Training in Neurorehabilitation Psychology: Defining Competencies, Requisite Skill Sets, and a Proposed Developmental Pathway.

Psychologists have been applying neurorehabilitation models of care for many years. These practitioners come from different training backgrounds and use a variety of titles to refer to themselves despite considerable overlap in practice patterns, professional identification, and salary. Titles like 'neurorehabilitation psychologist' and 'rehabilitation neuropsychologist' are sometimes used by practitioners in the field to indicate their specialty area, but are not formally recognized by the American Psychological Association, the American Board of Professional Psychology, or by training councils in clinical neuropsychology (CN) or rehabilitation psychology (RP). Neither the CN or RP specialties alone fully address or define the competencies, skill sets, and clinical experiences required to provide high quality, comprehensive neurorehabilitation psychology services across settings. Therefore, irrespective of practice setting, we believe that both clinical neuropsychologists and rehabilitation psychologists should ideally have mastery of specific, overlapping competencies and a philosophical approach to care that we call neurorehabilitation psychology in this paper. Trainees and early career professionals who aspire to practice in this arena are often pressured to prioritize either CN or RP pathways over the other, with anxiety about perceived and real potential for falling short in their training goals. In the absence of an explicit training path or formal guidelines, these professionals emerge only after the opportunity, privilege, or frank luck of working with specific mentors or in exceptional patient care settings that lend themselves to obtaining integrated competencies in neurorehabilitation psychology. This paper reflects the efforts of 7 practitioners to preliminarily define the practice and philosophies of neurorehabilitation psychology, the skill sets and competencies deemed essential for best practice, and essential training pathway elements. We propose competencies designed to maximize the integrity of training and provide clear guideposts for professional development.

The Nitric Oxide System in Peripheral Artery Disease: Connection with Oxidative Stress and Biopterins.

Peripheral artery disease (PAD) pathophysiology extends beyond hemodynamics to include other operating mechanisms, including endothelial dysfunction. Oxidative stress may be linked to endothelial dysfunction by reducing nitric oxide (NO) bioavailability. We aimed to investigate whether the NO system and its regulators are altered in the setting of PAD and to assess the relationship between NO bioavailability and oxidative stress. Sera from 35 patients with intermittent claudication (IC), 26 patients with critical limb ischemia (CLI), and 35 non-PAD controls were analyzed to determine levels of tetrahydrobiopterin (BH4), dihydrobiopterin (BH2), nitrate/nitrite (nitric oxides, or NOx), arginine, citrulline, asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), and the oxidative stress markers 8-Oxo-2'-deoxyguanosine (8-OHdG), 4-hydroxynonenal (4-HNE), advanced glycation end products (AGEs), and protein carbonyls. NOx was significantly lower in IC and CLI patients compared to controls in association with elevated oxidative stress, with the greatest NOx reductions observed in CLI. Compared with controls, IC and CLI patients had reduced BH4, elevated BH2, and a reduced BH4/BH2 ratio. SDMA, the arginine/SDMA ratio, and the arginine/ADMA ratio were significantly higher in CLI patients. The NO system and its regulators are significantly compromised in PAD. This dysregulation appears to be driven by increased oxidative stress and worsens as the disease progresses from claudication to CLI.

An urban medical system's exploratory study of medication errors.

AIMS: This study sought to identify patterns of medication errors with respect to shifts, day of week, unit involved, severity, medication class and cause of errors and to propose possible solutions. DESIGN: This was a retrospective explorative study using a database containing 605 medication events from two medical centres. Variables assessed include medication type, the error severity, and time the medication was ordered, the unit that the error occurred on and the day of the week of the errors. METHODS: Simple percentages were used to report the results, and point-biserial correlation was employed to test for significant differences between the day and night shifts. RESULTS: There were no statistically significant findings when comparing event severity against the a.m. or p.m. shifts. The medication classes with the most errors were antibiotics, and the most common reason cited for errors was dose omission. The most commonly reported severity level was a 2 which requires increased patient monitoring.

Role of Transforming Growth Factor-ß in Skeletal Muscle Fibrosis: A Review.

Transforming growth factor-beta (TGF-ß) isoforms are cytokines involved in a variety of cellular processes, including myofiber repair and regulation of connective tissue formation. Activation of the TGF-ß pathway contributes to pathologic fibrosis in most organs. Here, we have focused on examining the evidence demonstrating the involvement of TGF-ß in the fibrosis of skeletal muscle particularly. The TGF-ß pathway plays a role in different skeletal muscle myopathies, and TGF-ß signaling is highly induced in these diseases. In this review, we discuss different molecular mechanisms of TGF-ß-mediated skeletal muscle fibrosis and highlight different TGF-ß-targeted treatments that target these relevant pathways.

Effects of Limb Revascularization Procedures on Oxidative Stress.

Revascularization procedures to treat patients with peripheral artery disease are among the most common operations performed by vascular surgeons. However, there are major limitations to revascularizations, readmission rates due to procedural complications are high, and greater risks of cardiovascular and limb adverse outcomes have been reported for patients with peripheral artery disease undergoing limb revascularization. Specifically, surgical revascularization may be associated with increased generation of reactive oxygen species based on the ischemia reperfusion injury theory, as restored blood flow and reoxygenation of ischemic areas may be accompanied by increased oxidative stress. In this review, we present the current evidence regarding the effects of revascularization procedures on oxidative stress. We also discuss potential therapeutic interventions to prevent ischemia reperfusion injury-mediated tissue damage.

Oxidative Stress and Arterial Dysfunction in Peripheral Artery Disease.

Peripheral artery disease (PAD) is an atherosclerotic disease characterized by a narrowing of the arteries in the lower extremities. Disease manifestations are the result of more than just reduced blood flow, and include endothelial dysfunction, arterial stiffness, and inflammation. Growing evidence suggests that these factors lead to functional impairment and decline in PAD patients. Oxidative stress also plays an important role in the disease, and a growing amount of data suggest a link between arterial dysfunction and oxidative stress. In this review, we present the current evidence for the involvement of endothelial dysfunction, arterial stiffness, and inflammation in the pathophysiology of PAD. We also discuss the links between these factors and oxidative stress, with a focus on nicotinamide adenine dinucleotide phosphate (NADPH) oxidase 2 (NOX2)-derived reactive oxygen species (ROS) and decreased nitric oxide (NO) bioavailability. Finally, the potential therapeutic role of NOX2 antioxidants for improving arterial function and functional status in PAD patients is explored.

Supervision in rehabilitation psychology: Application of Beatrice Wright's value-laden beliefs and principles.

Clinical supervision is of critical importance for training subsequent generations of psychologists. Specialty training in rehabilitation psychology requires exposure to specific knowledge, skills, and attitudes related to disability and specialized supervision and mentorship. In the literature to date, minimal guidance exists regarding supervision training and methods specifically for rehabilitation psychologists. This article aims to provoke discussion regarding supervision practice and dissemination of the values fundamental to our specialty. The foundational wisdom of Dr. Beatrice Wright (1983) is applied for the purposes of this endeavor. Examples of clinical supervision scenarios are presented as teaching vignettes to demonstrate ways in which supervisors and mentors can incorporate this content, promote discussion, and apply it to real-world practice.

The Internet Process Addiction Test: Screening for Addictions to Processes Facilitated by the Internet.

The Internet Process Addiction Test (IPAT) was created to screen for potential addictive behaviors that could be facilitated by the internet. The IPAT was created with the mindset that the term "Internet addiction" is structurally problematic, as the Internet is simply the medium that one uses to access various addictive processes. The role of the internet in facilitating addictions, however, cannot be minimized. A new screening tool that effectively directed researchers and clinicians to the specific processes facilitated by the internet would therefore be useful. This study shows that the Internet Process Addiction Test (IPAT) demonstrates good validity and reliability. Four addictive processes were effectively screened for with the IPAT: Online video game playing, online social networking, online sexual activity, and web surfing. Implications for further research and limitations of the study are discussed.

Endovascular repair of traumatic thoracic aortic tears.

BACKGROUND: Patients with thoracic aorta injuries (TAI) present a unique challenge. The purpose of this study was to review the outcomes of thoracic endovascular aortic repair (TEVAR) in patients with TAI. METHODS: A retrospective chart review of all patients admitted for TEVAR for trauma was performed. RESULTS: In a 5-year period, 19 patients (6 women and 13 men; average age, 42 y) were admitted to our trauma center with TAI. Mechanism of injury was a motor vehicle crash in 12 patients, motorcycle crash in 2 patients, automobile-pedestrian accident in 2 patients, 1 fall, 1 crush injury, and 1 stab wound to the back. A thoracic endograft was used in 6 patients and proximal aortic cuffs were used in 13 patients (68%). One patient (5%) died. There were no strokes, myocardial infarctions, paraplegia, or renal failure. CONCLUSIONS: TEVAR for TAI appears to be a safe option for patients with multiple injuries. TEVAR in young patients is still controversial because long-term endograft behavior is unknown.

Underreporting of bloodborne exposures in a dental school clinic.

This study explored the rate of underreporting of bloodborne exposures among dental students in a U.S. dental school during the final two years of clinical practice. It also explored the reasons students cite for failing to report bloodborne exposures. Surveys of the dental students found that senior students reported only 43 percent of the exposure incidents they experienced in their final year of clinical education and that the rate of reporting declined from the junior year to the senior year. We subsequently undertook an educational campaign to raise awareness among the students regarding the importance of reporting exposure incidents. Surveys were repeated for the next two years at the end of each academic year. The following year, the senior class indicated they had reported 79 percent of the experienced exposure incidents. This was not only a significant improvement over the previous year, but also demonstrated an improvement in reporting from their junior year to senior year, reversing the previously noted trend for exposure reporting to drop off in the senior year.

Staged endovascular treatment of bilateral ruptured and intact ovarian artery aneurysms in a postmenopausal woman.

Ovarian artery aneurysms have rarely been reported in the literature, with almost all being unilateral and occurring in the peripartum period. We herein describe a unique case of a postmenopausal patient with a ruptured ovarian aneurysm and an intact contralateral aneurysm that were both successfully treated by endovascular techniques.

Percutaneous treatment of a traumatic renal-caval arteriovenous fistula presenting as high output cardiac failure.

A 67-year-old dialysis-dependent man presented to the cardiology service with worsening high output cardiac failure and was found to have a harsh, right-sided abdominal bruit on examination. Of significance, he had undergone several laparotomies related to a stab wound experienced 7 years earlier. A computed tomography scan revealed right renal artery pseudoaneurysms with fistulous communication to the vena cava. Successful percutaneous coil embolization and cyanoacrylate gluing enabled fistula closure without renal infarction. Symptoms of cardiac failure ultimately resolved following treatment. Catheter-based therapies provide minimally invasive and effective strategies for treating complicated fistulas involving the renal vasculature.

Clinical quality assurance surveillance and targeted interventions: managing unfavorable trends in a dental school clinic.

Dental schools establish quality assurance (QA) programs that are intended to improve patient care, comply with requirements of liability carriers and regulatory agencies, and maintain accreditation. Data collection, trend analysis, and interventions are typically used in QA programs to monitor and improve compliance. The purpose of this article is to discuss unfavorable trends and examine the effect of targeted interventions in three clinical operations: infection control, removable prosthodontics, and case reviews of students' patient care in progress (interim case reviews) at a U.S. dental school. Infection control compliance was evaluated and interventions were implemented beginning in 2002 to correct unfavorable trends in two protocols: placement of students' mobile supply cart and the use of overgloves. A predelivery esthetic consent was introduced in spring 2004 to decrease esthetic failures in removable prosthodontics. For interim case reviews, two areas received interventions going back to 2003: reevaluation following initial periodontal therapy and orthodontic screening. The data presented are not meant to show conclusive success of particular interventions, but to display broad trends and suggest methods to manage quality assurance parameters. These trends suggest we had better success with the interventions that were simple, valuable, measurable, and repeatable than with interventions that less fit these criteria.

Clinical uses of naltrexone: a review of the evidence.

The implication of the opioidergic system in the pathogenesis of various substance use disorders has led to renewed interest in expanding the clinical uses of naltrexone, an opioid antagonist. This article examines the evidence for the efficacy of naltrexone in a variety of substance use and psychiatric disorders. Naltrexone can be an effective treatment for alcohol and opioid dependence if issues of compliance are adequately addressed. Thus far, no definitive role has been found for naltrexone in the treatment of other psychiatric disorders. Further research needs to be done in self-injurious behavior, gambling, cocaine, and nicotine dependence.

Adrenocorticotropin and cortisol responses to a naloxone challenge and risk of alcoholism.

BACKGROUND: Because abnormalities in opioid neurotransmission appear to underlie some of the inherited risk for alcoholism, we examined the effects of naloxone, an opioid antagonist, on corticotropin and cortisol responses in nonalcoholic subjects differentiated by paternal history of alcoholism. METHODS: Placebo-controlled, balanced, within-subject design involving 2 test days over a period of 3 to 7 days. Thirty-six subjects (67% male; 53% paternal-history-positive; mean age = 25.0 years) were screened to exclude substance abuse or dependence. Subjects received intravenous naloxone 125 microg/kg or placebo, with sessions in random order. Plasma corticotropin and cortisol were measured for up to 120 min post infusion. RESULTS: Corticotropin responses at baseline and following naloxone did not differ by paternal history of alcoholism; however, paternal-history-positive subjects exhibited greater cortisol concentrations at baseline, and at 15 and 30 min after naloxone administration. Paternal-history-positive subjects also had an earlier and greater peak cortisol response to naloxone and a nonsignificant trend for a greater area under the cortisol time curve than paternal-history-negative subjects. CONCLUSIONS: These findings suggest that individuals with greater vulnerability to alcoholism may have altered Hypothalamic-pituitary axis (HPA) dynamics, a finding that is consistent with a growing body of data on the role of opioidergic neurotransmission in the inherited risk of alcoholism.

Mecamylamine modifies the pharmacokinetics and reinforcing effects of alcohol.

BACKGROUND: Central nicotinic cholinergic receptors modify alcohol-induced mesolimbic dopamine activation, which seems to be important in the reinforcing properties of alcohol. Consistent with this model, acute administration to rats of the tertiary nicotinic receptor antagonist mecamylamine blocks both alcohol consumption and alcohol-induced dopamine release in the nucleus accumbens. This study was conducted to test the hypothesis that, during the ascending limb of the blood alcohol concentration curve, mecamylamine would reduce the stimulating and pleasurable effects of an intoxicating dose of alcohol in humans. METHODS: Ten female and 10 male volunteers with no history of alcohol or substance use disorders, including nicotine dependence, completed the study. During two laboratory sessions, subjects consumed three aliquots of an alcohol-containing drink, with a total ethanol content of 0.7 g/kg (in women) or 0.8 g/kg (in men), over a 30-min period. Two hours before the first drink, subjects were pretreated with mecamylamine or placebo, with the order of sessions counterbalanced. Primary outcome measures included the Drug Effect Questionnaire, the central stimulation subscale of the Alcohol Sensation Scale, and the stimulant subscale of the Biphasic Alcohol Effects Scale. Breath alcohol level (BAL) was examined to identify the ascending and descending limbs of the blood alcohol curve and to assess pharmacokinetic interactions between alcohol and mecamylamine. RESULTS: Significant effects of time, study drug, and their interaction were observed. Compared with placebo, mecamylamine reduced BAL. After controlling for BAL at each time point, mecamylamine also reduced the Drug Effect Questionnaire and Alcohol Sensation Scale stimulant subscale scores, with a trend for a similar effect on the Biphasic Alcohol Effects Scale score. CONCLUSIONS: Mecamylamine seems to modify both the pharmacokinetic profile of alcohol and the rewarding effects of alcohol in healthy volunteers.