Valence asymmetries in attitude ambivalence.

Existing models of ambivalence suggest that as the number of conflicting reactions (e.g., attitude components) increases, so too does the experience of ambivalence. Interestingly, though, these models overwhelmingly assume that this relationship is independent of valence. Across 3 studies we observe that this effect is in fact heavily influenced by 2 established valence asymmetries: positivity offset (baseline positive reactions even in the absence of positive information) and negativity bias (greater impact of negative reactions than positive reactions). Consistent with positivity offset, we observe that subjective ambivalence is greater when people have univalent negative rather than univalent positive attitudes. However, as conflicting information is acquired, subjective ambivalence rises more quickly when that information is negative rather than positive. The latter effect is consistent with negativity bias and suggests that although people feel more conflicted when they have only negative (vs. only positive) reactions, they also feel more conflicted when they have mostly positive (vs. mostly negative) reactions. Our investigation also uncovers an interesting consequence of these asymmetries: When people have mixed reactions, they do not experience maximum ambivalence at equal levels of positivity and negativity, as suggested by canonical ambivalence theory. Rather, subjective ambivalence peaks when positive reactions outnumber negative reactions. These effects are found to have downstream consequences for other dimensions of attitude strength. (PsycINFO Database Record

Autosplenectomy Causing Catastrophic Pneumococcal Meningitis in a Patient with Lupus/Antiphospholipid Antibody Syndrome.

We present the case ofa26-year-old female who presented to the hospital with pneumococcal meningitis. A review of her records showed atrophic spleen, and a hypercoagulable workup was positive for Systemic Lupus Erythematous (SLE)/Antiphospholipid Antibody Syndrome (APS). An autosplenectomy from thrombotic occlusion of the splenic artery made her susceptible to pneumococcal meningitis. Autoimmune conditions, particularly SLE and APS, are important causes of hypercoagulable states in a young population, and earlier detection of these conditions and appropriate treatment helps to decrease morbidity and mortality among these patients.

Case Report: What is Your Differential Diagnosis for Bilateral Cerebellar Infarct?

Neurovascular variants are not frequently described outside of specialty literature. Infarction involving these atypical neurovascular structures present with unusual clinical findings and radiologic imaging. A 63-year-old man with hypertension, diabetes, and former tobacco use presented from the Department of Corrections with global headache, nausea, vomiting, and double vision. He was found to be hypertensive to 240/120. CT imaging noted acute ischemic changes in the bilateral posterior inferior cerebellar artery distribution. Follow up 3-D time-of-flight (TOF) magnetic resonance angiography (MRA) of the cranial region demonstrated abrupt cut off of an azygous right posterior inferior cerebellar artery (PICA) and presumed absence of the left PICA. The patient underwent occipital craniotomy for evolving ischemic stroke and development of hydrocephalus, and ultimately recovered without neurologic deficits.

Brachial artery injuries in children.

Treatment of brachial artery injuries in children, particularly those resulting from supracondylar humeral fractures, is controversial when distal pulses are absent yet the hand remains warm and pink. This article presents a retrospective study of eight children, ages 3 to 13, who underwent brachial arterial exploration because of absent distal pulses following arm trauma. Absent pulses indicate diminished blood flow, and in all eight cases brachial artery obstruction or severance was confirmed at surgery. In four of the children, who presented with cold, devascularized hands as a result of posterior elbow dislocations, supracondylar humeral fracture, or dog bites, there is no debate regarding revascularization. The other four children, with type III supracondylar humerus fractures, had pulseless, pink hands as a result of brachial artery thrombosis or arterial tethering. Brachial artery flow was reestablished in all cases with return of distal pulses, and no vascular complications. The authors believe that artery exploration is indicated when distal pulses are not present.

Telemonitoring with case management for seniors with heart failure.

OBJECTIVE: To assess the impact of supplementing nurse case management with Internet-connected telemonitoring on clinical outcomes in an elderly heart failure (HF) population. STUDY DESIGN: Randomized clinical trial allocating high-risk HF subjects to the telehealth system with case management (THCM) versus case management (CM) alone. METHODS: Medicare Advantage members with HF and recent hospitalization were randomized to THCM or CM. Consenting participants received THCM for 6 months or the health plan's usual Medicare specialized CM as long as deemed necessary. The primary outcome measure was a composite of all-cause hospitalization, ED visit, or death. Because only a subset of those who were randomized consented and participated, the strategies were evaluated as-treated rather than by intention-to-treat, with multivariate adjustment in logistic regression models for confounding introduced by postrandomization exclusions. RESULTS: The treated sample size was 164 subjects in THCM and 152 in CM. Treatment arms did not differ significantly for the primary composite outcome (45% for THCM vs 40% for CM, relative risk 1.18; P = .22). Telehealth alerts prompted frequent telephonic contact, increasing THCM case managers' workload. The participant population overall had 42% fewer inpatient days during the intervention period compared with the previous year. CONCLUSIONS: Despite effective implementation of an Internet-based telehealth intervention in an elderly HF population, there was no discernible impact on overall morbidity or mortality. Notably, limited postrandomization participation decreased power to detect a difference. The reduction in days hospitalized for trial participants overall underscores the benefit of CM for such HF patients.

Computerized alert reduced D-dimer testing in the elderly.

OBJECTIVE: To assess the effect of a targeted age-specific computerized alert to reduce D-dimer testing in elderly patients. STUDY DESIGN: A single-crossover cluster randomized trial of computerized alerts during physician order entry involving 8 ambulatory care clinics in a group-model integrated care delivery system. METHODS: The rate of completed D-dimer tests per 1000 patient visits, ratio of completed venous ultrasonography to completed D-dimer tests, and rate of completed venous ultrasonography per 1000 patient visits. RESULTS: The rate of completed D-dimer tests per 1000 visits among patients 65 years and older in intervention clinics decreased from 5.02 to 1.52 (95% confidence interval [CI], -4.20 to -2.80; P <.001), which persisted throughout the study period. The rate of completed D-dimer tests per 1000 visits among patients 65 years and older in control clinics decreased from 3.14 to 2.11 (95% CI, -1.66 to -0.04; P <.001 for interaction). After activation of the alert in control clinics, the rate of completed D-dimer tests per 1000 visits among patients 65 years and older decreased from 2.11 to 0.81 (95% Cl, -1.79 to -0.80; P <.001). After activation of the alert in each clinic group, the ratios of completed venous ultrasonography to completed D-dimer tests increased from 1.17 to 4.05 (95% CI, 2.52-3.22) and from 2.25 to 7.29 (95% CI, 3.74-6.35) in intervention clinics and control clinics, respectively (P <.001 for both). CONCLUSION: An electronic age-specific alert targeted to a specific condition reduced D-dimer testing in this elderly population of outpatients and demonstrated a persistent effect.

Mountain pine beetle attack associated with low levels of 4-allylanisole in ponderosa pine.

Mountain pine beetle (Dendroctonus ponderosae) is the most important insect pest in southern Rocky Mountain ponderosa pine (Pinus ponderosa) forests. Tree mortality is hastened by the various fungal pathogens that are symbiotic with the beetles. The phenylpropanoid 4-allylanisole is an antifungal and semiochemical for some pine beetle species. We analyzed 4-allylanisole and monoterpene profiles in the xylem oleoresin from a total of 107 trees at six sites from two chemotypes of ponderosa pine found in Colorado and New Mexico using gas chromatography-mass spectroscopy (GC-MS). Although monoterpene profiles were essentially the same in attacked and nonattacked trees, significantly lower levels of 4-allylanisole were found in attacked trees compared with trees that showed no evidence of attack for both chemotypes.

Kaiser Permanente's Convergent Medical Terminology.

This paper describes Kaiser Permanente's (KP) enterprise-wide medical terminology solution, referred to as our Convergent Medical Terminology (CMT). Initially developed to serve the needs of a regional electronic health record, CMT has evolved into a core KP asset, serving as the common terminology across all applications. CMT serves as the definitive source of concept definitions for the organization, provides a consistent structure and access method to all codes used by the organization, and is KP's language of interoperability, with cross-mappings to regional ancillary systems and administrative billing codes. The core of CMT is comprised of SNOMED CT, laboratory LOINC, and First DataBank drug terminology. These are integrated into a single poly-hierarchically structured knowledge base. Cross map sets provide bi-directional translations between CMT and ancillary applications and administrative billing codes. Context sets provide subsets of CMT for use in specific contexts. Our experience with CMT has lead us to conclude that a successful terminology solution requires that: (1) usability considerations are an organizational priority; (2) "interface" terminology is differentiated from "reference" terminology; (3) it be easy for clinicians to find the concepts they need; (4) the immediate value of coded data be apparent to clinician user; (5) there be a well defined approach to terminology extensions. Over the past several years, there has been substantial progress made in the domain coverage and standardization of medical terminology. KP has learned to exploit that terminology in ways that are clinician-acceptable and that provide powerful options for data analysis and reporting.