Addiction and Suicide: A Review.

(Reprinted with permission from The American Journal on Addictions 24: 98-104, 2015).

Resident wellness: institutional trends over 10 years since 2003.

BACKGROUND: The surveys in this study were carried out at the Graduate Medical Education Division at Oregon Health & Science University (OHSU). OHSU implemented two significant wellness initiatives: a wellness program in 2004, and a policy allowing 4 half-days off each academic year to pursue personal or family health care needs in 2010. This study provides a secondary data analysis of five cross-sectional surveys of career satisfaction of resident and fellow trainees. METHODS: All trainees were surveyed five times over a 10-year period using anonymous, cross-sectional web-based survey instruments. Surveys included questions about career satisfaction, perceived stress, sleep hours, burnout, and related factors. RESULTS: This represents 10 years of accumulated responses from over 2,200 residents with results showing continual improvement in their career satisfaction. Response rates ranged from 56% to 72%. During the study period, there was a significant positive change in overall resident career satisfaction, with little change in factors traditionally considered to be predictive of overall career satisfaction such as sleep hours or perceived stress level. In addition, our data support that availability of time for personal tasks could positively impact the overall training experience. CONCLUSION: We postulate that the improvements in satisfaction relate to two major institutional innovations designed to promote resident wellness.

Addiction and suicide: A review.

BACKGROUND: Addiction specialists frequently find themselves faced with suicidal behavior in their addictions patients. Although many addiction treatment programs will not accept clients with recent suicidal behavior, up to 40% of patients seeking treatment for substance dependence report a history of suicide attempt(s).(1-3) Risk factors for suicide have been studied in the general population and among people with mental illness, less is known about risk factors in those with substance use disorders and co-occurring disorders. METHODS: Studies, psychological autopsies and recent reviews on risk factors for suicide and suicide attempts in patients with alcohol and drug use disorders and the relationship with co-occurring mental illness were examined. RESULTS AND CONCLUSIONS: Suicidal behavior is a significant problem for people with co-occurring disorders seeking addiction treatment. Several predisposing and precipitating risk factors such as marital and interpersonal relationship disruption, occupational and financial stressors, recent heavy substance use and intoxication as well as a history of previous suicide attempts and sexual abuse combine in an additive fashion with personality traits and mental illnesses to intensify risk for suicidal behavior in addiction patients. Major depression, bipolar disorder, borderline personality disorder and post-traumatic stress disorder are especially associated with suicidal behavior in people with addictive disorders. DISCUSSION AND SCIENTIFIC SIGNIFICANCE: Treatment implications of these findings are discussed. Addiction treatment providers should routinely gather information about client's suicidal histories, thoughts, and plans in order to assess risk and develop treatment plans for suicidality at various points in treatment.

Use of a voice and video internet technology as an alternative to in-person urgent care clinic visits.

This study aimed to determine the feasibility of patient-initiated online Internet urgent care visits, and to describe patient characteristics, scope of care, provider adherence to protocols, and diagnostic and therapeutic utilization. A total of 456 unique patients were seen via Internet-based technology during the study period, generating 478 consecutive total patient visits. Of the 82 patients referred for an in-person evaluation, 75 patients (91.5%) reported to the clinic as instructed. None of the 82 patients recommended for in-person evaluation required an emergency department referral, hospital admission or urgent consultative referral. We conclude that real-time online primary and urgent care visits are feasible, safe and potentially beneficial in increasing convenient access to urgent and primary care.

Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services.

PURPOSE: To evaluate awareness and utilization of a new institutional policy to grant residents time off to access personal and family health care. METHOD: In 2012, two years after policy implementation, an electronic survey was sent to all 546 residents and fellows at a tertiary care academic medical center in the United States. Residents were asked questions regarding awareness of the time-off policy, use of the policy, health care status, reasons for policy use, and barriers to use. RESULTS: A total of 490 (90%) residents responded. Eighty-nine percent of those surveyed were aware of the policy. Of those who were aware, 49.7% used the policy to access health care. Top reasons for policy use were for personal routine or preventive health care, dental care, and urgent health care needs. The most commonly reported barrier to policy use was concern about the impact the resident's absence would have on colleagues. CONCLUSIONS: Implementation of policies to prospectively schedule residents' time off during business hours to address health care needs is an important means to promote resident wellness. Such policies remove one commonly cited barrier to residents' access to health care. However, residents still reported concerns about impact on peers and patients as the main reason they were reluctant to take the time off to address their health care needs. More work is needed on both wellness policy implementation practices and on refining the systems that will allow seamless and guiltless transitions of care.

Survey of Residents' Attitudes and Awareness Toward Teaching and Student Feedback.

BACKGROUND: Teaching medical students is an important component of residency; however, little is known about student feedback regarding resident teaching skills. OBJECTIVE: We sought to explore resident awareness of medical student feedback mechanisms and how feedback is obtained, and also identified attitudes about teaching more commonly found in residents who seek feedback. METHODS: We surveyed all resident physicians at a university-affiliated academic health center about awareness of student feedback regarding their teaching abilities, and their attitudes related to teaching that may impact whether residents seek feedback. RESULTS: Of 605 residents, 335 (55%) responded, with 72% (242 of 335) noting they did not formally review student feedback of their teaching with their advisor during regularly scheduled meetings, 42% (140 of 332) reporting they did not know of any formal feedback mechanisms, and 28.4% (95 of 334) reporting they had not received feedback from students in any format. Although only a quarter of residents solicit feedback always or often, more than half would like feedback always or often. Reported barriers to feedback included student apprehension, time constraints, and lack of a formal system. A majority of residents had positive attitudes toward teaching and felt that student feedback would help teaching ability and medical proficiency. CONCLUSIONS: A large percentage of residents at 1 teaching institution reported not receiving feedback from students on their teaching abilities. Residents who did receive feedback were more likely to have actively solicited it. Overall, residents believe that this feedback from students would benefit their clinical and teaching performance.

Urate lowering efficacy of febuxostat versus allopurinol in hyperuricemic patients with gout

BACKGROUND: The prescribed maximum dose of allopurinol is 300 mg/day to maintain a serum uric acid (sUA) concentration of OBJECTIVE: To determine the efficacy and safety of febuxostat compared with allopurinol in lowering sUA level in patients with hyperuricemia in gout with a baseline sUA ? 8 mg/ dl.DATA SOURCES: Electronic searches through COCHRANE, EMBASE, PUBMED, and Manual Search. Search terms included the following: febuxostat, allopurinol, hyperuricemia, gout.STUDY SELECTION: Randomized, double-blinded, parallel-group clinical trials with meta-analysis quality scale of A-B were included. Intervention included administration of febuxostat and allopurinol in determined dosagesand duration in    each study.ANALYSIS: All outcomes were examined using the random effects model. Dichotomous data were analyzed by calculating the odds ratio, with 95% confidence interval and a significant p value of 0.1 was used.RESULTS: Pooled data showed significant decrease in sUA level from baseline with febuxostat 80 mg than with allopurinol with OR 0.31 (95% CI, 0.24-0.39, p = 0.00001). The risk of developing any adverse event with allopurinol is greater compared to febuxostat with RR 0.90 (95% CI, 0.84-0.96, p = 0.002).CONCLUSION: Febuxostat has significant urate lowering efficacy than allopurinol, and in patients with renal impairment without requiring dose adjustment, with lower incidence of any adverse events. However, elevated liver enzymes brought about by febuxostat were noted.

A comparison between physicians and demographically similar peers in accessing personal health care.

PURPOSE: Residents are a unique subpopulation of physicians, training in a complex work and educational environment that may create barriers to accessing preventive and illness-related health care. This study was designed to investigate residents' utilization of personal health care services and compare with those of demographically similar peers. METHOD: All 675 residents in a large, urban, tertiary care U.S. academic medical center were invited to participate in a confidential, Web-based, cross-sectional survey in January 2008. Survey responses to questions addressing personal health care were compared with those of a demographically similar group using the 2008 survey from the Behavioral Risk Factor Surveillance System (BRFSS). The final weights in BRFSS were used for a post hoc stratified adjustment in analysis. Logistic regression was employed to compare subgroups. RESULTS: Sixty-six percent of residents completed the survey. A significantly lower percentage of residents reported having a primary care provider (44%) or dentist (65%) or having routine health and dental care visits (39% and 53%, respectively) within the past year than those in the demographically similar group of 2008 BRFSS. In that group, 83% reported having a primary care provider, and 63% and 79% reported having routine primary and dental health care visits, respectively. CONCLUSIONS: The residents were significantly less likely than demographically similar peers to have a primary care provider or dentist or to participate in routine health maintenance. Further research into barriers preventing residents from accessing health care, and opportunities to address them, is needed.

Plug the leak: align public spending with public need.

We explore the history behind the current structure of graduate medical education funding and the problems with continuing along the current funding path. We then offer suggestions for change that could potentially manage this health care spill. Some of these changes include attracting more students into primary care, aligning federal graduate medical education spending with future workforce needs, and training physicians with skills they will require to practice in systems of the future.

Collaborative assessment and management of suicidality (CAMS): feasibility trial for next-day appointment services.

BACKGROUND: Despite the ubiquity of suicidality in behavioral health settings, empirically supported interventions for suicidality are surprisingly rare. Given the importance of resolving suicidality and therapists' anxieties about treating suicidal patients, there is a clear need for innovative services and clinical approaches. The purpose of the current study was an attempt to address some of these needs by examining the feasibility and use of a new intervention called the "Collaborative Assessment and Management of Suicidality" (CAMS) within a "Next-Day Appointment" (NDA) outpatient treatment setting. METHODS: As part of a larger feasibility study, n = 32 suicidal patients were randomly assigned to CAMS care versus Enhanced Care as Usual (E-CAU) in an outpatient crisis intervention setting attached to a safety net hospital. Intent to treat suicidal patients were seen and assessed before, during, and after treatment (with follow-up assessments conducted at 2, 4, 6, and 12 months). RESULTS: The feasibility of using CAMS in the NDA setting was clear; both groups appeared to initially benefit from their respective treatments in terms of decreased suicidal ideation and overall symptom distress. Although patients rated both treatments favorably, the CAMS group had significantly higher satisfaction and better treatment retention than E-CAU. At 12 months post-treatment, CAMS patients showed significantly better and sustained reductions in suicidal ideation, overall symptom distress, and increased hope in comparison to E-CAU patients. CONCLUSIONS: CAMS was both feasible in this NDA setting and effective in treating suicidal ideation, distress, and hopelessness (particularly at 12 months followup).

Addiction and suicidal behavior in acute psychiatric inpatients.

OBJECTIVE: This study aims to evaluate the relationship of alcohol/drug use and effect severities to the degree of suicidality in acutely admitted psychiatric patients. Both degree of substance dependency and degree of substance-induced syndrome were analyzed. In addition, length of stay, involuntary status, and against medical advice discharge status were determined as they related to these variables. METHODS: Structured clinical admissions and discharge ratings were gathered from 10,667 consecutive, single-case individual records, from an urban acute care county psychiatric hospital. RESULTS: Data indicate that of the most severely suicidal group, 56% had substance abuse or dependence, 40% were rated as having half or more of their admission syndrome substance induced, and most had nonpsychotic diagnoses. There was an inverse relationship between degree of substance problem and length of stay. Although these patients more commonly left against medical advice, and were readmitted more frequently, they were less likely to be involuntarily committed. CONCLUSIONS: A large, potentially lethal, and highly expensive subgroup of patients has been characterized, which might be called the "New Revolving Door acute psychiatric inpatient." This group, which uses the most expensive level of care in the mental health system but is substantially addiction related, poses special challenges for inpatient psychiatric units, addiction treatment providers, and health care planners.

Substance-induced suicidal admissions to an acute psychiatric service: characteristics and outcomes.

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients.

Effects of combined granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-2, and interleukin-12 based immunotherapy against intracranial glioma in the rat.

Cytokines play a major role in the regulation of the immune system. Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been shown to be useful for immunotherapy against glioma because it can stimulate dendritic cells to present tumor antigen. Interleukin-2 (IL-2) is involved in T-cell expansion, and interleukin-12 (IL-12) drives the T-helper cell type I response. Previous studies have shown that each of these cytokines alone can induce the regression of tumor cells. In the present study we postulated that peripheral infusion of GM-CSF along with either IL-2 or IL-12 and irradiated tumor cells can lead to increased survival from 9L brain tumors. 9L gliosarcoma cells (10(6)) were implanted in the brains of syngeneic Fischer 344 rats. Osmotic minipumps were utilized for subcutaneous, continuous delivery of GM-CSF, either alone or with IL-2 or IL-12. Irradiated 9L cells were injected subcutaneously at various time points during treatment. Delayed-type hypersensitivity (DTH) and immunohistological analysis were used to further characterize the anti-tumor response. Treatment with GM-CSF and irradiated tumor cells led to an increase in survival rate in rats with intracranial 9L tumors when compared to untreated animals. The addition of IL-2 or IL-12 to the GM-CSF/tumor cell therapy further increased the survival rate up to 90%. The anti-tumor response was associated with vigorous DTH against 9L cells and increased infiltration of CD4+ and CD8+ lymphocytes into the tumor. These results suggest that the combined infusion of GM-CSF and other cytokines may be effective adjuvants in treating brain tumors.

When "Emily Dickinson" Met "Steven Spielberg": Assessing Social Information Processing in Literacy Contexts.

Current research and theory on social information processing is used to frame the peer interactions of "Emily Dickinson," a 16-year-old girl with a long history of oral language problems and social isolation, but strong interests in literacy. In ongoing assessment that prioritized authentic and ecologically valid data collected in classroom settings, the Crick and Dodge (1994) model was used to guide an analysis of Emily's social-cognitive abilities and disabilities during peer interaction. These observations revealed that Emily had evolved a social schema that strategically recruited her strong literacy interests and skills to initiate and mediate social interaction with peers. This suggests that literacy curricula may be a valuable site for assessing and scaffolding social/communication problem-solving in students with language disabilities.