Acceptance and commitment therapy as an adjunct to the MOVE! programme: a randomized controlled trial.

OBJECTIVE: The current study tested the efficacy of an acceptance and commitment therapy (ACT) group intervention for disinhibited eating behaviour as an adjunct to the Veterans Affairs MOVE!© weight management programme. METHODS: Veterans (N = 88) with overweight or obesity who completed the MOVE! weight management programme and self-identified as having problems with 'stress-related eating' were randomized to four 2-h weekly ACT sessions or a continued behavioural weight-loss (BWL) intervention. Assessments were completed at baseline, post-treatment and 3- and 6-month follow-up on outcomes of interest including measures of disinhibited eating patterns, obesity-related quality of life, weight-related experiential avoidance and weight. RESULTS: The BWL group exhibited significantly greater reductions in binge eating behaviour at post-treatment compared with the ACT group. Significant improvements in other outcomes were found with minimal differences between groups. In both groups, decreases in weight-related experiential avoidance were related to improvements in binge eating behaviour. CONCLUSIONS: Taken together, the continued BWL intervention resulted in larger improvements in binge eating behaviour than the ACT intervention. The two groups showed similar improvements in other disinhibited eating outcomes. Future studies are encouraged to determine if more integrated or longer duration of ACT treatment may maximize eating outcomes in MOVE.Trial Registration Number: This trial was registered with ClinicalTrials.gov database (NCT01757847).

Plasma noradrenaline and state anxiety levels predict placebo response in learned immunosuppression.

Large interindividual differences exist in the presence and extent of placebo responses in both experimental and clinical studies, but little is known about possible predictors of these responses. We employed a behaviorally conditioned immunosuppression paradigm in healthy men to analyze predictors of learned placebo responses. During acquisition, the subjects received either the immunosuppressant cyclosporin A (n = 32) or a placebo (n = 14) (unconditioned stimuli (US)) together with a novel-tasting drink (conditioned stimulus (CS)). During evocation, the subjects were reexposed to the CS alone. In responders (n = 15), the CS alone caused a significant inhibition of interleukin (IL)-2 production by anti-CD3-stimulated peripheral blood T cells, closely mimicking the drug effect. Nonresponders (n = 17) did not show responses different from those of the controls. Multiple-regression analyses showed that baseline IL-2, plasma noradrenaline, and state anxiety predicted nearly 60% of the variance in the conditioned IL-2 response. These data provide first evidence for putative biological and psychological predictors of learned placebo responses.

Monophyly of terrestrial adephagan beetles as indicated by three nuclear genes (Coleoptera: Carabidae and Trachypachidae).

The beetle suborder Adephaga is traditionally divided into two sections on the basis of habitat, terrestrial Geadephaga and aquatic Hydradephaga. Monophyly of both groups is uncertain, and the relationship of the two groups has implications for inferring habitat transitions within Adephaga. Here we examine phylogenetic relationships of these groups using evidence provided by DNA sequences from all four suborders of beetles, including 60 species of Adephaga, four Archostemata, three Myxophaga, and ten Polyphaga. We studied 18S ribosomal DNA and 28S ribosomal DNA, aligned with consideration of secondary structure, as well as the nuclear protein-coding gene wingless. Independent and combined Bayesian, likelihood, and parsimony analyses of all three genes supported placement of Trachypachidae in a monophyletic Geadephaga, although for analyses of 28S rDNA and some parsimony analyses only if Coleoptera is constrained to be monophyletic. Most analyses showed limited support for the monophyly of Hydradephaga. Outside of Adephaga, there is support from the ribosomal genes for a sister group relationship between Adephaga and Polyphaga. Within the small number of sampled Polyphaga, analyses of 18S rDNA, wingless, and the combined matrix supports monophyly of Polyphaga exclusive of Scirtoidea. Unconstrained analyses of the evolution of habitat suggest that Adephaga was ancestrally aquatic with one transition to terrestrial. However, in analyses constrained to disallow changes from aquatic to terrestrial habitat, the phylogenies imply two origins of aquatic habit within Adephaga.

Hypothesis testing in evolutionary developmental biology: a case study from insect wings.

Developmental data have the potential to give novel insights into morphological evolution. Because developmental data are time-consuming to obtain, support for hypotheses often rests on data from only a few distantly related species. Similarities between these distantly related species are parsimoniously inferred to represent ancestral aspects of development. However, with limited taxon sampling, ancestral similarities in developmental patterning can be difficult to distinguish from similarities that result from convergent co-option of developmental networks, which appears to be common in developmental evolution. Using a case study from insect wings, we discuss how these competing explanations for similarity can be evaluated. Two kinds of developmental data have recently been used to support the hypothesis that insect wings evolved by modification of limb branches that were present in ancestral arthropods. This support rests on the assumption that aspects of wing development in Drosophila, including similarities to crustacean epipod patterning, are ancestral for winged insects. Testing this assumption requires comparisons of wing development in Drosophila and other winged insects. Here we review data that bear on this assumption, including new data on the functions of wingless and decapentaplegic during appendage allocation in the red flour beetle Tribolium castaneum.

Phylogenetic analysis of the Wnt gene family and discovery of an arthropod wnt-10 orthologue.

Wnt genes encode a conserved family of secreted signaling proteins that play many roles in arthropod and vertebrate development. We have investigated both the phylogenetic history and molecular evolution of this gene family. We have identified a novel Wnt gene in a diversity of arthropods that it is likely an orthologue of the vertebrate Wnt-10 group. Wnt-10 is one of only two cases in which orthology between protostome and deuterostome genes could be consistently assigned based on our analyses. Despite difficulties in assessing orthologies, all of our trees suggest that the most recent common ancestor of protostomes and deuterostomes possessed more than the five Wnt genes known from either arthropods or nematodes. This suggests that Wnt gene loss has occurred during protostome evolution. In addition, we examined the rate of amino acid evolution in the two arthropod/deuterostome orthology groups we identified. We found little rate variation across taxa, with the exception that Drosophila Wnt-1 is evolving more rapidly than all vertebrate and most arthropod orthologues.

Cardiovascular risk factors in homeless adults.

Homelessness is a growing problem in the United States, with population numbers ranging from 300,000 to several million. This article reviews five studies that focused on identification and assessment of cardiovascular risk factors in the homeless population. A case study presents the successful outcome of a homeless male with several risk factors. Assessment and intervention by a nurse practitioner led to his re-entry into the domiciled population. Implications for clinical practice and recommendations for further research are discussed.

El proceso diagnóstico en las alteraciones endocrinológicas

Las alteraciones endocrinológicas, tanto diagnosticadas como no diagnosticadas, representan una gran parte de la practica médica. El presente artículo, dirigido al diagnostico y tratamiento de las alteraciones mas comunes y tambien de las menos comunes que afectan la glándula tiroides, las glándulas suprarenales y el metabolismo del calcio, constituyen una excelente guía para el médico sobre cuándo evaluar la función de una glándula, cuándo descartar la posibilidad de una enfermedad maligna y cuándo referir al paciente

The pre-Flexnerian reports: Mark Twain's criticism of medicine in the United States.

By the time Mark Twain was born, in 1835, the political forces of Jacksonian democracy had created an era of unregulated medical practice in the United States. Licensure laws were almost nonexistent, and any citizen could practice medicine. Regular ("allopathic") medicine was competing with at least two dozen other sects, including homeopathic, botanical, and hydropathic medicine. Although allopathy presented itself as the "scientific" branch of medicine and proclaimed the practices of the other sects to be "quackery," its therapies were aggressive and toxic and had no proven advantage over the treatments used by competitors. Through the efforts of the American Medical Association (AMA), allopathic medicine eliminated its competition by promoting the reestablishment of licensure laws in the late 1800s. In a continuation of the same endeavor, the AMA sought to identify weak and inadequate medical schools and commissioned Abraham Flexner to write the famous Flexner report of 1910 (the year of Mark Twain's death). Twain, an insightful political observer and social critic who was familiar with the competing medical systems and the medical politics of the 19th century, questioned the wisdom of limiting patients' medical options. He doubted the competence and intentions of physicians as a group even as he maintained confidence in the abilities of his own physicians. He was critical of the empirical medical practices used during his youth, but he saw hope in the new scientific orientation of medicine in the early 20th century. Twain's commentaries provide a unique perspective on pre-Flexnerian medicine in the United States.

Ratings of students' performances in a third-year internal medicine clerkship: a comparison between problem-based and lecture-based curricula.

PURPOSE: To compare clinical performances in a third-year medicine clerkship between studies from a problem-based learning (PBL) curriculum and students from a traditional, lecture-based learning (LBL) curriculum. METHOD: The study participants were 88 PBL students and 364 LBL students rotating through a common third-year internal medicine clerkship at the Bowman Gray School of Medicine at Wake Forest University, classes of 1991-1995. Faculty and housestaff assessed the students' performances using four clinical rating scales. The student also completed the medicine student ("shelf") test of the National Board of Medical Examiners (NBME). RESULTS: On average, the PBL students received significantly higher ratings from housestaff and faculty on all four rating scales. No difference in scores on the NBME medicine shelf test was observed. CONCLUSION: The results support the hypothesis that preclinical PBL curricula as found at the Bowman Gray School of Medicine may enhance third-year students' clinical performances.

Pheochromocytoma. Update on diagnosis, localization, and management.

Pheochromocytoma, although rare, is associated with a high degree of morbidity and mortality if not recognized. A high degree of suspicion in patients with new-onset hypertension; hypertension with sudden worsening or development of diabetes mellitus; or a family history of MEN, neuroectodermal tumors, or simple pheochromocytoma should prompt biochemical confirmation with either 24-hour urine catecholamines (norepinephrine and epinephrine) or total MET (NMET plus MET). Following confirmation of the diagnosis, radiologic studies with CT and (if needed) MIBG are employed to localize the tumor. Surgical removal is the only definitive therapy. Medical management with alpha-blocking agents, to control symptoms and prevent a hypertensive crisis, is generally advocated for 2 weeks preoperatively and intraoperatively. Occasionally, beta-blockers, employed only after adequate alpha-blockade, are necessary to control tachycardia and tachyarrhythmias. High-dose MIBG and combination chemotherapy have been used adjunctively to treat malignant pheochromocytoma, although neither modality provides lasting satisfactory results. Normal urine assays performed 2 weeks postoperatively ensure the complete removal of all tumor. Additionally, lifelong follow-up (yearly initially) is necessary to detect any signs of benign recurrence or malignancy because these have been reported to occur as long as 41 years after the initial surgical resection. Biochemical evidence of excess catecholamine production usually precedes the clinical manifestations of catecholamine excess when these tumors recur.

The endocrine response to critical illness.

The endocrine response to stress is complex. Elevations in the serum concentrations of the "classic" stress hormones, epinephrine and cortisol, occur following many kinds of physiologic challenge and are accompanied by elevations in corticotropin, GH, and glucagon levels. These changes are probably responsible for the hyperglycemia and hypercatabolism common to most critical illness. If volume depletion is present, vasopressin, renin, and aldosterone secretion are also likely to be stimulated. These hormones, if present in excess, may produce fluid retention and hyponatremia. In some critically ill patients, there is a dissociation of renin and aldosterone production called hyperreninemic hypoaldosteronism, but the clinical importance of this syndrome is poorly understood. Thyroid hormone metabolism is commonly affected by critical illness, which results in characteristic abnormalities of thyroid function testing known as the euthyroid sick syndrome. The reproductive axis is exquisitely sensitive to physiologic stress; hypogonadotropic hypogonadism is a common finding in critical illness. The ongoing challenge to the clinician is to determine whether seemingly abnormal hormone measurements in critically ill patients reflect an appropriate homeostatic response to severe illness or, instead, whether they denote an independent metabolic disorder that might actually cause or contribute to the patient's unstable condition. In view of the exceedingly complex (and poorly understood) interactions involved in the human response to a severe illness, a thoughtful approach to the whole patient is essential and far preferable to indiscriminate hormone testing. Such testing, at best, may be uninterpretable in light of the clinical circumstances or, at worst, may lead to therapeutic misadventures.

Pituitary apoplexy.

Pituitary apoplexy is a clinical syndrome of headache, visual deficits, ophthalmoplegia, and alteration in mental status resulting from the sudden hemorrhage or infarction of a pituitary adenoma. Infarction of a normal gland also may occur in certain circumstances. Its manifestations are variable, ranging from a clinically benign event to a catastrophic presentation with permanent neurologic deficits or even death. It frequently mimics other intracranial processes and, without a high index of suspicion, may be difficult to diagnose. Radiographic studies, particularly CT and MR imaging, are helpful for diagnosis in both the acute and subacute settings. In its most fulminant presentation, prompt neurosurgical decompression is necessary to preserve sight and life. Corticosteroid replacement is also essential in the acute phase because of the high incidence of adrenal insufficiency. Fortunately, however, with proper management most patients may have good outcomes.

Acute adrenal insufficiency.

Acute adrenal insufficiency is a rare disorder associated with high morbidity and mortality if allowed to progress unrecognized. A constellation of nonspecific symptoms including weakness, easy fatigue, nausea, anorexia, and weight loss are typical features of adrenal insufficiency. The index of suspicion should be particularly high if the patient has hyperpigmentation; hyponatremia and/or hyperkalemia; a history of autoimmune disease (hypothyroidism, diabetes) or recent prior use of exogenous steroids or if the patient is on anticoagulant therapy. Any decline in clinical status (hypotension, fever, decreasing mental status), especially in the setting of an acute intercurrent illness, should be treated aggressively, even before laboratory confirmation of the diagnosis. Diagnostic testing is fairly straightforward and readily available. The development of purified synthetic corticosteroid preparations has provided a safe and effective means of replacement. Early awareness, recognition, and intervention remain significant steps in altering the course of acute adrenal insufficiency.