Effects of LifeSkills training on medical students' performance in dealing with complex clinical cases

OBJECTIVE

Sound clinical judgment is the cornerstone of medical practice and begins early during medical education. The authors consider the effect of personality characteristics (hostility, anger, cynicism) on clinical judgment and whether a brief intervention can affect this process.

METHODS

Two sophomore medical classes (experimental, comparison) were assessed on several personality dimensions and responded to a series of clinical vignettes. The experimental group received cognitive behavior training to improve stress, coping, and interpersonal skills. Participants were reassessed within 1 week of the initial assessment.

RESULTS

Significant associations between hostility and cynicism and maladaptive responses to the clinical vignettes were noted. Following the intervention, hostility, cynicism, anger, and aggression were significantly reduced, with concomitant reductions in maladaptive decision-making.

CONCLUSION

The relationship between the quality of clinical decision-making and personality characteristics was confirmed. The potential to modify this relationship using a brief cognitive behavior intervention suggests that such interventions should be an essential component of medical education.

Acceptability of microbicidal surrogates among Zambian women

OBJECTIVES AND GOAL

This study assessed the acceptability after the use of vaginal lubricants as surrogates for microbicides among women in Zambia and the role of cultural factors as facilitators or impediments to their potential use for HIV risk reduction within the Zambian context.

STUDY DESIGN

HIV seronegative women (N = 301) recruited from the University Teaching Hospital HIV Voluntary Counseling and Testing Center were randomized into group, individual, or enhanced usual care arms. Participants attended pre- and post-HIV test counseling, followed by a 3-session, 2-hour once-a-month intervention introducing them to vaginal lubricants (2 types of gels, suppositories) in addition to male and female condoms. Supplies were offered at months 4 and 5; assessments were at baseline, 6, and 12 months.

RESULTS

At baseline, the majority of women reported minimal previous exposure to vaginal products and low levels of condom use. Participants' use of products was influenced by product characteristics and perceived partner acceptability; the majority of participants preferred drier products and suppository delivery systems. The basis for decisions regarding vaginal product acceptability changed over time and followed product exposure, and was greatly influenced by perceptions of partner acceptability.

CONCLUSION

Results illustrate the influence of male partners on Zambian seronegative women's preferences for microbicidal products, and the change in preferred characteristics over time.

Sexual Risk Intervention In Multiethnic Drug And Alcohol Users

An estimated 38.6 million persons globally are living with HIV, of whom over 1.1 million reside in Zambia. Of the 2 million cases in the US, 64% of new cases among women are among African Americans. Alcohol and drug use represents a significant risk factor for HIV transmission among both Zambians and African Americans. In addition, gender dynamics in both the US and Zambia promote transmission. This study examines two interventions targeting HIV risk behavior among HIV positive substance users, women in Miami, USA (the New Opportunities for Women (NOW) Project) and men in Lusaka, Zambia (the Partner Project). The study compares the efficacy of these two culturally tailored sexual behavior interventions provided in group and individual session formats. US and Zambian participants increased sexual barrier use and reduced substance-related sexual risk. Comparatively greater gains were made by higher risk Zambian males than US females in both group and individual conditions. Among lower risk participants, women in the group condition achieved and sustained the greatest comparative risk reductions. Results suggest that cost effective group HIV transmission risk reduction interventions for multiethnic individuals can be successfully implemented among both female and male drug and alcohol users in multinational settings.

HIV Medication Adherence and Substance Use: The Smartest Women's Project

Antiretroviral (ARV) medication for substance users has been a controversial issue with respect to whether current substance users can successfully maintain their medication regimens. This study compared ARV adherence across current substance users, former substance users and those with no history or current use and the relative impact of a medication adherence intervention on all three groups. Of the 481 predominantly African American and Latina women from Miami, New York and New Jersey enrolled in the SMARTEST Women's Program, 338 participants were prescribed antiretroviral medication at study entry. All three groups, current users (n=60), former users (n=107) and never users (n=171), reported relatively high levels of adherence at baseline. Of those participants with less than 80% adherence at baseline, former users showed the most significant decrease in viral load post-intervention and at long term (two year) follow-up. These findings suggest former users to be the most reliable source of self-reported adherence and to profit most from the study intervention. They also suggest that additional research on targeted interventions for current substance users may be necessary to improve medication adherence for this group of women living with HIV.

Influencing sexual practices among HIV-positive Zambian women

This study assessed and compared the efficacy of culturally tailored behavioral interventions to increase use and acceptability of sexual barrier products among HIV-positive women in Zambia. It also sought to evaluate cultural preferences as facilitators or impediments to potential use of vaginal chemical barriers for sexual risk reduction within the Zambian context. Women (N=240), recruited from the University Teaching Hospital HIV Voluntary Counseling and Testing Center, were randomized into group or individual intervention arms. Participants attended a baseline assessment, three intervention sessions and follow up assessments at six and 12 months. All participants increased use and acceptability of female condoms and vaginal products and maintained male condom use at six and 12 months. Preliminary data indicated that group participants increased male condom use at six months and trial use and acceptability of female condoms and lubricants predicted their use in the group condition. Results support group interventions to increase sexual barrier use and acceptability in HIV-positive women within the Zambian context. From a public health standpoint, groups may represent a cost-effective and culturally congruent intervention.

Efficacy of a group medication adherence intervention among HIV positive women: the SMART/EST Women's Project

This intervention sought to improve overall quality of life and health behavior in women living with human immunodeficiency virus (HIV). We contrasted the effect of a group cognitive behavioral stress management expressive supportive therapy (CBSM+) intervention plus a healthier lifestyles (HL) component with an individual educational/informational format plus HL on HIV-medication adherence. Women, n = 237, predominantly African-American and Latina, living with HIV were recruited from Miami, New York and New Jersey and randomized to group or individual conditions (ten weekly sessions) plus group or individual HL, i.e., four conditions. Women reported relatively high levels of adherence at baseline. Participants in any of the group conditions increased self-reported adherence and emotion-focused coping skills in comparison with individual participation. This study suggests that group interventions may be an important adjunct in increasing medication adherence for HIV positive women.

Improving dietary habits in disadvantaged women with HIV/AIDS: the SMART/EST women's project

There is a lack of information on whether brief nutrition education can succeed in improving longer-term dietary patterns in disadvantaged populations with HIV/AIDS. In the SMART/EST II Women's Project 466 disadvantaged women with HIV/AIDS were randomized to one of four groups and received a two-phase training consisting of a coping skills/stress management and nutrition education provided either in a group or individually. At baseline the majority of participants had excessive fat and sugar consumption and suboptimal intakes of vegetables, fruits, calcium-rich foods and whole grains. Dietary patterns for all participants improved after the nutrition intervention primarily due to decreases in high fat and high sugar foods such as soda and fried foods and were still significantly better 18 months later. There were only short-term differences in improvements between the four groups. These findings support the value of even brief nutrition education for disadvantaged women living with HIV/AIDS.

Influence of partner participation on sexual risk behavior reduction among HIV-positive Zambian women

Sexual risk behavior interventions in sub-Saharan Africa focus predominantly on individual and couples counseling. This cognitive-behavioral group intervention was adapted from an urban US context to urban Zambia. Preliminary data analyses assessed the influence of partner participation on sexual risk behavior among HIV-positive Zambian women. Female participants (n=180) attended four group intervention sessions and received sexual behavior skill training and male and female condoms; male partners (n=152) were randomly assigned to high- or low-intensity gender-concordant group intervention sessions. Sexual risk behavior, strategies, attitudes, and knowledge were assessed at baseline, 6, and 12 months. At baseline, 19% of males reported using alcohol before sex, 10% reported using alcohol to cope, and negative coping was associated with sexual risk behavior. In contrast, 1% of women reported using alcohol before sex, and 15% used alcohol as an HIV-coping strategy. Consistent barrier use was reported by 48% of women and 74% of men. After intervention, female high intensity participants reported higher rates of condom use (F=5.68, P=.02), more positive condom attitudes, safer sex intentions, and less alcohol use. These findings highlight the influence of male partners in implementation of effective risk reduction interventions.

Decreased depression up to one year following CBSM+ intervention in depressed women with AIDS: the smart/EST women's project

This prospective multisite Phase III clinical trial (Miami, New York, New Jersey) investigated the long-term (one year) effects of a 10-week group cognitive-behavioral stress management/expressive supportive therapy (CBSM+) intervention on disadvantaged minority women living with AIDS. The CBSM+ intervention consisted of 10-weekly group session of stress management, cognitive-behavioral skill training, relaxation techniques and expressive-supportive therapeutic strategies. The primary study outcome was self-reported depression scores as measured by the BDI. The CBSM+ Group intervention significantly decreased depression scores on the BDI for women following the intervention and maintained the decreased level at one-year follow-up.

Discovery of nonxanthine adenosine A2A receptor antagonists for the treatment of Parkinson's disease

During a program to investigate the biochemical basis of side effects associated with the antimalarial drug mefloquine, the authors made the unexpected discovery that the (-)-(R,S)-enantiomer of the drug is a potent adenosine A2A receptor antagonist. Although the compound was ineffective in in vivo animal models of central adenosine receptor function, it provided a unique nonxanthine adenosine A2A receptor antagonist lead structure and encouraged the initiation of a medicinal chemistry program to develop novel adenosine A2A antagonists for the management of Parkinson's disease (PD). The authors have synthesized and screened more than 2,000 chemically diverse and novel adenosine A(2A antagonists. Early examples from two distinct chemical series are the thieno[3,2-dy]pyrimidine VER-6623 and the purine compounds VER-6947 and VER-7835, which have high affinity at adenosine A2A receptors (K(i) values 1.4, 1.1, and 1.7 nmol/L, respectively) and act as competitive antagonists. In particular, VER-6947 and VER-7835 demonstrate potent in vivo activity reversing the locomotor deficit caused by the D2 receptor antagonist haloperidol, with minimum effective doses comparable with that of KW6002 (0.3 to 1 mg/kg). In conclusion, the authors have discovered potent, selective, and in vivo active nonxanthine adenosine A2A antagonists that have considerable promise as a new therapy for PD.

A Sexual Barrier Intervention for HIV+/- Zambian Women: Acceptability and Use of Vaginal Chemical Barriers

OBJECTIVES: The purposes of this study were to (a) assess the efficacy of a culturally tailored behavioral intervention to increase use and acceptability of sexual barrier products among HIV+ and HIV- Zambian women, (b) compare group versus individual interventions to increase barrier use and acceptability, and (c) validate the role of cultural factors as facilitators or impediments to sexual risk reduction. METHODS: A sample of 150 HIV+ and HIV- Zambian women was recruited from the University Teaching Hospital HIV Voluntary Counseling and Testing Centre, randomized into one of three conditions, and assessed at baseline and 6 months. Group and individual intervention participants attended a 3-session intervention plus pre- and post-HIV test counseling; control participants received pre- and post-test counseling only. RESULTS: Group intervention participants increased use of sexual barriers and had higher levels of acceptability than did individual intervention participants. HIV- group participants increased use of chemical barriers and female condoms. CONCLUSIONS: Results support the use of group interventions to increase sexual barrier use and acceptability and decrease sexual risk behavior in both HIV+ and HIV- women.

Stress Management and Workplace Disability in the US, Europe and Japan

Although the health care costs and the number of disability cases across all medical illnesses have increased, disability management programs implementing stress management interventions have been found to improve physical and mental health, reduce costs to employers, and facilitate the reintegration of injured individuals into the work environment. Stress management programs limit the impact and chronicity of disabilities and can be used to reduce and control the cost of disability in the workplace. Providing the most efficacious behavioral interventions thereby allows employers, employees and health professionals to work cooperatively to achieve optimum health and cost effectiveness. This review presents a variety of group and individual interventions, which have been utilized to aid disabled employees in coping with work-related injuries and medical illness. The implementation of stress management interventions in the workplace is described in detail, with special emphasis on the use of cognitive behavioral stress management. Finally, this review outlines a team approach to the application of a workplace stress management intervention aimed at reducing the overall impact of disability.

A brief sexual barrier intervention for women living with AIDS: acceptability, use, and ethnicity

Interventions aimed at reducing sexual transmission of human immunodeficiency virus/sexually transmitted diseases (HIV/STDs) have focused primarily on male condom use among seronegative men and women. However, female-controlled sexual barriers (female condoms and vaginal microbicides) offer women living with acquired immunodeficiency syndrome (AIDS) alternative methods to protect themselves and others from disease transmission. A pilot behavioral intervention was conducted to increase sexual barrier use and enhance and assess factors related to acceptability. Participants (N = 178) were drawn from the Stress Management and Relaxation Training with Expressive Supportive Therapy (SMART/EST) Women's Project, a multisite phase III clinical trial for women living with AIDS (Miami, FL; New York City, NY; Newark, NJ). Intervention participants (n = 89) were matched for age and ethnicity with control condition participants (n = 89). Women were African American (52%), Haitian (15%), Hispanic (19%), Caucasian (10%), and other ethnicities (4%). The intervention condition received barrier products (male and female condoms and spermicides based on nonoxynol-9 in the form of vaginal gel, film, and suppositories) during three sessions held over 3 months. Data on barrier use and acceptability were analyzed at baseline and 3 and 9 months postintervention. Use of N-9 spermicides on a trial basis increased significantly by 3 months in the intervention conditions (22%-51%, P <.05). Cultural differences in acceptability were greatest between Haitian women and women in other ethnic groups. Exposure to this pilot behavioral intervention was associated with increased acceptability and use of chemical barriers without decreased use of male condoms.

The muscarinic receptor agonist xanomeline has an antipsychotic-like profile in the rat

The muscarinic receptor agonist xanomeline was examined and compared with the antipsychotics clozapine and/or haloperidol in the following in vivo rat models: apomorphine-induced disruption of prepulse inhibition (PPI), amphetamine-induced hyperlocomotion, and the conditioned emotional response (CER) test. The effects of xanomeline were also assessed ex vivo on dopamine turnover in the rat medial prefrontal cortex. Under conditions of varying dose and prepulse intensity, xanomeline, like haloperidol, had no effect on PPI. In contrast, the muscarinic receptor antagonist scopolamine and the muscarinic receptor agonist pilocarpine both induced significant dose-dependent deficits in PPI. Haloperidol and xanomeline, but not pilocarpine, dose dependently reversed apomorphine-induced disruption of PPI. Thus, xanomeline induced a clear antipsychotic-like effect in PPI, whereas pilocarpine appeared to induce a psychotomimetic-like effect. Xanomeline attenuated amphetamine-induced hyperactivity at doses that had no effect on spontaneous activity, possibly indicating a separation between attenuation of limbic hyperdopaminergic function and the induction of hypolocomotion. Haloperidol and clozapine also reversed amphetamine-induced hyperlocomotion, but at similar doses to those that reduced spontaneous locomotion. Clozapine, but not haloperidol had an anxiolytic-like effect in the CER test. The effects of xanomeline in the CER test were similar to those of clozapine, although at the anxiolytic dose it tended to disrupt baseline levels of lever pressing. Finally, haloperidol, clozapine, pilocarpine, and xanomeline, all induced an increase in dopamine turnover in medial prefrontal cortex. The antipsychotic-like effects of xanomeline in the animal models used here suggest that it may be a useful treatment for psychosis.

KW-6002 (Kyowa Hakko Kogyo)

Kyowa Hakko is developing KW-6002, an adenosine A2A receptor antagonist, for the potential treatment of Parkinson's disease (PD) [183211]. The company subsequently began evaluating the compound for depression, and in June 2000 initiated a phase II trial for this indication. Good results have been obtained in a preclinical depression model and Kyowa Hakko hopes that KW-6002 will be representative of a new class of antidepressants [376107]. KW-6002 is undergoing phase II trials for PD in Japan [343257] and in Europe, including the UK 1271929], [321641], [402754]. As expected, KW-6002 entered phase II trials for PD in the US in October 1999 [321640], [342643], [360980], [402754]. The drug is of particular interest due to the absence of the involuntary movement adverse effects characteristic of L-DOPA therapy [271929]. Roche was to codevelop KW-6002 with Kyowa in the US and Europe, but withdrew from the development of this drug in April 1999 [321640]. Kyowa will continue with the drug's development in the US [321640]. NDAs are estimated to be filed around the end of 2001 and the drug is expected to be launched in Western Europe during 2002. An NDA is expected to be filed in Japan approximately three to four years later than in Western Europe [271929].

Improved sensitivity proteomics by postharvest alkylation and radioactive labelling of proteins

We describe approaches to improve the detection of proteins by postharvest alkylation and subsequent radioactive labeling with either [3H]iodoacetamide or 125I. Database protein sequence analysis suggested that cysteine is not suitable for detection of the entire proteome, but that cysteine alkylating reagents can increase the number of proteins able to be detected by iodination chemistry. Proteins were alkylated with beta-(4-hydroxyphenyl)ethyl iodoacetamide, or with 1,5-l-AEDANS (the Hudson Weber reagent). Subsequent iodination using the Iodo-Gen system was found to be most efficient. The enhanced sensitivity obtainable by using these approaches is expected to be sufficient for visualization of the lowest copy number proteins from human cells, such as from clinical samples. However, we argue that significantly improved methods of protein separation will be necessary to resolve the large number of proteins expected to be detectable with this sensitivity.

Measurement of anxiety in transgenic mice

A wide range of approaches has been used to study anxiety in mice. All presuppose that aversive stimuli, such as foot shock or novelty, induce a central state of fear, which can be quantified through specific behavioural and physiological measures. This review discusses the validity of the various approaches in terms of their similarity to different human anxiety disorders, their ability to detect compounds which modulate human anxiety, and their relevance to animal defensive processes. The most commonly used models of anxiety suitable for screening transgenic and knockout mice are discussed, with an emphasis placed on controlling for factors which could confound results. As all models used to date have limitations and no single paradigm adequately models all aspects of anxiety, this review recommends the use of a broad range of anxiety models in order to provide a comprehensive characterisation of the behavioural phenotype of transgenic mice.

Nonpharmacological interventions with chronic cancer pain in adults

BACKGROUND

Pain is often poorly controlled in cancer patients. Chronic pain affects adult patients at all stages of cancer management. Optimal pain management may require attention to psychosocial variables and the inclusion of nonpharmacological techniques.

METHODS

Three nonpharmacological strategies that are effective in reducing pain caused by cancer--patient psycho-education, supportive psychotherapy, and cognitive-behavioral interventions--are reviewed. Recommendations for physicians to facilitate a mental health referral are also discussed.

RESULTS

Effective treatment of cancer pain begins with assessing the severity, characteristics, and impact of pain. Emotional distress (especially anxiety, depression, and beliefs about pain) has emerged as predictive of patient pain levels. Appropriate pain management may require a multidisciplinary approach.

CONCLUSIONS

Patient psycho-education has empowered patients to actively participate in pain control strategies. Supportive psychotherapy can assist patients in managing the stressors associated with cancer, and cognitive-behavioral therapy helps patients to recognize and modify the factors that contribute to physical and emotional distress.

A comparison of maladaptive behaviors of athletes and nonathletes

A comparison of maladaptive behavior tendencies of men and women who were athletes and nonathletes was undertaken. Participating students (N = 200) were divided into four groups: male athletes, male nonathletes, female athletes, and female nonathletes. Maladaptive behavior tendencies were determined from responses on C. MacAndrew's (1965) Alcoholism Scale. The statistical analysis used was an independent groups 2 x 2 analysis of variance to determine significant main effects and interaction effects. The mean maladaptive behavior score (MBS) for athletes (M = 21.87) was significantly higher (p < .05) than the MBS for nonathletes (M = 20.24). The MBS for the men (M = 21.68) was significantly higher (p < .05) than the MBS for the women (M = 20.43). No significant interaction (p > .05) between gender and athletic status was found. Male athletes are more likely than the other 3 groups to have maladaptive behavior tendencies. Research directed toward greater understanding and the development of preventive and coping techniques for this population is needed.

Utility of ethological analysis to overcome locomotor confounds in elevated maze models of anxiety

The elevated plus-maze is a commonly used model to identify putative anxiolytic and anxiogenic drugs. However, the validity of elevated plus-maze and other recently developed variants such as the elevated zero-maze has recently been questioned on the grounds that both the reference anxiolytic drug chlordiazepoxide and the psychostimulant d-amphetamine increase open arm exploration and stimulate locomotor activity. These findings suggest that measures of "anxiety" in the elevated maze cannot be adequately dissociated from simple changes in locomotor activity, which may confound the interpretation of results obtained using these models. A variety of approaches to assess drug effects on locomotor activity in the elevated maze have been suggested, including the use of total and closed arm entries, as well as supplementary tests such as exploration of the holeboard apparatus. However, all these approaches utilise the measurement of exploration in a novel environment, and as such, could potentially be influenced by either changes in anxiety or locomotor activity. Recently, it has been shown that ethological measures of "risk assessment", such as stretched-attend postures and head-dipping, are sensitive indicators of drug-effects in the elevated maze. The present study assessed the utility of ethological analysis in dissociating locomotor activity from "anxiety" by comparing the effects of d-amphetamine to those of chlordiazepoxide in the rat elevated zero-maze. The results showed that both chlordiazepoxide and d-amphetamine increase the amount of time spent in the open arms and reduce "risk assessment" without increasing line crossing or rearing. These results confirm that under certain test conditions, psychostimulants are capable of producing "false-positives" in elevated maze models, and that both traditional methods and the ethological measures used in this study fail to unequivocally dissociate drug effects on anxiety from effects on locomotor activity. Further studies using other species and different classes of psychostimulants are warranted to determine the generality of these findings.

Infantile hypertrophic pyloric stenosis: delays in diagnosis and overutilization of imaging modalities

Infantile Hypertrophic Pyloric Stenosis (IHPS) can usually be diagnosed by the detection of a pyloric olive on examination performed by an experience examiner. In babies with typical symptoms and a palpable olive, no further confirmation of diagnosis is required. We retrospectively reviewed the diagnostic evaluations of 93 consecutive patients with proven IHPS. Many patients who had the diagnosis confirmed on physical examination underwent one or more unnecessary and redundant studies. The performance of these studies was associated with delayed diagnosis and possibly with adverse clinical health problems. An algorithm for management of patients with suspected IHPS is proposed. Prompt examination by an experienced examiner is key to the evaluation of such patients.

Effects of diazepam and buspirone on the behaviour of wild voles (Microtus socialis) in two models of anxiety

Exploration models of anxiety rely almost universally on the use of laboratory species. Furthermore, the spontaneous patterns of locomotion displayed are often interpreted as being an expression of antipredator defense. However, there is no direct link between the experience of these animals and the proposed motivation for their behaviour. To address this problem, the behaviour of wild trapped voles (Microtus socialis), a small-rodent species that is heavily predated upon, was examined in the elevated plus-maze and the black/white exploration model. It was hypothesised that the patterns of locomotion in these exploration models of anxiety should be similar to those reported for laboratory animals if the reactions of the laboratory animals are related to antipredator defense. Data revealed that voles show a similar preference for the protected areas in these models (closed arms or dark section) and that this preference can be modified by buspirone and diazepam. Interestingly, although the effective doses of each drug was the same within each model, it differed between models, with the minimum effective doses of these compounds being lower in the black/white exploration model (1 mg/kg) than in the elevated plus-maze (4 mg/kg). These data provide valuable information concerning the actions of anxiolytic compounds in wild trapped animals as assessed by formal laboratory models and provide useful verification that findings in these models may be generalised to species other than laboratory rodents.