Differences in Referral Access to Care Between Gastrointestinal Subspecialty Patients: Barriers and Opportunities.

Purpose: Referral access to subspecialty care for patients with gastrointestinal (GI) diseases is not well defined, but has significant importance to patients. We hypothesized that patients experience barriers to care in two common gastroenterology subspecialties, Hepatology and Motility, in a university medical center. Methods: Two hundred thirteen clinic patients (mean age 46.5 years; 66.5% female; 85.6% Caucasians) completed a formatted questionnaire on access to care. Hepatology patients were older (49.7 years, p=0.008); motility patients predominantly female (76.8%, p<0.001). Gender distribution was even for hepatology (51.2% female). Both groups were overweight (mean body mass index 28.4). Results: Patients waited a mean 89.5 days to be seen by a subspecialist. There were differences by subspecialty (107.6 days for motility vs. 64.3 days for hepatology, p=0.022). A larger percentage of motility patients were told nothing was wrong with them (16.8%, p<0.01) and could not be helped (42.1%, p=0.000). Conclusions: Access to care for subspecialty gastroenterology patients in a university center appears to be impacted by a number of variables. While there are similarities, differences exist between these two subspecialties. Motility patients were more likely to have been told they have nothing wrong with them, suffer setbacks financially, and suffer mood problems. Their wait time for appointments was also greater than hepatology patients. Further investigations of referral access for gastroenterology patients may yield additional insights into disease-specific barriers to accessing subspecialty care.

Rotational Thromboelastometry or Conventional Coagulation Tests in Liver Transplantation: Comparing Blood Loss, Transfusions, and Cost.

INTRODUCTION: Orthotopic liver transplantation (OLT) can be associated with significant bleeding requiring multiple blood product transfusions. Rotational thromboelastometry (ROTEM) is a point-of-care device that has been used to monitor coagulation during OLT. Whether it reduces blood loss/transfusions during OLT remains controversial. MATERIALS AND METHODS: We aim to compare ROTEM with conventional coagulation tests (aPTT, PT, INR, platelet count, fibrinogen) to guide transfusion of platelets, cryoprecipitate, and fresh frozen plasma (FFP) during OLT over 3 years. Thirty-four patients who had transfusions guided by ROTEM were compared to 34 controls who received transfusions guided by conventional coagulation tests (CCT). Intraoperative blood loss, type/ amount of blood products transfused, and direct costs were compared between the two groups. RESULTS: The ROTEM group had significantly less intra-operative blood loss (2.0 vs. 3.0 L, p = 0.04) and fresh frozen plasma (FFP) transfusion (4 units vs. 6.5 units, p = 0.015) compared to the CCT group (2.0L vs. 3.0L, p = 0.04). However, total number of patients transfused cryoprecipitate was increased in ROTEM (n = 25;73%) as compared to CCT (n = 19; 56%), p = 0.033. The direct cost of blood products plus testing was reduced in the ROTEM group ($113,142.89 vs. $127,814.77). CONCLUSION: In conclusion implementation of a ROTEM-guided transfusion algorithm resulted in a reduction in intra-operative blood loss, FFP transfusion and a decrease in direct cost during OLT. ROTEM is a useful and safe point of care device in OLT setting.

Dispositional mindfulness and rejection sensitivity: The critical role of nonjudgment.

The pain of rejection is a crucial component of normal social functioning; however, heightened sensitivity to rejection can be impairing in numerous ways. Mindfulness-based interventions have been effective with several populations characterized by elevated sensitivity to rejection; however, the relationship between mindfulness and rejection sensitivity has been largely unstudied. The present study examines associations between rejection sensitivity and multiple dimensions of dispositional mindfulness, with the hypothesis that a nonjudgmental orientation to inner experiences would be both associated with decreased rejection sensitivity and attenuate the impact of sensitivity to rejection on general negative affect. A cross-sectional sample of undergraduates (n = 451) completed self-report measures of rejection sensitivity, dispositional mindfulness, and trait-level negative affect. Significant zero-order correlations and independent effects were observed between most facets of dispositional mindfulness and rejection sensitivity, with nonjudging demonstrating the largest effects. As predicted, rejection sensitivity was associated with negative affectivity for people low in nonjudging (ß = .27, t = 5.12, p < .001) but not for people high in nonjudging (ß = .06, t = .99, p = .324). These findings provide preliminary support for mindfulness, specifically the nonjudging dimension, as a protective factor against rejection sensitivity and its effects on affect.

Development and Validation of a Measure of Self-Critical Rumination.

Self-criticism is a form of negative self-evaluation that has strong associations with many forms of psychopathology. Rumination is a maladaptive form of repetitive thinking that is associated with many psychological disorders. Although measures of several different types of rumination (e.g., general rumination, depressive rumination, anger rumination) have been developed, none focuses specifically on self-critical rumination. An initial pool of items addressing self-critical rumination was developed by adapting items from existing rumination measures and through a writing task administered to both student and clinical samples. Following an evaluation of content validity, 24 items were administered to a large sample of undergraduates along with measures of related constructs. The final 10-item version of the Self-Critical Rumination Scale showed excellent internal consistency, a clear single-factor structure, convergent relationships with related constructs, and incremental validity over other measures of self-criticism and rumination in predicting both general distress and features of borderline personality disorder.

Anger Rumination as a Mediator of the Relationship Between Mindfulness and Aggression: The Utility of a Multidimensional Mindfulness Model.

OBJECTIVES: Mindfulness training reduces anger and aggression, but the mechanisms of these effects are unclear. Mindfulness may reduce anger expression and hostility via reductions in anger rumination, a process of thinking repetitively about angry episodes that increases anger. Previous research supports this theory but used measures of general rumination and assessed only the present-centered awareness component of mindfulness. The present study investigated associations between various aspects of mindfulness, anger rumination, and components of aggression. METHOD: The present study used self-report measures of these constructs in a cross-sectional sample of 823 students. RESULTS: Structural equation modeling revealed that anger rumination accounts for a significant component of the relationship between mindfulness and aggression, with the largest effect sizes demonstrated for the nonjudgment of inner experiences facet of mindfulness. CONCLUSION: Nonjudgment and present-centered awareness may influence aggression via reduced anger rumination. The importance of examining mindfulness as a multidimensional construct is discussed.

Dysfunctional responses to emotion mediate the cross-sectional relationship between rejection sensitivity and borderline personality features.

A growing body of evidence has tied borderline personality disorder (BPD) to heightened sensitivity to rejection; however, mechanisms through which rejection sensitivity contributes to BPD features have not been identified. Rejection may lead to the dysfunctional emotion regulation strategies common in BPD, such as impulsive responses to distress, anger rumination, difficulties engaging in goal-oriented behavior, nonacceptance of emotions, and low emotional clarity. The present study used self-report measures and bootstrapping procedures to investigate the role of difficulties in emotional regulation in the relationship between rejection sensitivity and borderline personality features in a cross-sectional sample of 410 undergraduates. Difficulties in emotion regulation accounted for significant variance in the relationships between rejection sensitivity and BPD features, with varying sets of deficits in emotion regulation skills accounting for associations with specific BPD features. Potential clinical implications and the need for replication in longitudinal studies are discussed.

Shame and borderline personality features: the potential mediating role of anger and anger rumination.

Two prominent emotions in borderline personality disorder (BPD) are shame and anger. Rumination has been demonstrated to occur in response to shame and to escalate anger, and rumination, particularly anger rumination, has been shown to predict BPD symptoms. The present study tested a structural equation model in which shame leads to the features of BPD via increased anger and anger rumination. A sample of 823 undergraduates completed self-report measures of shame, trait-level anger, anger rumination, and BPD features. The hypothesized model of shame to anger and anger rumination to BPD features was largely supported. Bootstrapping was used to establish significant indirect effects from both situational and global forms of shame via anger rumination to BPD features, and from global shame via anger to most BPD features. The alternative hypothesis that anger and anger rumination contribute to BPD features via increased shame was also examined, with no significant indirect effects found. Recognizing this function of anger and anger rumination may be important in understanding the relationship between shame-proneness and BPD features and may have implications for treatment. Further research into determining other ways individuals maladaptively respond to shame, and understanding the functions of anger and anger rumination, is recommended.

Mollie Stevens Smart (1916-2012).

Presents an obituary for Mollie Stevens Smart (1916-2012). Mollie attended the University of Toronto, from which she graduated with honors in psychology at age 20 in 1936. She studied and worked at the Merrill-Palmer Institute in Detroit, earning a master's degree in child development from the University of Michigan in 1941. She earned her doctorate in educational psychology at the University of Delhi in 1969. An author, teacher, and mentor, Mollie won Fulbright research grants to India and New Zealand and lectured in the United States, India, New Zealand, Canada, and China. She wrote 26 books, most co-authored with her husband, Russell (Rus) C. Smart. Beginning in the 1940s, when Freudian theory had a strong grip on the popular view of child development, the books placed the developing child in the context of family and community systems. The Smarts' best-selling college textbook Children: Development and Relationships (1967, 1973, 1977, 1982) was based on the theories of Erik Erikson and Jean Piaget. Mollie was a member of the American Psychological Association throughout her professional career and held memberships also in the Society for Research in Child Development, the National Council on Family Relations, the Groves Conference on Marriage and Family, and the Fulbright Association. After moving to Ridgefield, Washington, in 2003 with her daughter Ellen following Rus's death in 1996, she applied her great knowledge to advise a community-based organization that serves the needs of new babies born into destitute families. Mollie died at home in Ridgefield on October 22, 2012, at age 96.

Alcoholic Hepatitis: Steroids vs. Pentoxifylline.

Alcoholic hepatitis (AH) remains a major cause of liver-related morbidity and mortality in the United States and is actually increasing in certain areas of Europe. Thus, there is a pressing need for new therapies/approaches. Major barriers for reducing morbidity, mortality, and costs of care include: lack of translational animal and human studies of new therapies for AH; limited trials of combination therapies in AH targeted at specific disease mechanisms (e.g., gut permeability, cytokines, oxidative stress); limited studies on non-invasive, non-mortality end points; few studies on mechanisms of steroid non-responsiveness; and inadequate prognostic indicators, to name only a few. In spite of these gaps, we have made major advances in understanding mechanisms for AH and appropriate therapies for AH. This article reviews mechanisms and rationale for use of steroids and pentoxifylline in AH and future directions in therapy.

UV promoted phenanthridine syntheses from oxime carbonate derived iminyl radicals.

Oxime carbonates were found to be excellent precursors for the clean and direct generation of iminyl radicals under UV irradiation. Suitably functionalised iminyls underwent cyclisations yielding various phenanthridines and also substituted quinolines and isoquinolines. EPR and X-ray analyses of oxime carbonates provided insight into the mechanism.

Object categorisation, object naming, and viewpoint independence in visual remembering: evidence from young children's drawings of a novel object.

A simple object-drawing task confirms a three-way association between object categorisation, viewpoint independence, and longer-term visual remembering. Young children (5- to 7-year-olds) drew a familiar object or a novel object, immediately after it had been hidden from view or on the following day. Both objects were shown from a full range of viewpoints or from just two viewpoints, from neither of which would either object normally be drawn after unrestricted viewing. When drawing from short-term memory after restricted viewing, both objects were most likely to be depicted from a seen viewpoint. When drawing from longer-term memory after restricted viewing, the novel object continued to be drawn from a seen viewpoint, but the mug was now most likely to be drawn from a preferred viewpoint from which it had not been seen. Naming the novel object with a novel count noun ("Look at this. This is a dax"), to signal that it belonged to an object category, resulted in it being drawn in the same way as the familiar object. The results concur with other evidence indicating that short-term and longer-term visual remembering are differentially associated with viewpoint-dependent representations of individual objects and viewpoint independent representations of object categories, respectively.

Identification and characterization of novel spliced variants of neuregulin 4 in prostate cancer.

PURPOSE: The neuregulin (NRG) 1, 2, and 3 genes undergo extensive alternative mRNA splicing, which results in variants that show structural and functional diversity. The aims of this study were to establish whether the fourth member of this family, NRG4, is expressed in prostate cancer, if it is alternatively spliced and whether any functional differences between the variants could be observed. EXPERIMENTAL DESIGN: The expression of NRG4 was determined using immunohistochemical staining of 40 cases of primary prostate cancer. Bioinformatic analysis and reverse transcription-PCR (RT-PCR) using NRG4 isotype-specific primers on a panel of normal and prostate cancer cell lines were used to identify alternatively spliced NRG4 variants. Expression of these variants was determined using isotype-specific antibodies. Transfection into Cos-7 cells of two of these green fluorescent protein-tagged variants allowed analysis of their subcellular location. Four of the variants were chemically synthesized and tested for their ability to activate the ErbB4 receptor. RESULTS: NRG4 was variably expressed in the cytoplasm in the majority of prostate cancer cases, and in a subset of cases in the membrane, high levels were associated with advanced disease stage. Four novel NRG4 splice variants (NRGA2, NRG4 B1-3) were characterized, where each seemed to have a different subcellular location and were also expressed in the cytoplasm of the prostate tumors. NRG4 B3 was also present in endothelial cells. In transfected cells, the A type variant (NRG4 A1) was localized to the membrane, whereas the B type variant (NRG4 B1), which lacks the predicted transmembrane region, had an intracellular localization. Only the variants with an intact epidermal growth factor-like domain activated ErbB4 signaling. CONCLUSION: NRG4 overexpression is associated with advanced-stage prostate cancer. The alternative splice variants may have different roles in cell signaling, some acting as classic receptor ligands and some with as-yet unknown functions.

Working memory capacity and suppression of intrusive thoughts.

We sought to show that individual differences in working memory capacity are related to the ability to intentionally suppress personally relevant intrusive thoughts, and that this effect cannot be explained by differences in negative mood. Sixty participants identified their most frequent intrusive thought and then completed a thought suppression task. Better performance on a measure of working memory capacity (OSPAN) was related to having fewer intrusions in the suppression condition but was unrelated to number of intrusions in the expression condition, suggesting a specific association with attempts to inhibit unwanted thoughts. In contrast, a more negative mood was related to having more intrusions in both conditions, suggestive of a more general influence on the accessibility of unwanted thoughts. Working memory capacity was not associated with negative mood or with the frequency of intrusive thoughts reported in everyday life. The findings extend previous results to the domain of personally relevant intrusive thoughts and support the idea that individual differences in the cognitive abilities supporting inhibitory mechanisms are relevant to clinical conditions such as obsessive-compulsive disorder and posttraumatic stress disorder.

Old losses: a retrospective study of miscarriage and infant death 1926-1955.

Childbearing-related losses of 16 elderly Caucasians (13 women and 3 men, aged 69-90) were examined retrospectively in this qualitative study. Recollections of social support, grief at the time of loss, and current meaning attributed to the loss were the foci of the study. Most respondents recalled having felt grief at the time of miscarriage, fetal death, or infant death, and most did not have lingering feelings of grief. Women who did not have grandchildren and who recalled insufficient social support appeared to be more vulnerable to feelings of lasting grief. A life course approach, which examines personal narrative in relation to ontological, generational, and historical time, fits with the interpretation given by elderly respondents to their childbearing losses.