Teaching residents mental health care

Objective

We tested the hypothesis that trained medical faculty can train residents effectively in a mental health care model.

Sensitization of DNA damage-induced apoptosis by the proteasome inhibitor PS-341 is p53 dependent and involves target proteins 14-3-3sigma and survivin

Proteasome inhibition following DNA damage results in the synergistic induction of apoptosis via a nuclear factor-kappaB-independent mechanism. In this study, we identify the role of p53 in mediating apoptosis by the sequence-specific treatment involving the DNA-damaging, topoisomerase I-targeting drug SN-38 followed by the proteasome inhibitor PS-341 (SN-38-->PS-341). The p53-dependent sensitization of DNA damage-induced apoptosis by PS-341 is accompanied by persistent inhibition of proteasome activity and increased cytosolic accumulation of p53, including higher molecular weight forms likely representing ubiquitinated species. In contrast, pretreatment with PS-341 followed by treatment with SN-38 (PS-341-->SN-38), which leads to an antagonistic interaction, results in transient inhibition of proteasome activity and accumulation of significantly lower levels of p53 localized primarily to the nucleus. Whereas cells treated with PS-341-->SN-38 undergo G2 + M cell cycle arrest, cells treated with SN-38-->PS-341 exhibit a decreased G2 + M block with a concomitant increase in the sub-G1 population. Decreased accumulation of cells in the G2 + M phase of the cell cycle in SN-38-->PS-341-treated cells compared with PS-341-->SN-38-treated cells correlates with enhanced apoptosis and reduced expression of two p53-modulated proteins, 14-3-3sigma and survivin, both of which play critical roles in regulating G2 + M progression and apoptosis. The functional role of 14-3-3sigma or survivin in regulating the divergent function of p53 in response to SN-38-->PS-341 and PS-341-->SN-38 treatment in inducing apoptosis versus G2 + M arrest/DNA repair, respectively, was confirmed by targeted down-regulation of these proteins. These results provide insights into the mechanisms by which inhibition of proteasome activity modulates DNA damage-induced apoptosis via a p53-dependent pathway.     

Characteristics of self referred patients attending minor injury units.

OBJECTIVE: To examine the characteristics, expectations, and use of health services of patients who self refer to minor injury units (MIUs). DESIGN: Preconsultation questionnaire administered to self referred patients attending with new problems. SETTING: Two MIUs in south Kent. MAIN RESULTS: Of 312 self referred patients, 265 (84.9%) presented with minor injuries and 47 (15.1%) with illnesses. In most cases the illness/injury was of recent origin: 119 (38.1%) said it was of less than six hours' duration and 115 (27.6%) between 6 and 24 hours' duration. Most (214; 68.6%) came from home, and for 268 (85.9%) it took 10 min or less to get to the MIU. 79 patients (25.3%) had used the MIU on on e to two occasions in the previous year, and 21 (6.7%) had used it on three or more occasions. In the same period, 44 (14.1%) had attended on accident and emergency (A&E) department on one to two occasions, and 17 (5.4%) has used A&E on three or more occasions, while 108 (34.6%) had been to a general practitioner on one to two occasions, and 144 (46.1%) on three or more occasions. If there had been no MIU available, 151 patients (48.4%) said they would have attended an A&E department, and 91 (29.4%) said they would have attended their general practitioner. The remainder would have self treated or were unsure. CONCLUSIONS: While the availability of an intermediate tier of care appears to result in greater overall workload for the health service, this must be balanced against the clinical and social costs involved in different patterns of service provision. The cost-effectiveness of these services need further study.     

Genetic discoveries and nursing implications for complex disease prevention and management.

The purpose of this article is to examine the management of patients with complex diseases, in light of recent genetic discoveries, and to explore how these genetic discoveries will impact nursing practice and nursing research. The nursing science processes discussed are not comprehensive of all nursing practice but, instead, are concentrated in areas where genetics will have the greatest influence. Advances in genetic science will revolutionize our approach to patients and to health care in the prevention, diagnosis, and treatment of disease, raising many issues for nursing research and practice. As the scope of genetics expands to encompass multifactorial disease processes, a continuing reexamination of the knowledge base is required for nursing practice, with incorporation of genetic knowledge into the repertoire of every nurse, and with advanced knowledge for nurses who select specialty roles in the genetics area. This article explores the impact of this revolution on nursing science and practice as well as the opportunities for nursing science and practice to participate fully in this revolution. Because of the high proportion of the population at risk for complex diseases and because nurses are occupied every day in the prevention, assessment, treatment, and therapeutic intervention of patients with such diseases in practice and research, there is great opportunity for nurses to improve health care through the application (nursing practice) and discovery (nursing research) of genetic knowledge.     

Aerobic exercise training for depressive symptom management in adults living with HIV infection.

Aerobic exercise training may help prevent or reduce depressive symptoms experienced by persons living with HIV infection. However, the psychological effects of aerobic exercise have not been studied extensively. This study evaluated the effects of an aerobic exercise training program on self-reported symptoms of depression in HIV-infected adults and examined the convergent validity of two widely used depressive symptom scales. Sixty HIV-infected adults participated in a randomized, controlled trial of a supervised 12-week aerobic exercise training program. As compared to study controls, exercise participants showed reductions in depressive symptoms on all indices, and total depressive symptoms scores were highly correlated. Additional study of the psychological effects of aerobic exercise programs in the target population is recommended.     

Developing a Valid Evaluation for Interpersonal and Communication Skills

Objectives The Accreditation Council for Graduate Medical Education requires that residency programs evaluate the acquisition of six general competencies, including Interpersonal and Communication Skills (ICS). To develop a 360-degree method for accomplishing this, a semantic-differentiation matrix for various communication traits for nurses to evaluate physician ICS was developed. The authors sought to determine whether this evaluation method could discriminate between more experienced medical communicators (faculty) and less experienced medical communicators (residents).
Methods A 98-item questionnaire measured several communication dimensions by using an eight-element semantic-differentiation scale. In addition, global assessment ratings assessed nursing perceptions of physician ICS skills. This process was repeated for various clinical scenarios.
Results There were 26 nurse evaluators, 19 emergency medicine (EM) residents (EM2 and EM3), and 30 EM faculty. Each physician received five independent evaluations (total, 245 evaluations). All EM residents (EM2 and EM3) were compared with the EM faculty. All eight items on the semantic-differentiation scale were compared. Likewise, the global assessment scores were compared. In every category, the faculty scored higher (Mann-Whitney U: p < 0.001).
Conclusions An evaluation process integrating a semantic-differentiation matrix was applied to various clinical scenarios (as well as global assessment items) and demonstrated discriminatory results. Faculty physicians scored significantly higher than resident physicians. The ability to provide discriminatory results is a requisite in the development of a valid evaluation process. The described semantic-differentiation matrix and global assessment questions may be valid measurements of ICS.     

Multiple, heart-cross-reactive epitopes of streptococcal M proteins

We present evidence that a highly purified pepsin extract of type 5 streptococcal M protein (pep M5) contains at least three epitopes that are cross-reactive with sarcolemmal membrane proteins of human myocardium. The tissue-cross-reactive determinants of pep M5 are also partially shared with pep M6 and pep M19. Three rabbits immunized with a single 300 micrograms dose of pep M5 developed significant levels of heart-cross-reactive antibodies, as determined by indirect immunofluorescence tests. All three sera also contained antibodies that cross-reacted with pep M6 and pep M19. The heart tissue--specific antibodies that were eluted from sarcolemmal membranes opsonized types 5, 6, and 19 streptococci, indicating that they were directed against protective M protein epitopes on the surface of virulent organisms. Immunofluorescence inhibition tests, using purified M proteins as soluble inhibitors of heart-cross-reactive antibodies, revealed the number and M protein serotype distribution of the tissue-cross-reactive epitopes. Immunoblot analyses demonstrated the sarcolemmal membrane proteins containing the various cross-reactive antigenic determinants.     

Virtual inhibitory quotient predicts response to ritonavir boosting of indinavir-based therapy in human immunodeficiency virus-infected patients with ongoing viremia

Depending on the degree of underlying resistance present, optimization of the pharmacokinetics of protease inhibitors may result in improved virologic suppression. Thirty-seven human immunodeficiency virus (HIV)-infected subjects who had chronic detectable viremia and who were receiving 800 mg of indinavir three times a day (TID) were switched to 400 mg of indinavir BID with 400 mg of ritonavir two times a day (BID) for 48 weeks. Full pharmacokinetic evaluations were obtained for 12 subjects before the switch and 3 weeks after the switch. Combination therapy increased the indinavir predose concentrations in plasma by 6.47-fold, increased the minimum concentration in serum by 3.41-fold, and reduced the maximum concentration in serum by 57% without significantly changing the area under the plasma concentration-time curve at 24 h. At week 3, 58% (21 of 36) of the subjects for whom postbaseline measurements were available achieved a viral load in plasma of <50 copies/ml or a reduction from the baseline load of > or =0.5 log(10) copies/ml. Of these subjects, 82% (14 of 17) whose viruses had three or fewer protease inhibitor mutations and 88% (14 of 16) whose viruses had an indinavir virtual phenotypic susceptibility test of more than sixfold less than that for the baseline isolate were considered virologic responders. The indinavir virtual inhibitory quotient, which is a function of baseline indinavir phenotypic resistance (estimated by virtual phenotype) and the indinavir predose concentration in plasma achieved with indinavir-ritonavir combination therapy, was the best predictor of a viral load reduction. Sixteen subjects discontinued the study by week 48 due to adverse events, predominantly related to hyperlipidemia. Pharmacokinetic intensification of indinavir-based therapy with ritonavir reduced the viral loads in subjects but added toxicity. The virtual inhibitory quotient, which incorporates both baseline viral resistance and the level of drug exposure in plasma, was superior to either baseline resistance or drug exposure alone in predicting the virologic response.     

Distribution of HbA(1c) levels for children and young adults in the U.S.: Third National Health and Nutrition Examination Survey

OBJECTIVE: To describe the distribution of HbA(1c) levels among children and young adults in the U.S. and to evaluate the effects of age, sex, race/ethnicity, socioeconomic status, parental history of diabetes, overweight, and serum glucose on HbA(1c) levels. RESEARCH DESIGN AND METHODS: We analyzed HbA(1c) data from the Third National Health and Nutrition Examination Survey, 1988-1994, for 7,968 participants aged 5-24 years who had not been treated for diabetes. After adjusting for the complex sample design, we compared the distributions of HbA(1c) in subgroups and developed multiple linear regression models to examine factors associated with HbA(1c). RESULTS: Mean HbA(1c) level was 4.99% (SD 0.50%) and varied from 4.93% (95% CI +/-0.04) in non-Hispanic whites to 5.05% (+/-0.02) in Mexican-Americans to 5.17% (+/-0.02) in non-Hispanic blacks. There were very small differences among subgroups. Within each age- group, among men and women, among overweight and nonoverweight subjects, and at any level of education, mean HbA(1c) levels were higher in non-Hispanic blacks than in non-Hispanic whites. After adjusting for confounders, HbA(1c) levels for non-Hispanic blacks (5.15%, 95% CI +/-0.04) and Mexican-Americans (5.01%, +/-0.04) were higher than those for non-Hispanic whites (4.93%, +/-0.04). CONCLUSIONS: These data provide national reference levels for HbA(1c) distributions among Americans aged 5-24 years and show statistically significant racial/ethnic differences in HbA(1c) levels that are not completely explained by demographic and health-related variables.