MUS condition (N = 204, M = 53 years-old, SD = 7). Three coders independently reviewed Veteran's medical records for MUS condition diagnosis or service-connection along with comorbid mental and physical health conditions. Service-connection refers to US Veterans Affairs disability benefits eligibility for conditions or injuries experienced during or exacerbated by military service.

RESULTS

Twenty-nine percent had a diagnosis of a MUS condition in their medical record, the most common were irritable colon/irritable bowel syndrome (16%) and fibromyalgia (11%). Slightly more Veterans were service-connected for a MUS condition (38%) as compared to diagnosed. There were high rates of diagnoses and service-connection for mental health (diagnoses 76% and service-connection 74%), musculoskeletal (diagnoses 86%, service-connection 79%), and illness-related conditions (diagnoses 98%, service-connection 49%).

CONCLUSION

Given that all participants were Gulf War Veterans who met criteria for a MUS condition, our results suggest that MUS conditions in Gulf War Veterans are under-recognized with regard to clinical diagnosis and service-connected disability. Veterans were more likely to be diagnosed and service-connected for musculoskeletal-related and mental health conditions than MUS conditions. Providers may need education and training to facilitate diagnosis of and service-connection for MUS conditions. We believe that greater acknowledgement and validation of MUS conditions would increase patient engagement with healthcare as well as provider and patient satisfaction with care.

Enhancing Diabetes Self-Management Education and Psychological Services for Veterans With Comorbid Chronic Health and Mental Health Conditions

Background

Veterans experience a higher prevalence of type 2 diabetes mellitus (T2DM) compared with the rate of their civilian counterparts. Veterans may experience vulnerability to chronic stress, in particular comorbid mental health conditions, and may not benefit from traditional diabetes education.

Methods

This study evaluated clinical and psychological measures among veterans engaged in health psychology services. Individualized motivational interviewing and cognitive behavioral interventions were provided to address T2DM distress and promote veterans' diabetes self-management. Pre-/postobjective and self-report measures were evaluated for clinical relevancy and statistically significant changes.

Results

The sample consisted of 13 older adults: mean age 62.8 years; 12 were male and 9 were prescribed insulin. More than half had comorbid hypertension, hyperlipidemia, and/or a diagnosis of chronic pain. Eleven participants were diagnosed with a mental health disorder. Baseline measures indicated mild depressive symptoms, mild anxiety symptoms, and moderate levels of T2DM distress. Postintervention reductions were shown for T2DM distress; emotional burden, and regimen-related distress, depressive symptoms, and enhanced diabetes empowerment.

Conclusions

Veterans with comorbid conditions may benefit from individualized psychology services that offer cognitive behavioral strategies for self-management of T2DM-related distress, integrated with traditional primary care and diabetes education.

Glycemic control and self-rated health among ethnically diverse adolescents with type 1 diabetes

OBJECTIVE

Patient-reported outcomes have received increased attention as treatment outcomes and indicators of wellbeing. A1c has been criticized as lacking patient-centered relevance because individuals are often unaware of their A1c, and studies also often fail to show a benefit of intensive control on quality of life. The goal of the present study was to examine self-rated health (SRH) in relation to diabetes self-care behaviors, socioeconomic factors, treatment regimen characteristics, and glycemic control among predominately Hispanic and African American adolescents with type 1 diabetes (T1D).

METHODS

Adolescents with T1D (N = 84) were recruited for a cross-sectional study evaluating psychosocial factors and identity development. SRH, self-care behaviors, treatment regimen, and demographic variables were collected through self-report while glycemic control (A1c) was determined through chart review.

RESULTS

Participants were predominantly racial and ethnic minorities (48% Hispanic, 27% African American; 52% female, M age 15.9, M diabetes duration 6.8, M A1c 10% [86 mmol/mol]). Significant bivariate relationships emerged between SRH and sex, A1c, self-care behavior, and insulin delivery method. Covariate-adjusted regression models showed only A1c was significantly and independently related to SRH. Mediation analyses illustrated a significant indirect effect for A1c between self-care and SRH.

CONCLUSION

These findings suggest glycemic control is associated with self-ratings of health among ethnically diverse adolescents with T1D. SRH appears to be an appropriate patient-reported outcome that is sensitive to glycemic control in this population.

Exploring the effect of a peptide additive on struvite formation and morphology: a high-throughput method

Precipitation of struvite (MgNH₄PO₄·6H₂O), a slow-release fertilizer, provides a means of recycling phosphate from wastewater streams. In this work, a high-throughput struvite precipitation method is developed to investigate the effects of a peptide additive. The reactions occurred in small volumes (300 μL or less) in a 96-well plate for 45 minutes. The formation of struvite was monitored by fitting absorbance at 600 nm over time to a first order model with induction time, with the addition of peptide inducing significant changes to the yield parameter and formation constant in that model. The impact of struvite seed dosing was also investigated, highlighting the importance of optimization when peptide is present. The composition of the precipitate was confirmed through Fourier-transform infrared spectroscopy, while morphology and crystal size were analyzed through optical microscopy. Crystals had a higher aspect ratio when precipitated with the peptide. Finally, the utility of the high-throughput platform was demonstrated with a 2⁵ full factorial design to capture the effects and interactions of: magnesium dose, mixing time, seed dose, pH, and temperature. Overall, this study quantifies novel effects of a sequence-defined peptide on struvite formation and morphology via a newly developed high throughput platform.

A high-throughput platform was developed to analyze struvite formation, finding that peptide addition modulates growth in a potentially favorable way.

Physical symptom complaints, cognitive emotion regulation strategies, self-compassion and diabetes distress among adults with Type 2 diabetes

AIMS

Diabetes-related distress is common among adults with Type 2 diabetes and is consistently associated with poorer self-management and treatment outcomes. However, little is known about the psychological factors that may contribute to or protect against diabetes distress. This study examined illness burden, and positive and negative ways of thinking and relating to oneself in times of stress, as independent correlates of diabetes distress, cross sectionally and longitudinally.

METHOD

A total of 120 adults treated for Type 2 diabetes reported their physical symptom complaints, cognitive emotion regulation, self-compassion and diabetes distress at baseline; 110 completed a 3-month follow-up assessment of diabetes distress. Pearson correlations and multivariable linear regression tested baseline and longitudinal relationships.

RESULTS

Baseline diabetes distress was associated with greater use of negative cognitive emotion regulation strategies (r = 0.43, P < 0.01), greater tendency towards self-criticism, self-judgement and over-identification (r = 0.37, P < 0.01), and greater physical symptom burden (r = 0.50, P < 0.01). Baseline physical symptoms and negative cognitive emotion regulation were independently associated with baseline diabetes distress. Baseline physical symptoms and negative aspects of self-compassion significantly predicted diabetes distress over 3 months. Positive aspects of cognitive emotion regulation and self-compassion were not independently associated with diabetes distress cross sectionally or longitudinally.

CONCLUSION

Greater symptom burden along with the use of negative cognitive emotion regulation and negative aspects of self-compassion were independently associated with diabetes distress. If these relations are explained by causal influence, these modifiable factors could be fruitful targets for intervention research.

Tangled Up in Blue: Unraveling the Links Between Emotional Distress and Treatment Adherence in Type 2 Diabetes

OBJECTIVE

We conducted comprehensive assessments of emotional distress to examine relations with diabetes medication adherence over time.

RESEARCH DESIGN AND METHODS

Ethnically and socioeconomically diverse adults treated for type 2 diabetes completed validated self-reports (SRs) for diabetes distress and depression, were administered semistructured depression interviews, and provided blood samples for A1C. Medication adherence among 104 participants was electronically monitored (EM) over the subsequent 3 months; validated SRs of medication adherence were also obtained. Hierarchical linear regression evaluated independent effects of diabetes distress and depression on adherence.

RESULTS

Mean ± SD 3-month medication adherence was 76.1% ± 25.7% for EM and 83.7% ± 21.9% for SR. Higher levels of SR (P < 0.001) and interview-based (P < 0.05) depressive symptom severity (P < 0.05) and diabetes-related distress (P < 0.01) showed a significant bivariate association with EM and SR nonadherence. Regression models showed baseline diabetes distress was a significant independent predictor of EM (β = -0.29; P = 0.001) and SR adherence (β = -0.24; P < 0.02) at follow-up. SR depression was an independent predictor of EM and SR adherence and reduced the effects of diabetes distress to nonsignificance. Subsequent models indicated this effect was driven by somatic rather than cognitive-affective symptoms of depression. Results were consistent but weaker for interview-based depressive symptoms.

CONCLUSIONS

Findings support diabetes-related distress and depression symptom severity as risk factors for type 2 diabetes medication nonadherence. Somatic symptoms captured by depression measures, but not cognitive-affective symptoms, independently predict nonadherence and should be further investigated as a potential link between emotional distress and nonadherence.

Diabetes distress from the patient's perspective: Qualitative themes and treatment regimen differences among adults with type 2 diabetes

AIMS

To explore diabetes distress in a sample of adults with type 2 diabetes, treated and not treated with insulin.

METHODS

Six focus groups were conducted with 32 adults with type 2 diabetes, divided by treatment regimen (insulin-treated N=15; 67% female; 60% black; 46% Hispanic; M age 54; M HbA1c 73mmol/mol (8.8%); non-insulin-treated N=17; 53% female; 65% black; 13% Hispanic; M age 58; M HbA1c 55mmol/mol (7.2%)). A coding team transcribed and analyzed interviews to describe themes. Themes were then compared between groups and with existing diabetes distress measures.

RESULTS

Participants in both groups described a range of sources of diabetes distress, including lack of support/understanding from others, difficulties communicating with providers, and distress from the burden of lifestyle changes. Insulin-treated participants described significant emotional distress related to the burden of their insulin regimen. They were more likely to report physical burden related to diabetes; to describe feeling depressed as a result of diabetes; and to express distress related to challenges with glycemic control. Non-insulin-treated participants were more likely to discuss the burden of comorbid medical illnesses.

CONCLUSIONS

Our data generate hypotheses for further study into the emotional burdens of diabetes for insulin-treated adults with type 2 diabetes and are in line with quantitative research documenting increased diabetes-related distress among insulin-treated individuals. Data describe needs, currently unmet by most models of care, for comprehensive assessment and tailored management of diabetes-related distress.

Specific domains of nucleolin interact with Hdm2 and antagonize Hdm2-mediated p53 ubiquitination

Nucleolin is an abundant multifunctional nucleolar protein with defined roles in ribosomal RNA processing, RNA polymerase I catalyzed transcription and the regulation of apoptosis. Earlier we reported that human nucleolin binds to the p53 antagonist human double minute 2 (Hdm2) as determined by reciprocal co-immunoprecipitation assays using cell lysates. We also demonstrated that nucleolin antagonizes Hdm2-mediated degradation of p53. Here, we identify specific domains of nucleolin and Hdm2 proteins that support mutual interaction and investigate the implications of complex formation on p53 ubiquitination and protein levels. Our data indicate that the nucleolin N-terminus as well as the central RNA-binding domain (RBD) are predominantly involved in binding to Hdm2. The nucleolin RBD robustly bound to the NLS/NES (nuclear localization and export signals) domain of Hdm2 in vitro, while the N-terminus of nucleolin preferentially associated with the Hdm2 RING (really interesting new gene) domain expressed in cells. We further demonstrate that the C-terminal glycine-arginine rich domain of nucleolin serves as the predominant binding domain for direct interaction with p53. While overexpression of nucleolin or its various domains had no significant effect on Hdm2 auto-ubiquitination, the nucleolin RBD antagonized the Hdm2 E3 ligase activity against p53, leading to p53 stabilization. Conversely, the adjacent glycine-arginine rich domain of nucleolin interacted with p53 causing a modest stimulatory effect on p53 ubiquitination. These data suggest that changes in nucleolin conformation can alter the availabilities of such domains in vivo to modulate the overall impact of nucleolin on Hdm2 activity and hence on p53 stability.

Drug-resistant Drosophila indicate glutamate-gated chloride channels are targets for the antiparasitics nodulisporic acid and ivermectin

The fruit fly Drosophila melanogaster was used to examine the mode of action of the novel insecticide and acaricide nodulisporic acid. Flies resistant to nodulisporic acid were selected by stepwise increasing the dose of drug in the culture media. The resistant strain, glc(1), is at least 20-fold resistant to nodulisporic acid and 3-fold cross-resistant to the parasiticide ivermectin, and exhibited decreased brood size, decreased locomotion, and bang sensitivity. Binding assays using glc(1) head membranes showed a marked decrease in the affinity for nodulisporic acid and ivermectin. A combination of genetics and sequencing identified a proline to serine mutation (P299S) in the gene coding for the glutamate-gated chloride channel subunit DmGluClalpha. To examine the effect of this mutation on the biophysical properties of DmGluClalpha channels, it was introduced into a recombinant DmGluClalpha, and RNA encoding wild-type and mutant subunits was injected into Xenopus oocytes. Nodulisporic acid directly activated wild-type and mutant DmGluClalpha channels. However, mutant channels were approximately 10-fold less sensitive to activation by nodulisporic acid, as well as ivermectin and the endogenous ligand glutamate, providing direct evidence that nodulisporic acid and ivermectin act on DmGluClalpha channels.

Learning without performance in PKC-deficient Drosophila

The performance of a task is often assumed to be a prerequisite for the learning of many tasks, including the associative conditioning of courtship in the fruit fly, Drosophila melanogaster. Transgenic flies specifically inhibited for the enzyme protein kinase C dissociate the acquisition of learning and memory from performance of the task. They fail to show immediate suppression of courtship but nonetheless develop normal memory of it.

Transport of CaM kinase along processes elicited by neuronal contact evokes an inhibition of arborization and outgrowth in D. melanogaster cultured neurons

Transgenic Drosophila strains expressing an inhibitory peptide of Ca2+/calmodulin dependent protein kinase II (CaM kinase), or a constitutively activated CaM kinase, show altered neuronal process morphology compared to wild type in scanning electron microscopy (SEM) of cultured mature neurons from embryonic neuroblasts. We observed significantly enhanced process growth in cells with inhibited enzyme, and reduced process growth in cells with activated enzyme, suggesting that active CaM kinase is involved in the inhibition of neurite growth during development. The subcellular distribution of CaM kinase in wild type neuronal cultures was determined using a gold particle labeling procedure which allowed the mapping of the enzyme directly in the scanning electron microscope (SEM). Before neuronal contact there was little labeling of processes, but after connections had been made the processes were heavily labeled. Our results suggest that the major transport of CaM kinase to the terminals does not occur until after or during the formation of neuronal connections when a functional synapse might be formed. Taken together, these results suggest a target-dependent transport of the enzyme along processes and an inhibitory role for CaM kinase on neurite branching.

Endogenously inhibited protein kinase C in transgenic Drosophila embryonic neuroblasts down regulates the outgrowth of type I and II processes of cultured mature neurons

Embryonic neurons were cultured from transgenic Drosophila melanogaster expressing a highly specific pseudosubstrate inhibitor of protein kinase C (PKC). Flies homozygous for this transgene, which is under the control of the yeast UAS promoter, were crossed to flies homozygous for the yeast heat shock inducible transcription factor GAL 4. Following heat shock, the progeny express the pseudosubstrate inhibitor at high levels. This strategy, which has the advantage of avoiding the non-specific effects of drugs, was used to study the role of PKC in process growth of cultured, differentiating neuroblasts. An external gold particle labeling procedure using a cell surface antigen expressed by mature neurons and processes was used to visualize neuronal processes directly in the scanning electron microscope. We observed that cell cultures expressing a low concentration of the pseudosubstrate inhibitor showed a significant decrease in the number of type I and II processes as compared to control cultures, while the proportions of neuroblasts, ganglion mother cells (GMCs), and mature neurons in the clusters were little affected.