Personalized risk communication and opioid prescribing in association with nonprescribed opioid use: A secondary analysis of a randomized controlled trial.

BACKGROUND: To determine the impact of personalized risk communication and opioid prescribing on nonprescribed opioid use, we conducted a secondary analysis of randomized controlled trial participants followed prospectively for 90 days after an emergency department (ED) visit for acute back or kidney stone pain. METHODS: A total of 1301 individuals were randomized during an encounter at four academic EDs into a probabilistic risk tool (PRT) arm, a narrative-enhanced PRT arm, or a general risk information arm (control). In this secondary analysis, both risk tool arms were combined and compared with the control arm. We used logistic regressions to determine associations between receiving personalized risk information, receiving an opioid prescription in the ED, and nonprescribed opioid use in general and by race. RESULTS: Complete follow-up data were available for 851 participants; 23.3% (n = 198) were prescribed opioids (34.2% of White vs. 11.6% of Black participants, p < 0.001). Fifty-six (6.6%) participants used nonprescribed opioids. Participants in the personalized risk communication arms had lower nonprescribed opioid use odds (adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.4-0.83). Black versus White participants had greater nonprescribed opioid use odds (aOR 3.47, 95% CI 2.05-5.87, p < 0.001). Black participants who were prescribed opioids had a lower marginal probability of using nonprescribed opioids versus those who were not (0.06, 95% CI 0.04-0.08, p < 0.001 vs. 0.10, 95% CI 0.08-0.11, p < 0.001). The absolute risk difference in nonprescribed opioid use for Black and White participants, respectively, in the risk communication versus the control arm, was 9.7% and 0.1% (relative risk ratio 0.43 vs. 0.95). CONCLUSIONS: Among Black but not White participants, personalized opioid risk communication and opioid prescribing were associated with lower odds of nonprescribed opioid use. Our findings suggest that racial disparities in opioid prescribing-which have been previously described within the context of this trial-may paradoxically increase nonprescribed opioid use. Personalized risk communication may effectively reduce nonprescribed opioid use, and future research should be designed specifically to explore this possibility in a larger cohort.

A Multicentered Randomized Controlled Trial Comparing the Effectiveness of Pain Treatment Communication Tools in Emergency Department Patients With Back or Kidney Stone Pain.

Objectives. To compare the effectiveness of 3 approaches for communicating opioid risk during an emergency department visit for a common painful condition. Methods. This parallel, multicenter randomized controlled trial was conducted at 6 geographically disparate emergency department sites in the United States. Participants included adult patients between 18 and 70 years of age presenting with kidney stone or musculoskeletal back pain. Participants were randomly assigned to 1 of 3 risk communication strategies: (1) a personalized probabilistic risk visual aid, (2) a visual aid and a video narrative, or 3) general risk information. The primary outcomes were accuracy of risk recall, reported opioid use, and treatment preference at time of discharge. Results. A total of 1301 participants were enrolled between June 2017 and August 2019. There was no difference in risk recall at 14 days between the narrative and probabilistic groups (43.7% vs 38.8%; absolute risk reduction = 4.9%; 95% confidence interval [CI] = -2.98, 12.75). The narrative group had lower rates of preference for opioids at discharge than the general risk information group (25.9% vs 33.0%; difference = 7.1%; 95% CI = 0.64, 0.97). There were no differences in reported opioid use at 14 days between the narrative, probabilistic, and general risk groups (10.5%, 10.3%, and 13.3%, respectively; P = .44). Conclusions. An emergency medicine communication tool incorporating probabilistic risk and patient narratives was more effective than general information in mitigating preferences for opioids in the treatment of pain but was not more effective with respect to opioid use or risk recall. Trial Registration. Clinical Trials.gov identifier: NCT03134092. (Am J Public Health. 2022;112(S1):S45-S55. https://doi.org/10.2105/AJPH.2021.306511).

Patient Preference and Risk Assessment in Opioid Prescribing Disparities: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Although racial disparities in acute pain control are well established, the role of patient analgesic preference and the factors associated with these disparities remain unclear. Objective: To characterize racial disparities in opioid prescribing for acute pain after accounting for patient preference and to test the hypothesis that racial disparities may be mitigated by giving clinicians additional information about their patients' treatment preferences and risk of opioid misuse. Design, Setting, and Participants: This study is a secondary analysis of data collected from Life STORRIED (Life Stories for Opioid Risk Reduction in the ED), a multicenter randomized clinical trial conducted between June 2017 and August 2019 in the emergency departments (EDs) of 4 academic medical centers. Participants included 1302 patients aged 18 to 70 years who presented to the ED with ureter colic or musculoskeletal back and/or neck pain. Interventions: The treatment arm was randomized to receive a patient-facing intervention (not examined in this secondary analysis) and a clinician-facing intervention that consisted of a form containing information about each patient's analgesic treatment preference and risk of opioid misuse. Main Outcomes and Measures: Concordance between patient preference for opioid-containing treatment (assessed before ED discharge) and receipt of an opioid prescription at ED discharge. Results: Among 1302 participants in the Life STORRIED clinical trial, 1012 patients had complete demographic and treatment preference data available and were included in this secondary analysis. Of those, 563 patients (55.6%) self-identified as female, with a mean (SD) age of 40.8 (14.1) years. A total of 455 patients (45.0%) identified as White, 384 patients (37.9%) identified as Black, and 173 patients (17.1%) identified as other races. After controlling for demographic characteristics and clinical features, Black patients had lower odds than White patients of receiving a prescription for opioid medication at ED discharge (odds ratio [OR], 0.42; 95% CI, 0.27-0.65). When patients who did and did not prefer opioids were considered separately, Black patients continued to have lower odds of being discharged with a prescription for opioids compared with White patients (among those who preferred opioids: OR, 0.43 [95% CI, 0.24-0.77]; among those who did not prefer opioids: OR, 0.45 [95% CI, 0.23-0.89]). These disparities were not eliminated in the treatment arm, in which clinicians were given additional data about their patients' treatment preferences and risk of opioid misuse. Conclusions and Relevance: In this secondary analysis of data from a randomized clinical trial, Black patients received different acute pain management than White patients after patient preference was accounted for. These disparities remained after clinicians were given additional patient-level data, suggesting that a lack of patient information may not be associated with opioid prescribing disparities. Trial Registration: ClinicalTrials.gov Identifier: NCT03134092.

Stories to Communicate Individual Risk for Opioid Prescriptions for Back and Kidney Stone Pain: Protocol for the Life STORRIED Multicenter Randomized Clinical Trial.

BACKGROUND: Prescription opioid misuse in the United States is a devastating public health crisis; many chronic opioid users were originally prescribed this class of medication for acute pain. Video narrative-enhanced risk communication may improve patient outcomes, such as knowledge of opioid risk and opioid use behaviors after an episode of acute pain. OBJECTIVE: Our objective is to assess the effect of probabilistic and narrative-enhanced opioid risk communication on patient-reported outcomes, including knowledge, opioid use, and patient preferences, for patients who present to emergency departments with back pain and kidney stone pain. METHODS: This is a multisite randomized controlled trial. Patients presenting to the acute care facilities of four geographically and ethnically diverse US hospital centers with acute renal colic pain or musculoskeletal back and/or neck pain are eligible for this randomized controlled trial. A control group of patients receiving general risk information is compared to two intervention groups: one receiving the risk information sheet plus an individualized, visual probabilistic Opioid Risk Tool (ORT) and another receiving the risk information sheet plus a video narrative-enhanced probabilistic ORT. We will study the effect of probabilistic and narrative-enhanced opioid risk communication on the following: risk awareness and recall at 14 days postenrollment, reduced use or preferences for opioids after the emergency department episode, and alignment with patient preference and provider prescription. To assess these outcomes, we administer baseline patient surveys during acute care admission and follow-up surveys at predetermined times during the 3 months after discharge. RESULTS: A total of 1302 patients were enrolled over 24 months. The mean age of the participants was 40 years (SD 14), 692 out of 1302 (53.15%) were female, 556 out of 1302 (42.70%) were White, 498 out of 1302 (38.25%) were Black, 1002 out of 1302 (76.96%) had back pain, and 334 out of 1302 (25.65%) were at medium or high risk. Demographics and ORT scores were equally distributed across arms. CONCLUSIONS: This study seeks to assess the potential clinical role of narrative-enhanced, risk-informed communication for acute pain management in acute care settings. This paper outlines the protocol used to implement the study and highlights crucial methodological, statistical, and stakeholder involvement as well as dissemination considerations. TRIAL REGISTRATION: ClinicalTrials.gov NCT03134092; https://clinicaltrials.gov/ct2/show/NCT03134092. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19496.

Evaluating meta-analytic methods to detect selective reporting in the presence of dependent effect sizes.

Selective reporting of results based on their statistical significance threatens the validity of meta-analytic findings. A variety of techniques for detecting selective reporting, publication bias, or small-study effects are available and are routinely used in research syntheses. Most such techniques are univariate, in that they assume that each study contributes a single, independent effect size estimate to the meta-analysis. In practice, however, studies often contribute multiple, statistically dependent effect size estimates, such as for multiple measures of a common outcome construct. Many methods are available for meta-analyzing dependent effect sizes, but methods for investigating selective reporting while also handling effect size dependencies require further investigation. Using Monte Carlo simulations, we evaluate three available univariate tests for small-study effects or selective reporting, including the trim and fill test, Egger's regression test, and a likelihood ratio test from a three-parameter selection model (3PSM), when dependence is ignored or handled using ad hoc techniques. We also examine two variants of Egger's regression test that incorporate robust variance estimation (RVE) or multilevel meta-analysis (MLMA) to handle dependence. Simulation results demonstrate that ignoring dependence inflates Type I error rates for all univariate tests. Variants of Egger's regression maintain Type I error rates when dependent effect sizes are sampled or handled using RVE or MLMA. The 3PSM likelihood ratio test does not fully control Type I error rates. With the exception of the 3PSM, all methods have limited power to detect selection bias except under strong selection for statistically significant effects. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Digital Whole Slide Imaging Compared With Light Microscopy for Primary Diagnosis in Surgical Pathology.

CONTEXT.­: The adoption of digital capture of pathology slides as whole slide images (WSI) for educational and research applications has proven utility. OBJECTIVE.­: To compare pathologists' primary diagnoses derived from WSI versus the standard microscope. Because WSIs differ in format and method of observation compared with the current standard glass slide microscopy, this study is critical to potential clinical adoption of digital pathology. DESIGN.­: The study enrolled a total of 2045 cases enriched for more difficult diagnostic categories and represented as 5849 slides were curated and provided for diagnosis by a team of 19 reading pathologists separately as WSI or as glass slides viewed by light microscope. Cases were reviewed by each pathologist in both modalities in randomized order with a minimum 31-day washout between modality reads for each case. Each diagnosis was compared with the original clinical reference diagnosis by an independent central adjudication review. RESULTS.­: The overall major discrepancy rates were 3.64% for WSI review and 3.20% for manual slide review diagnosis methods, a difference of 0.44% (95% CI, -0.15 to 1.03). The time to review a case averaged 5.20 minutes for WSI and 4.95 minutes for glass slides. There was no specific subset of diagnostic category that showed higher rates of modality-specific discrepancy, though some categories showed greater discrepancy than others in both modalities. CONCLUSIONS.­: WSIs are noninferior to traditional glass slides for primary diagnosis in anatomic pathology.

The contribution of school safety to weight-related health behaviors for transgender youth.

INTRODUCTION: The aim of the present study is to examine gender identity disparities in different kinds of weight-related health behaviors, including physical activity, participation in physical education at school, and healthy and unhealthy eating habits, and to investigate the relationship between school safety and such behaviors in a sample of transgender and non-transgender students. METHOD: We analyzed a statewide sample of 31,609 students (Mage = 14.04, SD = 1.70; 1.1% transgender). We used multilevel regression models to examine the interactive effects of gender identity and perceptions of school safety on the 4 different outcome variables (physical activity, physical education, healthy and unhealthy eating habits). All models included student- and school-level characteristics as controls. RESULTS: Findings indicated that transgender students, when compared to non-transgender students, reported (a) feeling less safe at school; (b) more physical activity, but less participation in physical education at school; and (c) both more healthy as well as unhealthy eating behaviors. Adjusted regression models showed a significant interaction between gender identity and perceived school safety on healthy eating behaviors; simple slopes indicated that transgender students have healthier eating behaviors when the school context is perceived as safe compared to those who perceived the school as less safe. CONCLUSIONS: School interventions are needed to improve school safety for transgender youth and to reduce gender identity-related disparities in healthy eating and physical activity. Research implications and limitations are discussed.

Wireless Participant Incentives Using Reloadable Bank Cards to Increase Clinical Trial Retention With Abused Women Drinkers: A Natural Experiment.

Retaining participants in longitudinal studies is a unique methodological challenge in many areas of investigation, and specifically for researchers aiming to identify effective interventions for women experiencing intimate partner violence (IPV). Individuals in abusive relationships are often transient and have logistical, confidentiality, and safety concerns that limit future contact. A natural experiment occurred during a large randomized clinical trial enrolling women in abusive relationships who were also heavy drinkers, which allowed for the comparison of two incentive methods to promote longitudinal retention: cash payment versus reloadable wireless bank cards. In all, 600 patients were enrolled in the overall trial, which aimed to incentivize participants using a reloadable bank card system to promote the completion of 11 weekly interactive voice response system (IVRS) phone surveys and 3-, 6-, and 12-month follow-up phone or in person interviews. The first 145 participants were paid with cash as a result of logistical delays in setting up the bank card system. At 12 weeks, participants receiving the bank card incentive completed significantly more IVRS phone surveys, odds ratio (OR) = 2.4, 95% confidence interval (CI) = [0.01, 1.69]. There were no significant differences between the two groups related to satisfaction or safety and/or privacy. The bank card system delivered lower administrative burden for tracking payments for study staff. Based on these and other results, our large medical research university is implementing reloadable bank card as the preferred method of participant incentive payments.

Testing for funnel plot asymmetry of standardized mean differences.

Publication bias and other forms of outcome reporting bias are critical threats to the validity of findings from research syntheses. A variety of methods have been proposed for detecting selective outcome reporting in a collection of effect size estimates, including several methods based on assessment of asymmetry of funnel plots, such as the Egger's regression test, the rank correlation test, and the Trim-and-Fill test. Previous research has demonstated that the Egger's regression test is miscalibrated when applied to log-odds ratio effect size estimates, because of artifactual correlation between the effect size estimate and its standard error. This study examines similar problems that occur in meta-analyses of the standardized mean difference, a ubiquitous effect size measure in educational and psychological research. In a simulation study of standardized mean difference effect sizes, we assess the Type I error rates of conventional tests of funnel plot asymmetry, as well as the likelihood ratio test from a three-parameter selection model. Results demonstrate that the conventional tests have inflated Type I error due to the correlation between the effect size estimate and its standard error, while tests based on either a simple modification to the conventional standard error formula or a variance-stabilizing transformation both maintain close-to-nominal Type I error.

Effect of an Advanced Pharmacy Practice Experience on Medication Therapy Management Services in a Centralized Retail Pharmacy Program.

BACKGROUND: Medication therapy management (MTM) delivery is increasingly important in managed care. Successful delivery positively affects patient health and improves Centers for Medicare & Medicaid Services star ratings, a measure of health plan quality. As MTM services continue to grow, there is an increased need for efficient and effective care models. The primary objectives of this project were to describe the delivery of MTM services by fourth-year Advanced Pharmacy Practice Experience (APPE) students in a centralized retail pharmacy system and to evaluate and quantify the clinical and financial contributions of the students. The secondary objective was to describe the engagement needed to complete comprehensive medication reviews (CMRs) and targeted interventions. PROGRAM DESCRIPTION: From May 2015 to December 2015, thirty-five APPE students from the University of Colorado Skaggs School of Pharmacy provided MTM services at Albertsons Companies using the OutcomesMTM and Mirixa platforms. Students delivered patient care services by phone at the central office and provided face-to-face visits at pharmacies in the region. With implementation of the MTM APPE in 2015, the team consisted of 2 MTM pharmacists and pharmacy students, as compared with 1 MTM pharmacist in 2014. The number of CMRs and targeted interventions completed and the estimated additional revenue generated during the 2015 time period were compared with those completed from May through December 2014. The patient and provider engagement needed to complete the CMRs and targeted interventions was summarized. OBSERVATIONS: 125 CMRs and 1,918 targeted interventions were billed in 2015, compared with 13 CMRs and 767 targeted interventions in 2014. An estimated $16,575-$49,272 of additional revenue was generated in 2015. To complete the interventions in 2015, the team engaged in 1,714 CMR opportunities and 4,686 targeted intervention opportunities. IMPLICATIONS/RECOMMENDATIONS: In this MTM rotation, students provided real-life care to patients, resulting in financial and clinical contributions. This model of education and care delivery can be replicated in the community pharmacy or managed care setting. APPE students are an important component of this model of care delivery, particularly when considering the level of patient engagement needed to complete MTM interventions. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose related to this work. All authors contributed to study concept and design. Rodgers collected the data, and data interpretation was performed by Vande Griend, along with Rodgers and Nuffer. The manuscript was written and revised primarily by Vande Griend, along with Nuffer and Rodgers. This project was presented at the Pharmacy Quality Alliance Annual Meeting in Arlington, Virginia, in May 2016.

No Quick Fixes: A Mixed Methods Feasibility Study of an Urban Community Health Worker Outreach Program for Intimate Partner Violence.

Community health workers (CHWs) provide peer support in diverse health care settings, but few studies have evaluated CHW interventions for intimate partner violence (IPV). We assessed the feasibility, acceptability, and safety of CHW outreach in four urban community health clinics and characterized the experiences and barriers to providing safe and effective services for women experiencing IPV. CHWs successfully enrolled and engaged IPV victims, who indicated satisfaction and increased safety with program participation. However, complex psychosocial barriers prevented many from achieving safety and security. More work is needed to assess the impact of well-integrated IPV-trained CHWs in primary care medical homes.

Brief Motivational Intervention for Intimate Partner Violence and Heavy Drinking in the Emergency Department: A Randomized Clinical Trial.

IMPORTANCE: Intimate partner violence (IPV) and heavy drinking are co-occurring public health problems, but integrated brief interventions for these conditions have not been tested. OBJECTIVE: To determine whether a brief motivational intervention provided at the time of an emergency department (ED) visit reduces IPV and heavy drinking. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial conducted at 2 US academic urban EDs between January 2011 and December 2014 to assess the effectiveness of a motivational intervention for IPV-involved female ED patients (ages: 18-64 years; N = 600) who exceeded sex-specific safe drinking limits. All received social service referrals; 2:2:1 to brief intervention (n = 242), assessed control (n = 237), or no-contact control (n = 121). INTERVENTIONS: A 20- to 30-minute manual-guided motivational intervention (recorded and monitored for fidelity) delivered by master's-level therapists with a follow-up telephone booster. The assessed control group received the same number of assessments as the brief intervention group; the no-contact control group was assessed only once at 3 months. MAIN OUTCOMES AND MEASURES: Incidents of heavy drinking and experiencing IPV measured over prespecified, 12 weekly assessments using an interactive voice response system. RESULTS: Of 600 participants, 80% were black women with a mean age of 32 years. Retention was 89% for 2 or more interactive voice response system calls. Seventy-eight percent of women completed the 3-month interview, 79% at 6 months, and 71% at 12 months. During the 12-week period following the brief motivational intervention, there were no significant differences between the intervention group and the assessed control group on weekly assessments for experiencing IPV (odds ratio [OR], 1.02; 95% CI, 0.98-1.06) or heavy drinking (OR, 0.99; 95% CI, 0.96-1.03). From baseline to 12 weeks, the number of women with any IPV in the past week decreased from 57% (134 of 237) in the intervention group to 43% (83 of 194) and from 63% (145 of 231) in the assessed control group to 41% (77 of 187) (absolute difference of 8%). From baseline to 12 weeks, the number of women with past week heavy drinking decreased from 51% (120 of 236) in the intervention group to 43% (83 of 194) and from 46% (107 of 231) in the assessed control group to 41% (77 of 187) (absolute difference of 3%). At 12 months, 43% (71 of 165) of the intervention group and 47% (78 of 165) of the assessed control group reported no IPV during the previous 3 months and 19% (29 of 152) of the intervention group and 24% (37 of 153) of the control group had reduced their alcohol consumption to sex-specific National Institute on Alcohol Abuse and Alcoholism safe drinking levels. CONCLUSIONS AND RELEVANCE: For women experiencing IPV and heavy drinking, the use of a brief motivational intervention in the ED compared with assessed and no-contact controls did not significantly reduce the days of heavy drinking or incidents of IPV. These findings do not support a brief motivational intervention in this setting. TRIAL REGISTRATION: clinicaltrials.gov Identifer: NCT01207258.

CHD1 and CHD2 are positive regulators of HIV-1 gene expression.

BACKGROUND: Retroviruses encode a very limited number of proteins and therefore must exploit a wide variety of host proteins for completion of their lifecycle. METHODS: We performed an insertional mutagenesis screen to identify novel cellular regulators of retroviral replication. RESULTS: This approach identified the ATP-dependent chromatin remodeler, chromodomain helicase DNA-binding protein 2 (CHD2), as well as the highly related CHD1 protein, as positive regulators of both MLV and HIV-1 replication in rodent and human cells. RNAi knockdown of either CHD2 or the related CHD1 protein, in human cells resulted in a block to infection by HIV-1, specifically at the level of transcription. CONCLUSIONS: These results demonstrate that CHD1 and CHD2 can act as positive regulators of HIV-1 gene expression.

The Social Health Intervention Project (SHIP): protocol for a randomized controlled clinical trial assessing the effectiveness of a brief motivational intervention for problem drinking and intimate partner violence in an urban emergency department.

BACKGROUND: There is a strong reciprocal association between two highly prevalent public health problems: intimate partner violence and heavy drinking, both of which remain major sources of morbidity and mortality. Brief interventions in the Emergency Department setting have been found to be effective in reducing alcohol-related injury but neither classic intimate partner violence nor substance abuse interventions have adequately integrated assessment and treatment for these co-occurring conditions. The overall goal of this study is to determine whether a motivational intervention delivered at the time of an Emergency Department visit will reduce heavy drinking and improve the safety of women experiencing intimate partner violence. METHODS AND DESIGN: We are completing data collection for a randomized controlled trial enrolling 600 female patients, age 18-64, presenting to one of two urban Emergency Departments, who self-disclose both problem drinking and intimate partner violence. Eligible patients are randomized to a brief manual-guided motivational intervention, and a phone booster at 10 days. The intervention, which is delivered by masters-level therapists during the Emergency Department visit, is recorded and monitored for fidelity. Primary outcomes are episodes of heavy drinking and incidents of intimate partner violence, assessed weekly by Interactive Voice Response System for 12 weeks and at 3, 6 and 12 months by interviewers blinded to group assignment. To identify the impact of assessment alone, we included a no-contact control group assessed only once at 3 months. Secondary outcomes include violence severity, changes in the Composite Abuse Scale and alcohol quantity/frequency, along with other health-related behaviors. The analysis will also explore the impact of likely mediators and moderators of the intervention. DISCUSSION: While screening and intervention for intimate partner violence is now recommended for women of child bearing age in health care settings, there is a need for rigorous evaluations of what works for whom. Upon completion, we will have high-quality evidence regarding the effectiveness of a low-intensity, brief motivational intervention, delivered by social workers in the Emergency Department setting, for decreasing episodes of heavy drinking and intimate partner violence. Ultimately, this is a model could be generalizable to other acute health care settings. TRIAL REGISTRATION: ClinicalTrials.gov REGISTRATION NUMBER: NCT01207258.

The anatomy of a community health center system-level intervention for intimate partner violence.

The US Preventive Services Task Force (USPSTF) now recommends screening for intimate partner violence (IPV) as part of routine preventive services for women. However, there is a lack of clarity as to the most effective methods of screening and referral. We conducted a 3-year community-based mixed-method participatory research project involving four community health centers that serve as safety net medical providers for a predominately indigent urban population. The project involved preparatory work, a multifaceted systems-level demonstration project, and a sustainability period with provider/staff debriefing. The goal was to determine if a low-tech system-level intervention would result in an increase in IPV detection and response in an urban community health center. Results highlight the challenges, but also the opportunities, for implementing the new USPSTF guidelines to screen all women of childbearing years for intimate partner violence in resource-limited primary care settings.

Adolescent bipolar disorder: a clinical vignette.

Adolescence is a vulnerable developmental phase marked by physical, psychological, and social changes that rapidly expose young people to a wide range of new stressors. When differentiating between bipolar disorder and teenage "acting out," a careful history is important. Adolescent bipolar disorder is a psychiatric illness characterized by fluctuating episodes of mood elevation and depression that is frequently neither recognized nor formally diagnosed. Adolescents with bipolar disorder often manifest a more nonepisodic, chronic course with continuous rapid-cycling patterns than do adults. Pharmacologic treatment of adolescent bipolar disorder is difficult and often requires combination therapy to address comorbidities like attention-deficit/hyperactivity disorder and anxiety disorder. Adjuncts to pharmacologic treatment of bipolar disorder can be beneficial. Psychosocial treatments include family education, enhanced parenting techniques, stress management, and the development of effective coping strategies.

Pilot study of medical-legal partnership to address social and legal needs of patients.

UNLABELLED: As a preliminary investigation of the effectiveness of medical-legal partnership in pediatrics, we conducted a 36-month prospective cohort study of the impact of clinic- and hospital-based legal services. We hypothesized that integration of legal services into pediatric settings would increase families' awareness of and access to legal and social services, decrease barriers to health care for children, and improve child health. METHODS: Health care providers referred families with legal or social needs to the Peninsula Family Advocacy Program (FAP). RESULTS: Fifty four families completed both baseline and six-month follow-up assessments. Comparison of follow-up with baseline demonstrated significantly increased proportions of families who utilized food and income supports and significantly decreased proportions of families avoiding health care due to lack of health insurance or concerns about cost. Two-thirds of respondents reported improved child health and well-being. CONCLUSIONS: This study suggests that adding an attorney to the medical team increases awareness of and access to social and legal services.

Phosphatidylinositol 4-kinase III-beta is required for Golgi maintenance and cytokinesis in Trypanosoma brucei.

The parasitic protozoan Trypanosoma brucei contains two type III phosphatidylinositol 4-kinases (alpha and beta). We have cloned the gene encoding the T. brucei type III phosphatidylinositol 4-kinase beta (TbPI4KIII-beta), expressed the protein in COS-7 cells, and confirmed that the protein catalyzes the phosphorylation of phosphatidylinositol. Depletion of TbPI4KIII-beta in procyclic T. brucei by RNA interference (RNAi) resulted in inhibition of cell growth and a distorted cellular morphology. RNAi cells had a distorted Golgi apparatus, and lysosomal and flagellar pocket proteins were mislocalized. Ultrastructural analysis revealed the internal accumulation of a heterogeneous population of vesicles, abnormal positioning of organelles, and a loss of cell polarity. Scanning electron microcopy revealed a twisted phenotype, and dividing cells often exhibited a detached daughter flagellum and lacked a cleavage furrow. Cell cycle analysis confirmed that cells depleted of TbPI4KIII-beta have a postmitotic cytokinesis block that occurs after a single round of mitosis, suggestive of a specific cell cycle block. In summary, TbPI4KIII-beta is an essential protein in procyclic T. brucei, required for maintenance of Golgi structure, protein trafficking, normal cellular shape, and cytokinesis.