Stress and salt sensitivity in primary hypertension.

As the development of hypertension and target organ damage becomes more prevalent, it becomes exceedingly important to determine the underlying mechanisms through which this detrimental development occurs. Specifically, our studies and others have explored mechanisms through which stress elicits a salt-sensitive response in approximately 20-30 % of the population, resulting in the early development of hypertension and target organ damage. Data associated with this stress-induced cardiovascular response pattern have recently demonstrated additional effects across the body systems including factors contributing to the development of osteoporosis, obesity, autoimmune disease, and chronic inflammation. As each of these diseases become more prevalent in conjunction with hypertension, further research may discover stress and salt sensitivity to be at the "heart" of the matter for the development of many of today's most deadly conditions.

Educating certified nursing assistants educational offerings on the run and more.

Certified nursing assistants (CNAs) are important partners in the delivery of quality care to patients. Nurse educators are challenged with providing "just-in-time" education to CNAs within the constraints of a fast-paced clinical environment. This article will discuss a successful CNA training program and lessons learned for improving just-in-time education to assistive personnel.

Identifying methamphetamine exposure in children.

OBJECTIVE: Methamphetamine (MAMP) use, distribution, and manufacture remain a serious public health and safety problem in the United States, and children environmentally exposed to MAMP face a myriad of developmental, social, and health risks, including severe abuse and neglect necessitating child protection involvement. It is recommended that drug-endangered children receive medical evaluation and care with documentation of overall physical and mental conditions and have urine drug testing. The primary aim of this study was to determine the best biological matrix to detect MAMP, amphetamine (AMP), methylenedioxymethamphetamine (MDMA), methylenedioxyamphetamine (MDA), and 3,4-methylenedioxyethylamphetamine (MDEA) in environmentally exposed children. METHODS: Ninety-one children, environmentally exposed to household MAMP intake, were medically evaluated at the Child and Adolescent Abuse Resource and Evaluation Diagnostic and Treatment Center at the University of California, Davis Children's Hospital. MAMP, AMP, MDMA, MDA, and MDEA were quantified in urine and oral fluid (OF) by gas chromatography mass spectrometry and in hair by liquid chromatography tandem mass spectrometry. RESULTS: Overall drug detection rates in OF, urine, and hair were 6.9%, 22.1%, and 77.8%, respectively. Seventy children (79%) tested positive for 1 or more drugs in 1 or more matrices. MAMP was the primary analyte detected in all 3 biological matrices. All positive OF (n = 5), and 18 of 19 positive urine specimens also had a positive hair test. CONCLUSIONS: Hair analysis offered a more sensitive tool for identifying MAMP, AMP, and MDMA environmental exposure in children than urine or OF testing. A negative urine or hair test does not exclude the possibility of drug exposure, but hair testing provided the greatest sensitivity for identifying drug-exposed children.

More frequent visits to wound care clinics result in faster times to close diabetic foot and venous leg ulcers.

OBJECTIVE: To determine whether patients with Wagner grades 1 and 2 diabetic foot ulcers (DFUs) or venous leg ulcers (VLUs) differed in terms of time to close depending on visit frequency to wound care centers. DESIGN: Retrospective cohort study. SETTING: Outpatients wound care centers. PATIENTS: Two hundred six patients with Wagner grade 1 or 2 DFUs and 215 patients with VLUs in the lower extremities collected from 9 wound care centers in 5 states (6 states for VLUs) during 2009/2010 and whose wounds had closed. INTERVENTIONS: For each type of DFU/VLU, 1 group had every-other-week visits, defined as more than 10 days between visits in the first 4 weeks, whereas the other group had weekly visits, defined as at least once a week. MAIN OUTCOMES MEASURES: Median time to close. MAIN RESULTS: For patients with DFUs, 63.8% of wounds had closed in the weekly visit group after 4 weeks compared with 2.0% in the every-other-week group (P = 2.3 × 10); for patients with VLUs, 78 of 105 wounds (52%) closed in the weekly visit group compared with 0% in the every-other-week group (P = 2.40 × 10). After controlling for all covariates in a Cox regression model, median time to close for weekly patients was 28 days versus 66 days for patients seen every other week. Adjusted median times to close VLUs in the same groups were 25 versus 55 days. CONCLUSIONS: More frequent visits can be extremely beneficial, with implications of lower costs and higher quality of life for patients.

Evidence of methamphetamine exposure in children removed from clandestine methamphetamine laboratories.

OBJECTIVE: To determine whether asymptomatic children removed from clandestine methamphetamine laboratories have evidence of exposure to methamphetamine. METHODS: Retrospective chart review of children removed from law enforcement-certified clandestine methamphetamine laboratories in the Tulsa area of Oklahoma and Sacramento County, California. Exposure was determined by positive urine toxicology for methamphetamine. RESULTS: One hundred four children were evaluated after removal from clandestine methamphetamine laboratories. Forty-eight children (46%) tested positive for methamphetamine. Timed urine results were known for 68 of 104, with no child testing positive after 6.5 hours from being removed from the laboratory. No child required emergency medical treatment at the time urine samples were obtained. CONCLUSIONS: Almost half of the children in this sample had evidence of exposure to methamphetamine soon after removal from methamphetamine manufacturing environments. Further research is indicated to determine the health effects of subclinical methamphetamine exposure.

Teaching psychiatry in primary care residencies: do training directors of primary care and psychiatry see eye to eye?

OBJECTIVE: This study compares the views of psychiatry residency training directors about psychiatry and mental health training in the primary care programs in their institutions with those of the primary care residency training directors. METHODS: A 16-item questionnaire surveying specific areas of training and perceived adequacy of current teaching was distributed to 1,544 U.S. primary care and psychiatry program directors. RESULTS: The response rate was 53%. Among psychiatry training directors, 85% responded that psychiatry training in their primary care programs was minimal to suboptimal, while 68% of family practice training directors responded that their psychiatry training was optimal to extensive. Among psychiatry training directors, 89% were dissatisfied with the psychiatry training in their primary care programs, and only 8% were satisfied. In contrast, almost half of primary care training directors were satisfied. However, within the primary care programs, there was a marked difference between family practice (majority satisfied) and the rest (internal medicine, obstetrics and gynecology, pediatrics, mostly unsatisfied). All primary care and psychiatry training directors agreed that most basic psychiatric skills and diagnoses were taught in the primary care programs. For all skills and syndromes examined, psychiatry training directors consistently and significantly rated the training to be less adequate than did primary care training directors. There was general agreement that primary care physicians should be able to treat most uncomplicated cases in patients with psychiatric disorders, and some but not other psychiatric conditions. CONCLUSION: Psychiatry and primary care training directors, except in family practice, generally agree that psychiatry training in primary care programs is inadequate and should be significantly enhanced. There should be more communication between psychiatry and primary care training programs for optimal curriculum development.

Seasonal influence on sulfate reduction and zinc sequestration in subsurface treatment wetlands.

To characterize the effects of season, temperature, plant species, and chemical oxygen demand (COD) loading on sulfate reduction and metals removal in treatment wetlands we measured pore water redox potentials and concentrations of sulfate, sulfide, zinc and COD in subsurface wetland microcosms. Two batch incubations of 20 day duration were conducted in each of four seasons defined by temperature and daylight duration. Four treatments were compared: unplanted controls, Typha latifolia (broadleaf cattail), and Schoenoplectus acutus (hardstem bulrush), all at low COD loading (267 mg/L), plus bulrush at high COD loading (534 mg/L). Initial SO4-S and zinc concentrations were 67 and 24 mg/L, respectively. For all treatments, sulfate removal was least in winter (4 degrees C, plant dormancy) greatest in summer (24 degrees C, active plant growth) and intermediate in spring and fall (14 degrees C), but seasonal variation was greater in cattail, and especially, bulrush treatments. Redox measurements indicated that, in winter, plant-mediated oxygen transfer inhibited activity of sulfate reducing bacteria, exacerbating the reduction in sulfate removal due to temperature. Doubling the COD load in bulrush treatments increased sulfate removal by only 20-30% when averaged over all seasons and did not alter the basic pattern of seasonal variation, despite tempering the wintertime increase in redox potential. Seasonal and treatment effects on zinc removal were broadly consistent with sulfate removal and presumably reflected zinc-sulfide precipitation. Results strongly suggest that interactive effects of COD loading rate, temperature, season, and plant species control not only sulfate reduction and zinc sequestration, but also the balance of competition between various microbial consortia responsible for water treatment in constructed wetlands.

Mental health and psychiatry training in primary care residency programs. Part I. Who teaches, where, when and how satisfied?

OBJECTIVE: Some 40% of patients treated by primary care physicians have significant mental health problems. Only about half eventually receive mental health care, usually by the primary care physicians, often inadequately. Recently, there has been an increased attempt to incorporate psychiatry in primary care training programs. The authors sought to assess the current status of psychiatry training in Internal Medicine (IM), Family Practice (FP), Pediatrics (Peds) and Obstetrics and Gynecology (Ob/Gyn) residency programs. METHOD: All 1365 directors of accredited residency training programs in IM, FP, Ob/Gyn and Peds received a 16-item anonymous questionnaire in 2001-2002, collecting descriptive data concerning their psychiatry training. RESULTS: A great majority of IM (71%), Ob/Gyn (92%) and Peds (85%) training directors felt that the training was minimal or suboptimal, as compared to 41% of FP training directors (P<.001). Sixty-four percent of FP program directors were satisfied with their training (P<.001). In contrast, 54% of other PC program directors were dissatisfied with their psychiatry training. All programs utilized ambulatory care setting extensively. Family Practice programs had more types of mental health teachers, teaching formats and teaching settings (P<.001). A majority of IM (57%) and Peds (70%) residencies desired more psychiatry training in their programs compared to only a third of FP and 40% of Ob/Gyn programs (P<.001). Teaching in clinical settings was preferred by all except Ob/Gyn programs (P<.001). Psychiatry departments contributed more to IM and Peds programs than others. CONCLUSION: A majority of primary care training programs are dissatisfied with the current status of their psychiatric training except for FP programs. Family Practice programs have the most variety in training formats, venues and teachers. There are some specialty-specific differences in perceived needs and desires in psychiatric training.

Mental health and psychiatry training in primary care residency programs. Part II. What skills and diagnoses are taught, how adequate, and what affects training directors' satisfaction?

OBJECTIVE: The purpose of this study is to describe the psychiatric skills and diagnostic categories taught in primary care training programs, their adequacy, the perceived needs and desires for curriculum enhancement and the factors affecting training directors' satisfaction. METHOD: All 1365 directors of accredited residency training programs in Internal Medicine (IM), Family Practice (FP), Obstetrics and Gynecology (Ob/Gyn), Pediatrics (Peds) and psychiatry received a 16-item anonymous questionnaire about psychiatry training in their program. Responses to the questionnaire to items concerning the skills and diagnostic categories taught, assessment of adequacy of teaching and desires for curriculum enhancement for specific skills and diagnostic categories were analyzed. The factors affecting training directors' satisfaction were explored. RESULTS: Interviewing skills were taught by a majority of all training programs and were considered adequate by 81% of FP and 54% of IM programs, in contrast to less than a majority of Ob/Gyn and Peds programs (P<.001). A majority provided diagnostic interviewing and counseling training, but only FP considered it adequate. A majority taught psychopharmacology and various psychiatric diagnoses, but only in FP did a majority consider them adequate. Both Peds and FP programs teach child psychiatry; significantly, more Peds compared to FP consider their training to be adequate. A vast majority of IM, Ob/Gyn and Peds programs, and 50% of FP programs desired more training in interviewing techniques and diagnostic interview. A majority of all programs desired more counseling and psychopharmacology training and more training in disorders of childhood and adolescence. The overall satisfaction rate for psychiatric training across specialties was 46% (n=657). Sixty-four percent of FP programs were satisfied compared to 31% of non-FP programs. Satisfaction was associated with increased amount of psychiatric training, diversity of training formats, venues, faculty and settings, the amount of contribution to teaching by psychiatry departments and the presence of current teaching in interviewing skills. There were specialty-specific differences in factors associated with satisfaction. In general, a smaller size of residency program was associated with satisfaction except in IM, where larger size was associated with satisfaction. Satisfaction was associated with the opinion that primary care physician should be ready and willing to treat more psychiatric conditions. CONCLUSION: Most primary care training programs currently offer training in most psychiatric skills and disorders, but a majority of training directors are dissatisfied with their psychiatry training. There is a difference in the estimation of adequacy concerning training between FP, which consistently rates their teaching to be adequate, and all other primary care programs, which consider their teaching inadequate. This difference may be partly due to actual differences in amount and diversity of training as well as differences in the threshold for satisfaction. A vast majority of primary care training programs desire more training in almost all aspects of psychiatry, and there may be specialty-specific needs and areas of curriculum enhancement. To enhance satisfaction, we should improve the quality as well as the quantity of training, as well as the diversity in training formats, venues and faculty.

Predicting perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pediatric cancer survivors.

OBJECTIVE: To examine predictors of perceived vulnerability to tobacco-related health risks and future intentions to use tobacco among pre-adolescents and adolescents previously treated for cancer. METHODS: Written self-report measures of tobacco knowledge, perceived vulnerability, perceived positive value of tobacco use, past and present tobacco use, and intentions to use tobacco were completed by 103 cancer survivors, 10-18 years of age (51.5% males, 78.6% Caucasians). Patient reports of peer and parent tobacco use were also obtained. RESULTS: Perceived vulnerability was influenced by demographic variables, knowledge, and gender-related past tobacco use. Fifty-seven percent of non-smoking survivors reported some intention to use tobacco. Survivors who perceived some positive value associated with tobacco use and who used tobacco in the past reported greater intentions for future tobacco use. CONCLUSION: Modifiable cognitive-motivational variables directly associate with smoking-related outcomes among pediatric survivors of childhood cancer. PRACTICE IMPLICATIONS: Preventive tobacco interventions with this vulnerable cohort are warranted and should inform about tobacco-related health risks and attempt to modify misperceptions of the positive value associated with tobacco use.

Involvement of nuclear export in human papillomavirus type 18 E6-mediated ubiquitination and degradation of p53.

The E6 protein from high-risk human papillomaviruses (HPVs) targets the p53 tumor suppressor for degradation by the proteasome pathway. This ability contributes to the oncogenic potential of these viruses. However, several aspects concerning the mechanism of E6-mediated p53 degradation at the cellular level remain to be clarified. This study therefore examined the role of cell localization and ubiquitination in the E6-mediated degradation of p53. As demonstrated within, following coexpression both p53 and high-risk HPV type 18 (HPV-18) E6 (18E6) shuttle from the nucleus to the cytoplasm. Mutation of the C-terminal nuclear export signal (NES) of p53 or treatment with leptomycin B inhibited the 18E6-mediated nuclear export of p53. Impairment of nuclear export resulted in only a partial reduction in 18E6-mediated degradation, suggesting that both nuclear and cytoplasmic proteasomes can target p53 for degradation. This was also consistent with the observation that 18E6 mediated the accumulation of polyubiquitinated p53 in the nucleus. In comparison, a p53 isoform that localizes predominantly to the cytoplasm was not targeted for degradation by 18E6 in vivo but could be degraded in vitro, arguing that nuclear p53 is the target for E6-mediated degradation. This study supports a model in which (i) E6 mediates the accumulation of polyubiquitinated p53 in the nucleus, (ii) E6 is coexported with p53 from the nucleus to the cytoplasm via a CRM1 nuclear export mechanism involving the C-terminal NES of p53, and (iii) E6-mediated p53 degradation can be mediated by both nuclear and cytoplasmic proteasomes.

Regulation of human p53 activity and cell localization by alternative splicing.

The development of cancer is a multistep process involving mutations in proto-oncogenes, tumor suppressor genes, and other genes which control cell proliferation, telomere stability, angiogenesis, and other complex traits. Despite this complexity, the cellular pathways controlled by the p53 tumor suppressor protein are compromised in most, if not all, cancers. In normal cells, p53 controls cell proliferation, senescence, and/or mediates apoptosis in response to stress, cell damage, or ectopic oncogene expression, properties which make p53 the prototype tumor suppressor gene. Defining the mechanisms of regulation of p53 activity in normal and tumor cells has therefore been a major priority in cell biology and cancer research. The present study reveals a novel and potent mechanism of p53 regulation originating through alternative splicing of the human p53 gene resulting in the expression of a novel p53 mRNA. This novel p53 mRNA encodes an N-terminally deleted isoform of p53 termed p47. As demonstrated within, p47 was able to effectively suppress p53-mediated transcriptional activity and impair p53-mediated growth suppression. It was possible to select for p53-null cells expressing p47 alone or coexpressing p53 in the presence of p47 but not cells expressing p53 alone. This showed that p47 itself does not suppress cell viability but could control p53-mediated growth suppression. Interestingly, p47 was monoubiquitinated in an Mdm2-independent manner, and this was associated with its export out of the nucleus. In the presence of p47, there was a reduction in Mdm2-mediated polyubiquitination and degradation of p53, and this was also associated with increased monoubiquitination and nuclear export of p53. The expression of p47 through alternative splicing of the p53 gene thus has a major influence over p53 activity at least in part through controlling p53 ubiquitination and cell localization.

Geriatric rehabilitation. 1. Social and economic implications of aging.

UNLABELLED: This self-directed learning module highlights the social and economic implications of aging. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and geriatric medicine. This article specifically focuses on the epidemiology of aging, the economics of aging, informal and formal social support systems, ageism and societal issues, and care and treatment settings. OVERALL ARTICLE OBJECTIVE: To summarize the social and economic implications of aging in the context of physical medicine and rehabilitation.

Geriatric rehabilitation. 3. Physical medicine and rehabilitation interventions for common disabling disorders.

UNLABELLED: This self-directed learning module highlights physical medicine and rehabilitation (PM and R) interventions for common disorders that cause disability in older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in PM and R and geriatric medicine. This article specifically focuses on PM and R interventions for arthritides, fractures, cardiovascular disorders, peripheral vascular disease, amputations, pulmonary disorders, cancer, stroke, traumatic brain injury, Parkinson's disease, spinal cord injury, peripheral neuropathies, and diabetic complications. OVERALL ARTICLE OBJECTIVE: To summarize the physical medicine and rehabilitation interventions for commonly disabling conditions of older adults.

Geriatric rehabilitation. 2. Physiatric approach to the older adult.

UNLABELLED: This self-directed learning module highlights the physiatric approach to the older adult. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation (PM and R) and geriatric medicine. This article specifically focuses on the advantages of the physiatric approach, PM and R training in geriatric rehabilitation, metrics in geriatric assessment, prevention, symptom management, medical management, falls, pain, and pharmacology. OVERALL ARTICLE OBJECTIVE: To summarize the physiatric approach to the older adult.

Ubiquitination and proteasome degradation of the E6 proteins of human papillomavirus types 11 and 18.

Human papillomaviruses (HPVs) are aetiological agents for genital warts and cervical cancer, the different pathologies of which are dependent on the type of HPV infection. Oncogenic HPV types associated with cancer are carcinogens by virtue of their oncogene products, which target key regulators of cell proliferation and apoptosis. The viral E6 protein from oncogenic HPV types plays a central role in carcinogenesis by exploiting the cellular proteasome degradation pathway in order to mediate the degradation of cellular proteins, most notably the prototype tumour suppressor protein p53. Much less is known about the cellular targets of E6 from the non-oncogenic HPV types associated with genital warts. It is also unclear what factors influence the level and stability of the viral E6 proteins in cells. This report demonstrates that both oncogenic and non-oncogenic HPV E6 proteins (from types 18 and 11, respectively) are ubiquitinated and targeted for degradation by the 26S proteasome. E6 domains required for the induction of p53 or DLG degradation, or E6AP binding, are not involved in proteasome-mediated degradation of HPV-18 E6. These results provide insight into the cellular modulation of E6 protein levels from both high-risk and low-risk HPV types.

Intervention to reduce intentions to use tobacco among pediatric cancer survivors.

PURPOSE: In this randomized controlled trial, we sought to determine whether a risk counseling intervention would increase knowledge and perceived vulnerability to tobacco-related health risks and decrease future intentions to use tobacco among preadolescents and adolescents previously treated for cancer. PATIENT AND METHODS: Participants included 103 cancer survivors between the ages of 10 and 18 years who were randomly assigned to either a standard care control (SCC) group or a tobacco intervention (TI) group. Patients in the SCC group received standard advice about the risks of tobacco use. Patients in the TI group received more intensive late effects risk counseling in addition to an educational video, goal setting, written physician feedback, smoking literature, and follow-up telephone counseling. The effect of our intervention was assessed by self-reported knowledge, perceived vulnerability, and intentions at baseline, 6, and 12 months. RESULTS: Compared with the SCC group, patients who received our intervention had significantly higher knowledge scores, higher perceived vulnerability scores, and lower intention scores at 12 months. No significant differences between the SCC and TI groups at 6 months, across all measures, were found. CONCLUSION: Pediatric survivors' knowledge, perceived vulnerability to health risks, and intentions to use tobacco can be modified by a risk counseling intervention. The delayed effect of our intervention indicates that these changes may evolve over time. Implications for health care providers who engage in tobacco counseling with young cancer survivors are discussed. Additional longitudinal studies are needed to determine definitive long-term intervention effects on actual tobacco use in this high-risk population.