Gender and racial/ethnic differences in physiologic responses in the Stimulant Reduction Intervention using Dosed Exercise Study.

Exercise may be beneficial for individuals in substance use disorder (SUD) treatment given the higher rates of both medical and psychiatric comorbidity, namely mood and anxiety disorders, compared to the general population. Gender and/or racial/ethnic differences in health benefits and response to prescribed exercise have been reported and may have implications for designing exercise interventions in SUD programs. METHOD: Data are from the National Drug Abuse Treatment Clinical Trials Network (NIDA/CTN) Stimulant Reduction Intervention using Dosed Exercise (STRIDE) trial. Gender differences across racial/ethnic groups in physiological responses and stimulant withdrawal severity across time were analyzed using linear mixed effects models. RESULTS: Males completed significantly more exercise sessions than females and were more adherent to the prescribed exercise dose of 12 Kcal/Kg/Week. Controlling for age, race/ethnicity, treatment group and stimulant withdrawal severity, there was a significant gender by time interaction for body mass index (BMI) (p < 0.001), waist circumference (p < 0.001) and heart rate measured prior to exercise sessions (p < 0.01). For females, body mass index (BMI) and waist circumference increased over time while for males BMI and waist circumference stayed unchanged or slightly decreased with time. Heart rate over time significantly increased for females at a higher rate than in males. Stimulant withdrawal severity was similar in males and females at baseline but males exhibited a significant decrease over time while females did not. Although baseline differences were observed, there were no time by race/ethnicity differences in physiologic responses. DISCUSSION: Gender differences in response to exercise may have implications for developing gender specific exercise interventions in SUD programs.

Racial and ethnic differences in treatment outcomes among adults with stimulant use disorders after a dosed exercise intervention.

The current study examined differences in substance abuse treatment outcomes among racial and ethnic groups enrolled in the Stimulant Reduction Intervention using Dosed Exercise (STRIDE) trial, a multisite randomized clinical trial implemented through the National Institute on Drug Abuse's (NIDA's) Clinical Trials Network (CTN). STRIDE aimed to test vigorous exercise as a novel approach to the treatment of stimulant abuse compared to a health education intervention. A hurdle model with a complier average causal effects (CACE) adjustment was used to provide an unbiased estimate of the exercise effect had all participants been adherent to exercise. Among 214 exercise-adherent participants, we found significantly lower probability of use for Blacks (z = -2.45, p = .014) and significantly lower number of days of use for Whites compared to Hispanics (z = -54.87, p = <.001) and for Whites compared to Blacks (z = -28.54, p = <.001), which suggests that vigorous, regular exercise might improve treatment outcomes given adequate levels of adherence.

Ten years of experience with intravesical and intrasphincteric onabotulinumtoxinA in children.

OBJECTIVE: To review 10 years of experience with both intravesical and intrasphincteric onabotulinumtoxinA (Botox(®)) injections in children. PATIENTS AND METHODS: Fifty three children aged between 1 and 18 years at first injection had a combined total of 134 injections (106 intravesical, 23 intrasphincteric and five combined) between January 2004 and December 2013 at Princess Margaret Hospital. Follow-up occurred 3 months post procedure, and then 3-6 monthly. Response to Botox was graded according to the International Children's Continence Society (ICCS) response to treatment scale. Response time was the time that the injection remained effective before symptoms relapsed to the ICCS 'no response' category Nevéus et al., 2006. RESULTS: Median response times to Botox by pathology are summarised in Table 1. For detrusor overactivity (DO), the response after each Botox injection was in the ICCS '>90% symptom reduction' category Nevéus et al., 2006. Two children had sustained responses to Botox for a tenth and eleventh injection, respectively. A total of 45% of children receiving intrasphincteric Botox for chronic dysfunctional voiding (DV) or detrusor sphincter dyssynergia (DSD) had no symptom recurrence. Intravesical Botox was effective for treating new-onset hydronephrosis secondary to neurogenic bladder in one child. Intravesical Botox had a sustained effect over five injections in eliminating trigonal hypersensitivity and pain with CIC in one child. Episodes of severe autonomic dysreflexia in one child with a high cord transection were effectively eliminated by intravesical Botox, and were sustained over three injections. Thirteen of the 134 Botox injections (9.7%) had a symptomatic culture-positive urinary tract infection (UTI) in the 2 weeks following injection. All had a history of previous UTI. Three children (2.8%) developed urinary retention after intravesical injection. DISCUSSION: Intravesical Botox remained effective after up to eleven injections. In children with DV or DSD, the response to Botox was more variable, but 45% experienced symptom resolution with no recurrence. Trigonal hypersensitivity with CIC improved in a child after Botox. Botox may confer long-term bladder and upper tract protection in the neurogenic patient group. Severe episodes of autonomic dysreflexia triggered by bladder fill in a child with high cord lesion were eliminated by intravesical Botox. CONCLUSION: This study demonstrated that intravesical Botox remained effective in response quality and response time in children up to an eleventh injection. This is one of the longer follow-up studies in children published to date. Botox was effective in numbing trigonal hypersensitivity, treating new-onset hydronephrosis secondary to neurogenic bladder, and eliminating episodes of autonomic dysreflexia in one patient each.

IL-1ß and BDNF are associated with improvement in hypersomnia but not insomnia following exercise in major depressive disorder.

Given the role of sleep in the development and treatment of major depressive disorder (MDD), it is becoming increasingly clear that elucidation of the biological mechanisms underlying sleep disturbances in MDD is crucial to improve treatment outcomes. Sleep disturbances are varied and can present as insomnia and/or hypersomnia. Though research has examined the biological underpinnings of insomnia in MDD, little is known about the role of biomarkers in hypersomnia associated with MDD. This paper examines biomarkers associated with changes in hypersomnia and insomnia and as predictors of improvements in sleep quality following exercise augmentation in persons with MDD. Subjects with non-remitted MDD were randomized to augmentation with one of two doses of aerobic exercise: 16 kilocalories per kilogram of body weight per week (KKW) or 4 KKW for 12 weeks. The four sleep-related items on the clinician-rated Inventory of Depressive Symptomatology (sleep onset insomnia, mid-nocturnal insomnia, early morning insomnia and hypersomnia) assessed self-reported sleep quality. Inflammatory cytokines (tumor necrosis factor-alpha, interleukin (IL)-1ß, IL-6) and brain-derived neurotrophic factor (BDNF) were assessed in blood samples collected before and following the 12-week intervention. Reduction in hypersomnia was correlated with reductions in BDNF (ρ = 0.26, P = 0.029) and IL-1ß (ρ = 0.37, P = 0.002). Changes in these biomarkers were not associated with changes in insomnia; however, lower baseline levels of IL-1ß were predictive of greater improvements in insomnia (F = 3.87, P = 0.050). In conclusion, improvement in hypersomnia is related to reductions in inflammatory markers and BDNF in persons with non-remitted MDD. Distinct biological mechanisms may explain reductions in insomnia.

Does exercise improve self-reported sleep quality in non-remitted major depressive disorder?

BACKGROUND: Sleep disturbances are persistent residual symptoms following remission of major depressive disorder (MDD) and are associated with an increased risk of MDD recurrence. The purpose of the current study was to examine the effect of exercise augmentation on self-reported sleep quality in participants with non-remitted MDD. Method Participants were randomized to receive selective serotonin reuptake inhibitor (SSRI) augmentation with one of two doses of exercise: 16 kilocalories per kilogram of body weight per week (KKW) or 4 KKW for 12 weeks. Depressive symptoms were assessed using the clinician-rated Inventory of Depressive Symptomatology (IDS-C). The four sleep-related items on the IDS-C (Sleep Onset Insomnia, Mid-Nocturnal Insomnia, Early Morning Insomnia, and Hypersomnia) were used to assess self-reported sleep quality. RESULTS: Significant decreases in total insomnia (p < 0.0001) were observed, along with decreases in sleep onset, mid-nocturnal and early-morning insomnia (p's <0.002). Hypersomnia did not change significantly (p = 0.38). Changes in total, mid-nocturnal and early-morning insomnia were independent of changes in depressive symptoms. Higher baseline hypersomnia predicted a greater decrease in depression severity following exercise treatment (p = 0.0057). No significant moderating effect of any baseline sleep on change in depression severity was observed. There were no significant differences between exercise treatment groups on total insomnia or any individual sleep item. CONCLUSIONS: Exercise augmentation resulted in improvements in self-reported sleep quality in patients with non-remitted MDD. Given the prevalence of insomnia as a residual symptom following MDD treatment and the associated risk of MDD recurrence, exercise augmentation may have an important role in the treatment of MDD.

Pro-inflammatory cytokines as predictors of antidepressant effects of exercise in major depressive disorder.

Exercise is an efficacious treatment for major depressive disorder (MDD) and has independently been shown to have anti-inflammatory effects in non-depressed subjects. Patients with MDD have elevated inflammatory cytokines but it is not known if exercise affects inflammation in MDD patients and whether these changes are clinically relevant. In the TReatment with Exercise Augmentation for Depression (TREAD) study, participants who were partial responders to a selective serotonin reuptake inhibitor were randomized to receive one of two doses of exercise: 16 kilocalories per kilogram of body weight per week (KKW), or 4 KKW for 12 weeks. Blood samples were collected before initiation and again at the end of the 12-week exercise intervention. Serum was analyzed using a multiplexed ELISA for interferon-γ (IFN-γ), interleukin-1ß (IL-1ß), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). Higher baseline levels of TNF-α were associated with greater decrease in depression symptoms over the 12-week exercise period (P<0.0001). In addition, a significant positive correlation between change in IL-1ß and change in depression symptom scores was observed (P=0.04). There were no significant changes in mean level of any cytokine following the 12-week intervention, and no significant relationship between exercise dose and change in mean cytokine level. Results suggest that high TNF-α may differentially predict better outcomes with exercise treatment as opposed to antidepressant medications for which high TNF-α is linked to poor response. Our results also confirm findings from studies of antidepressant medications that tie decreasing IL-1ß to positive depression treatment outcomes.

Dolphin shows and interaction programs: benefits for conservation education?

Dolphin shows and dolphin interaction programs are two types of education programs within zoological institutions used to educate visitors about dolphins and the marine environment. The current study examined the short- and long-term effects of these programs on visitors' conservation-related knowledge, attitude, and behavior. Participants of both dolphin shows and interaction programs demonstrated a significant short-term increase in knowledge, attitudes, and behavioral intentions. Three months following the experience, participants of both dolphin shows and interaction programs retained the knowledge learned during their experience and reported engaging in more conservation-related behaviors. Additionally, the number of dolphin shows attended in the past was a significant predictor of recent conservation-related behavior suggesting that repetition of these types of experiences may be important in inspiring people to conservation action. These results suggest that both dolphin shows and dolphin interaction programs can be an important part of a conservation education program for visitors of zoological facilities.

A simulation study on the abatement of CO2 emissions by de-absorption with monoethanolamine.

Because of the adverse effect of CO2 from fossil fuel combustion on the earth's ecosystems, the most cost-effective method for CO2 capture is an important area of research. The predominant process for CO2 capture currently employed by industry is chemical absorption in amine solutions. A dynamic model for the de-absorption process was developed with monoethanolamine (MEA) solution. Henry's law was used for modelling the vapour phase equilibrium of the CO2, and fugacity ratios calculated by the Peng-Robinson equation of state (EOS) were used for H2O, MEA, N2 and O2. Chemical reactions between CO2 and MEA were included in the model along with the enhancement factor for chemical absorption. Liquid and vapour energy balances were developed to calculate the liquid and vapour temperature, respectively.

A computer-assisted administration of the Continuous Visual Memory Test.

The Continuous Visual Memory Test (CVMT) is a continuous design recognition test designed for the assessment of visual memory for clinical and research applications. Comparisons were made between the traditional and a computer-assisted format of the CVMT using 51 university students. Formats were compared on five CVMT dependent measures, concurrent validity, split-half reliability, and selected dependent measures from the California Verbal Learning Test (CVLT). Participants scored higher on the computer format dependent measures, with the exception of false alarms (new items incorrectly identified as old), which remained comparable between formats. Adequate concurrent validity (r =.70) and split-half reliability (rs =.61-.70) were demonstrated for CVMT Total Score. Restriction of range and ceiling effects precluded reliability and validity conclusions for CVMT Delay. The computer format showed a nonsignificant trend towards lower correlations with CVLT dependent measures.

Canonical correlation and chi-square: relationships and interpretation.

A 2 x 2 chi-square can be computed from a phi coefficient, which is the Pearson correlation between two binomial variables. Similarly, chi-square for larger contingency tables can be computed from canonical correlation coefficients. The authors address the following series of issues involving this relationship: (a) how to represent a contingency table in terms of a correlation matrix involving r - 1 row and c - 1 column dummy predictors; (b) how to compute chi-square from canonical correlations solved from this matrix; (c) how to compute loadings for the omitted row and column variables; and (d) the possible interpretive advantage of describing canonical relationships that comprise chi-square, together with some examples. The proposed procedures integrate chi-square analysis of contingency tables with general correlational theory and serve as an introduction to some recent methods of analysis more widely known by sociologists.

The role of extreme events in the impacts of selective tropical forestry on erosion during harvesting and recovery phases at Danum Valley, Sabah.

Ten years' hydrological investigations at Danum have provided strong evidence of the effects of extremes of drought, as in the April 1992 El Niño southern oscillation event, and flood, as in January 1996. The 1.5 km2 undisturbed forest control catchment experienced a complete drying out of the stream for the whole 1.5 km of defined channel above the gauging station in 1992, but concentrated surface flow along every declivity from within a few metres of the catchment divide after the exceptional rains of 19 January 1996. Under these natural conditions, erosion is episodic. Sediment is discharged in pulses caused by storm events, collapse of debris dams and occasional landslips. Disturbance by logging accentuates this irregular regime. In the first few months following disturbance, a wave of sediment is moved by each storm, but over subsequent years, rare events scour sediment from bare areas, gullies and channel deposits. The spatial distribution of sediment sources changes with time after logging, as bare areas on slopes are revegetated and small gullies are filled with debris. Extreme storm events, as in January 1996, cause logging roads to collapse, with landslides leading to surges of sediment into channels, reactivating the pulsed sediment delivery by every storm that happened immediately after logging. These effects are not dampened out with increasing catchment scale. Even the 721 km2 Sungai Segama has a sediment yield regime dominated by extreme events, the sediment yield in that single day on 19 January 1996 exceeding the annual sediment load in several previous years. In a large disturbed catchment, such road failures and logging-activity-induced mass movements increase the mud and silt in floodwaters affecting settlements downstream. Management systems require long-term sediment reduction strategies. This implies careful road design and good water movement regulation and erosion control throughout the logging process.

Using writing instruments: invariances in young children and adults.

In 2 studies, developmental changes in variability associated with handwriting were investigated. In Study 1, variability in grip patterns and pen positioning relative to a flat surface were examined in 3- and 5-year-olds and adults. The results indicated that between 3 and 5 years of age there is a reduction in the number of grips that individual children routinely use and a reduction in variability associated with pen-surface positioning. In Study 2, the 3-year-old children who participated in Study 1 were tested 6 months later. In comparison to young 3-year-old children, older 3-year-olds use an adult grip pattern more often and are less variable in pen-surface positioning, although the use of multiple grip patterns is still common. The findings from both studies are considered in relation to prior research that emphasized modal patterns of motor development and newer work that uses developmental changes in variability to understand the acquisition of motor skill.

Behavior problems in children with diabetes: disentangling possible scoring confounds on the Child Behavior Checklist.

OBJECTIVE: The Child Behavior Checklist (CBCL; T. M. Achenbach, 1991), when used to assess the behavior of children with diabetes, may contain confounds because some behavioral items can have a physiologic etiology, and may skew reports of behavioral disturbance. METHODS: Two techniques were used to disentangle possible scoring confounds in the behavioral ratings of children with and without diabetes: (1) the Somatic Complaints scale was deleted, or (2) Diabetes Items, identified a priori with 89% agreement by nine medical personnel, were deleted. RESULTS: As expected, with traditionally scored protocols, children with diabetes obtained higher Internalizing and Total Behavior Problem scores than controls. This group difference persisted whether the Somatic Complaints scale or the Diabetes Items were deleted. CONCLUSIONS: Compared to controls, children with diabetes obtained mildly elevated scores on six of the eight CBCL scales, regardless of scoring method, suggesting that their mildly elevated behavioral profile is not confounded by physiologic symptomatology.

The effect of a comprehensive Medicaid expansion on physicians' obstetric practices in Washington State.

BACKGROUND: In 1989 Washington State implemented a comprehensive expansion of its Medicaid perinatal program, augmenting services, increasing provider reimbursement, and broadening eligibility. This study examines the influence of this legislation on physicians' obstetric practices and attitudes toward caring for pregnant Medicaid patients. METHODS: Family physicians and obstetrician-gynecologists were surveyed at the start and 18 months after the Medicaid expansion. The study sample comprised physicians responding to the survey in both years. RESULTS: A greater proportion of family physicians provided unlimited obstetric care to Medicaid patients after the expansion. Sixty percent of family physicians and 56 percent of obstetrician-gynecologists were more willing to provide prenatal care to Medicaid patients as a result of the expansion. Physicians and their office staff were more comfortable with Medicaid patients in the later time period. Many physicians felt that they were better able to link their patients to a variety of social services after the expansion. CONCLUSIONS: A Medicaid expansion program can increase provider participation in Medicaid and increase provider comfort in caring for Medicaid patients.

Family environment and the interrelation of family structure, child behavior, and metabolic control for children with diabetes.

Examined perceptions of the family environment in a cross-regional sample of 90 families who had children with diabetes and 89 controls. Families were classified as either traditional (intact) or nontraditional (single-parent or blended families). Parents of children with diabetes reported less family expressiveness, which was a predictor of clinically higher levels of child behavior problems than controls. Parents in nontraditional families reported lower levels of organization, less emphasis on active-recreational pursuits, and more child behavior problems than traditional families. An additive effect of diabetes and nontraditional family structure was found for children with diabetes from nontraditional families, who reported substantially less cohesion than all other groups. Nontraditional family structure was more disruptive for children with diabetes than for controls; it was the best predictor of behavior problems and was related to poorer metabolic control.

Implementation issues in generalist education.

Devising a strategy for the implementation of a generalist medical educational program can be aided by grouping the many issues to be addressed into developmental stages. In this way, problems can be anticipated and resources marshalled. Initially, leadership and institutional support for the program must be developed. Next, detailed financial, curricular, and site planning must be undertaken. Implementation of the program must contend with faculty, site, and trainee concerns while consolidating financial and institutional support. Finally, in institutionalizing the program, financing must be secured and ongoing evaluation should provide information necessary to regularly reassess the program and renew its goals.

A comparison of student clerkship experiences in community practices and residency-based clinics.

BACKGROUND: In our required family medicine clerkship, we used data from student logbook records of clinical experience to compare the learning experiences of students in community practices and residency-based clinics. METHODS: Sixty-eight University of Washington students collected data on patients seen during the final two weeks of their family medicine clerkships. We compared patient demographics, location of patient encounters, and clinical problems seen at nine residency and eight community locations in a four-state area. National Ambulatory Medical Care Survey data were used to compare student experiences to national practices. RESULTS: Log data documented that both community practices and residency sites met the course curriculum goals. Some variations occurred between the two types of clerkship sites, however. Students at community practices saw a higher mean number of patients and did more procedures than students at residency sites. Students at residencies were more likely to see patients for health maintenance and pregnancy care and less likely to see lacerations, sprains or strains, and some chronic diseases. CONCLUSION: Episodic log data were successfully used to monitor the objective educational strategies for residency- and community-based student clerkship sites. Although all students met clerkship objectives, there were significant differences in certain aspects of students' clinical experiences at the two types of clerkship sites.

Thorotrast-induced ruptured hepatic angiosarcoma.

The use of Thorotrast as a contrast medium is now of historical interest. Thorotrast-induced angiosarcoma, though rare, still generates considerable clinical interest because of the characteristic opacification of the liver, spleen, and lymph nodes, and the long latency period between exposure and the onset of the tumor. We present a case of hepatic angiosarcoma which developed 37 years after the administration of Thorotrast.