Osteoporosis and depression: A historical perspective

In the early 1980s, researchers studying osteoporosis noted that depression was one of the major negative consequences of bone loss and fractures. These researchers believed that osteoporosis and fractures occurred first, causing a reactive depression. Meanwhile, a similar but distinct psychiatry literature noted that osteoporosis or bone loss appeared to be an undesirable consequence of major depression. Here, depression was seen as the causal factor, and osteoporosis was the outcome. The psychiatric perspective is more biological, based on the presence of hypercorticoidism in depressed individuals. Those who believe that osteoporosis leads to depression point out that depression is a consequence of many chronic illnesses. Regardless of the correct causal order, the strong positive relationship between osteoporosis and depression merits further clinical and research attention in the future.     

Expression of NOS–2, COX–2 and Th1/Th2 cytokines in migraine

Nitric oxide (NO) probably plays an important role in the pathogenesis of migraine without aura (MWA). As the activation of NO–ergic cascade has been shown to be closely linked to cyclooxygenase pathway and to cause some differences in peripheral blood lymphocyte populations, we investigated if the Th1/Th2 balance in peripheral blood of MWA patients was affected in comparison to controls. Twenty–six MWA patients and 10 healthy controls (C) were enrolled in this study. Blood samples were taken at baseline (T0) and during an induced migraine attack (T1). Total RNA from human peripheral blood lymphocytes (PBLs) was isolated and reverse–transcribed to prepare complementary DNA. COX–2, NOS–2 and β–actin were amplified using PCR. PBLs from patients and controls were stimulated with phorbol 12–myristate 13–acetate plus ionomycin in the presence of brefeldin A. Cells were surface–stained with fluorochrome–conjugated anti–CD3 and anti–CD8 monoclonal antibodies (mAbs) and intracellularly stained with fluorochrome– conjugated anti–IFN–γ or anti–IL–4 mAbs. The level of cytokine expression was analyzed by gating on the CD4+ lymphocyte subset. Th1 and Th2 type cytokines (IFN–γ, IL–2, IL–4) were directly assayed in serum by ELISA. Preliminary results indicate that NOS–2 was upregulated in MWA patients at basal time if compared to controls, whereas after NOD administration NOS–2 was significantly decreased. COX–2 was upregulated in MWA patients at basal time and it had an opposite trend after NOD administration. The homeostatic Th1/Th2 balance defined by the IFN–γ or IL–4 cytokine expression was unchanged in MWA patients in comparison to controls, and NOD administration did not affect that pattern. The cell activation machinery was not altered after mitogenic activation, as shown by CD69 expression level. Cytokine serum levels showed no significant changes in all studied situations. This study confirms the relevance of the NOS/COX system in MWA but, in contrast with previous studies, excludes their effect and activation on peripheral cytokine production. More sophisticated experimental models are needed to investigate the ability of NOS/COX to activate migraine pain.     

Measuring health-related quality of life (HRQOL) in osteoporotic males using the Male OPAQ

Summary  

The Male Osteoporosis Assessment Questionnaire (OPAQ™) is a health-related quality of life (HRQOL) instrument that can differentiate between men with and without fracture. The Male OPAQ™ is a reliable and validated instrument that may be utilized in clinical trials seeking to include male populations.     

Teamwork and Delegation in Medical Homes: Primary Care Staff Perspectives in the Veterans Health Administration

BACKGROUND

The patient-centered medical home (PCMH) relies on a team approach to patient care. For organizations engaged in transitioning to a PCMH model, identifying and providing the resources needed to promote team functioning is essential.

OBJECTIVE

To describe team-level resources required to support PCMH team functioning within the Veterans Health Administration (VHA), and provide insight into how the presence or absence of these resources facilitates or impedes within-team delegation.

DESIGN

Semi-structured interviews with members of pilot teams engaged in PCMH implementation in 77 primary care clinics serving over 300,000 patients across two VHA regions covering the Mid-Atlantic and Midwest United States.

PARTICIPANTS

A purposive sample of 101 core members of pilot teams, including 32 primary care providers, 42 registered nurse care managers, 15 clinical associates, and 12 clerical associates.

APPROACH

Investigators from two evaluation sites interviewed frontline primary care staff separately, and then collaborated on joint analysis of parallel data to develop a broad, comprehensive understanding of global themes impacting team functioning and within-team delegation.

KEY RESULTS

We describe four themes key to understanding how resources at the team level supported ability of primary care staff to work as effective, engaged teams. Team-based task delegation was facilitated by demarcated boundaries and collective identity; shared goals and sense of purpose; mature and open communication characterized by psychological safety; and ongoing, intentional role negotiation.

CONCLUSIONS

Our findings provide a framework for organizations to identify assets already in place to support team functioning, as well as areas in need of improvement. For teams struggling to make practice changes, our results indicate key areas where they may benefit from future support. In addition, this research sheds light on how variation in medical home implementation and outcomes may be associated with variation in team-based task delegation.

     

Sentinel node biopsy in clinical stage 1 melanoma: rationale for restaging and follow-up

Lymph node involvement appears to be the most significant prognostic factor in patients affected by melanoma and has been shown to reduce the five-year survival by 40%. We studied 31 patients (15 M; 16 F; age range, 28-83 years) with clinical stage 1 (CS1) intermediate thickness (0.75-4 mm) melanoma. Scintigraphic examination of the nodes was performed in all patients, 29 of whom underwent surgical biopsy of the SN after 24 hours. Early images were acquired 5, 15 and 79 min and late images 60-180 min following perilesional injection of 2-4 microdoses of 99mTc-nanocolloid (15-20 MBq). A cobalt marker was used to project the SN on the skin surface which was later stained with indelible ink. For intraoperative localization we used a portable probe and perilesional injection of patent blue violet dye, which proved positive in 24/29 patients (83%). After surgery histological examination of the sentinel lymph nodes (SNs) (hematoxylin-eosin and immunohistochemistry) found positivity for metastatic cells in 6 patients. They all underwent elective lymph node dissection (ELND); five are N0+ and are currently undergoing supportive therapy with interferon alpha with an 8-24-month follow-up, while one N+ patient died 14 months after surgery. Follow-up (3-26 months) of N0- patients has not evidenced any locoregional recurrence so far. Only one case showed hematogenic metastases. This procedure might radically change the therapeutic approach to CS1 melanoma because it is simple, scarcely invasive, and shows a favorable cost-benefit ratio.     

Sex and gender in older adults' experience of Parkinson's disease

OBJECTIVES: This article reports on the gendered experience of Parkinson's disease (PD). Data derived from 15 months of ethnographic study among community-dwelling older adults living with PD in eastern Iowa. METHODS: The study utilized several methods: participant observation at PD support group meetings, illness narrative interviews with PD sufferers, and a questionnaire. RESULTS: A total of 171 PD sufferers (106 men, 65 women) enrolled in the study. Illness narratives revealed gender differences in the impact of specific symptoms on daily life: Women's narratives emphasized the impact of the on/off effect and "thinking problems," whereas men's narratives emphasized the consequences of their physical appearance. In comparison, quantitative data found little sex difference in symptomatology. DISCUSSION: The comparison of qualitatively and quantitatively derived data reveals the importance of attending to both sex and gender. Qualitative data demonstrate how the meaning of PD symptoms is gendered and illustrate an example of how gender and sex research differ. All narratives reflect the importance of role continuity, but men's put at the forefront appearance and social isolation whereas women's underscore their relational aspects of domestic activities. These data imply that providers must look beyond symptomatology to the gendered saliency of particular somatic phenomena.