A multisite, longitudinal study assessing prevalence of depression in student pharmacists

OBJECTIVE

Conduct a multisite, survey-based study assessing rates of self-reported depressive symptoms among student pharmacists enrolled in the first 3 years (P1-P3) of 4-year Doctor of Pharmacy (PharmD) curricula.

METHODS

This study followed a cross-sectional observational design conducted at Washington State University, College of Pharmacy and Pharmaceutical Sciences, and the University of Arkansas for Medical Sciences, College of Pharmacy. Student pharmacists in the first 3 years of pharmacy school (P1-P3) of the PharmD curricula were invited to voluntarily complete the Center for Epidemiologic Studies Depression Scale (CES-D) to collect self-reported measures of depression. The CES-D is a validated 20-item instrument using a 4-point Likert scale.

RESULTS

A total of 1795 surveys were evaluated from P1-P3 students at Washington State University, College of Pharmacy and Pharmaceutical Sciences and University of Arkansas for Medical Sciences, College of Pharmacy over a 4-year period (2019-2022). Overall, 1150 (64.1%) surveys indicated the presence of depressive symptoms on CES-D. The highest rate of reported depressive symptoms was recorded in 2021 (71.4%), notably during the coronavirus disease 2019 pandemic, whereas the lowest rate was prepandemic in 2019 (57.8%). The P1 cohort had the highest depression rate in 2020 and 2021, whereas the P2 cohort was highest in 2019 and 2022. The P3 cohort screening positive for depression increased from 52.6% to 69.3% over the 4-year period.

CONCLUSION

This multisite, longitudinal study confirms that self-reported depressive symptoms in student pharmacists are significantly higher than what is reported in undergraduate students. Opportunities exist for pharmacy educators and university wellness services to better identify and serve student pharmacists experiencing depression or depressive episodes.

Opening the Black Box: Agreement and Reliability of a Situational Judgment Test Across Multiple Institutions

OBJECTIVE

The primary objective of this study was to examine the levels of agreement and reliability of a situational judgment test (SJT) using a diverse pool of pharmacy practice faculty as subject matter experts. Secondary aims included analyses to build support for test validity and fairness.

METHODS

An SJT containing 18 scenarios and 118 responses assessing empathy, integrity, and teamwork was developed and delivered to pharmacy practice faculty at 5 schools of pharmacy across the United States. Reliability was assessed by examining internal consistency, inter-rater reliability, and split-half reliability. Only responses which attained an inter-rater agreement>0.7 were included in the final version of the SJT. All responses were scored using a near-miss system, allowing higher scores for answers more closely aligned with the key, which was determined by the faculty who completed the SJT. Test fairness was reported using descriptive statistics.

RESULTS

Thirty-nine faculty across the 5 participating institutions completed the SJT. The final version of the SJT included 105 responses, achieving an inter-rater agreement of>0.7 (inter-rater reliability of 0.98). Split-half reliability was 0.72. The average score was 85.7%, and no differences in performance were observed based on demographic characteristics.

CONCLUSION

An SJT designed to assess empathy, integrity, and teamwork achieved reasonable levels of reliability among pharmacy practice faculty across the United States, and the results provided initial support for test validity and fairness. These results support a pilot to assess this SJT among students representing multiple institutions.

PharmD Education Program Diversity, Equity, & Inclusion: Aligning Accreditation, Curricula, and the Oath

In November 2021, the Oath of a Pharmacist was updated to include the following statement, "I will promote inclusion, embrace diversity, and advocate for justice to advance health equity." These words underscore the responsibility of Doctor of Pharmacy (PharmD) programs and the Accreditation Council for Pharmacy Education to reconsider how diversity, equity, inclusion, and antiracism are integrated within curricula and programmatic processes. To fully embrace the new Oath, the Accreditation Council for Pharmacy Education and PharmD programs should consider the incorporation of diversity, equity, inclusion, and antiracism concepts utilizing the recommendations of external expert bodies with overlapping and complementary frameworks. The intent is not to add more to the accreditation standards or curricula, but rather to intentionally integrate inclusive approaches into programmatic processes and delivery. This can be accomplished through the alignment of our accreditation standards, PharmD programs, and the Oath that is the foundation of the pharmacy profession.

Implementing Mental Health First Aid Training in a Doctor of Pharmacy Program

OBJECTIVE

In this study, we aimed to describe the implementation of Mental Health First Aid (MHFA) training as a required curricular component in a Doctor of Pharmacy (PharmD) program; and analyze the impact of MHFA training on student pharmacist's perceptions of stigma, comfort, confidence, and willingness to intervene when someone is experiencing a mental health issue.

METHODS

Student pharmacists completed an all-day MHFA training as a required element of the PharmD curriculum during the spring of 2022. Pre- and post-survey was completed by students during the in-person training. Questions included items from the Opening Minds to Stigma Scale for Healthcare Providers; question, persuade, refer gatekeeper training for suicide prevention; and questions developed by the authors to assess the impact of the training on participant-reported stigma, confidence, and willingness to provide care to those potentially experiencing a mental issue.

RESULTS

A total of 235 student pharmacists completed the MHFA training. A statistically significant reduction of stigma was seen for 9 of the 15 statements from Opening Minds to Stigma Scale for Healthcare Providers. Additionally, all responses related to comfort and willingness to provide care and confidence improved significantly after completing MHFA.

CONCLUSION

MHFA training was implemented as a mandatory requirement for all student pharmacists in the didactic portion of a PharmD program. This training led to reduced stigma around mental illness and improved confidence, comfort, and willingness to intervene among student pharmacists.

A systematic review of patient interactions with student pharmacists in educational settings

BACKGROUND

Patients may contribute to various aspects of student pharmacists' education within clinical, experiential and educational settings. There is an emerging body of literature describing and evaluating the contribution of patients to health care education; however, little is known about patients' contribution to pharmacy education specifically within educational settings.

OBJECTIVE

To explore the evidence relating to the involvement of patients in the education of student pharmacists, in terms of the nature, extent, and outcomes of their contribution.

METHODS

A systematic literature search was undertaken within Embase, MEDLINE, Education Resources Information Center, International Pharmaceutical Abstracts, PubMed, PsycINFO, CINAHL, and Scopus databases from inception to April 10, 2020. Inclusion criteria included primary research studies reporting on the active involvement of patients in pharmacy education, within an educational setting. Quality assessment appraisal for the included studies was conducted using the Mixed Methods Appraisal Tool.

RESULTS

Twelve studies were eligible for inclusion in this systematic review. Nine studies explored the use of patients as educators providing valuable insight about their lived experience. Six studies involved patients in question-and-answer sessions, providing students with opportunities to inquire about their lived experience in relation to medicines, health care, and medical conditions. Studies that reported on students' learning outcomes demonstrated improvements in communication skills, deeper understanding of patients' lived experience particularly relating to mental illness, and increased confidence in providing care for patients. Among patients, participation in the educational process led to greater satisfaction, empowerment, and knowledge from sharing personal experiences. There were no clinical outcomes measured among patients participating in the included studies. The 5 nonrandomized quantitative studies ranged from low to moderate levels of quality, the 4 mixed-methods studies were of low quality, and the 3 qualitative studies were of high quality.

CONCLUSION

The involvement of patients in the education of student pharmacists was found to benefit both patients and students. Student-specific outcomes included development of communication skills and new insights about patients' lived experience. Further research is needed to better understand the long-term impact of patient involvement in pharmacy education, in terms of students' learning outcomes and clinical outcomes among patients.

A call to action: Community pharmacists to address COVID-19-related behavioral health concerns

Owing to the extended nature and worldwide exposure of the coronavirus disease (COVID-19) pandemic, it is likely that the presence and impact of behavioral health conditions will increase. For example, it is anticipated that individuals living with a major depressive disorder could reach as high as 60% of the population owing to the ongoing disruption from COVID-19. In 2017, the annual rate of individuals experiencing a major depressive episode was only 7.1%. Pharmacists, specifically community pharmacists, are well positioned to provide needed intervention and triage services to individuals living with, and struggling with, a mental health condition. Pharmacists, therefore, need additional training and support to be effective in serving the community in this way.

Training Student Pharmacists in Suicide Awareness and Prevention

Objective. To determine whether students gained knowledge, confidence, and skills in identifying and preventing suicide in patients, peers, friends, and family after receiving training in suicide prevention. Methods. Student pharmacists participated in a 3.5-hour suicide prevention training program. A pre- and post- intervention assessment and pre- and post-intervention survey were administered before and after completion of the training program. Questions were designed to assess knowledge of, comfort with, and confidence in assessing and intervening with individuals at risk of suicide. A standardized patient prescription counseling session was conducted two weeks after the training session. Videos of the counseling sessions were reviewed to determine whether student pharmacists assessed the patient for suicide risk. Additionally, a post-counseling reflection was completed asking students to reflect on incorporation of the suicide prevention training into their prescription counseling session. Results. One-hundred seventy-one student pharmacists participated in the training. Knowledge increased across all areas as evidenced by improved scores on the post-intervention knowledge assessment. Students' comfort level with asking about suicidal ideation and their confidence with intervening significantly increased from the pre- to post-intervention survey. After the training, 40% stated they knew someone who may need help and 21% said they had decided to seek help for themselves. Conclusion. The training program increased student pharmacists' knowledge of and confidence in assessing and counseling individuals considering suicide. Encouraging student pharmacists to participate in prevention training may aid future providers in preventing death by suicide.

The impact of a mental health course elective on student pharmacist attitudes

BACKGROUND AND PURPOSE

A mental health first aid elective course was developed at a four-year doctor of pharmacy program. The objectives of the course were to de-stigmatize the attitudes of enrolled student pharmacists and provide tools to triage and manage mental health crises. The purpose of this work is to investigate the impact of a newly developed mental health first aid elective course.

EDUCATIONAL ACTIVITY AND SETTING

Student pharmacists enrolled in a two-credit mental health first aid elective course and electronically completed the Opening Minds Scale for Health Care Providers (OMS-HC) pre-course, post-course, and months post-course to quantitatively measure changes in attitudes around stigma in various domains. Students also submitted a guided reflection post-course to collect self-perceived changes in attitudes. The reflection evaluated the changes in perceptions, confidence, and willingness to practice mental health first aid.

FINDINGS

Forty-second and third-year student pharmacists participated and 31 were included in the pre-protocol analysis for pre- and post-course paired comparisons. Improvements in the OMS-HC domains of "disclosure and help-seeking" and "attitudes of health care providers" at post-course were observed. Self-reflections submitted post-course supported the quantitative analysis results of the OMS-HC scores. Improvements were noted in attitudes towards individuals with mental health disorders and in confidence and willingness to initiate conversations on mental health.

SUMMARY

The implementation of a mental health first aid elective course positively influenced student pharmacists' attitudes on mental health and improved confidence and willingness to provide mental health related interventions.

Developing Self-Directed Learners

Objective. To discuss the meaning of self-directed learning, challenges with implementation, and strategies to overcome obstacles in educational settings. In this paper we define self-directed learning, differentiate it from similar terminology, and discuss the empirical evidence for its development and strategies for its use within higher education. Summary. Self-directed learning as a defined teaching pedagogy has been around since the 1960s and can be used in classroom and experiential settings. It is a term that is commonly used to describe a set of skills that college graduates should possess. A self-directed learning environment is dramatically different from a lecture-based classroom where the educator determines the goals, the assessments administered, and pacing of the course content. During the self-directed learning process, the learner sets goals, determines how progress will be assessed, defines the structure and sequence of activities and a timeline, identifies resources, and seeks out feedback. When teaching individuals who are new to this model, care must be taken to appropriately scaffold and structure learning to develop the underlying soft skills needed for students to be successful as self-directed learners. When implementing this pedagogy in a classroom setting, challenges are faced both by the learner and the educator. Faculty members should proactively plan for potential challenges during the course design process.

Consideration of Aggressive and Strategic Approaches to Address Declining Enrollment in US Pharmacy Schools

Members from Cohort 13 of the Academic Leadership Fellows Program (ALFP) 2016-2017 were challenged to present a debate on the topic: "In Turbulent Times, Pharmacy Education Leaders Must Take Aggressive Action to Prevent Further Declines in Enrollment" at the American Association of Colleges of Pharmacy INfluence 2017 meeting in Rio Grande, Puerto Rico. This paper is the result of thoughtful insights emerging from this debate. We present a discussion of the question of whether pharmacy education leaders must take aggressive action or strategic approaches to prevent further declines in enrollment. There are many thoughts regarding current declines in enrollment. Some educators contend that a more aggressive approach is needed while others argue that, while aggressive actions might lead to short-term gains, a more viable approach involves strategic actions targeting the underlying causes for decreasing enrollment. This paper explores themes of enrollment challenges, current and future workforce needs, and financial issues for both pharmacy programs and students. In summation, both aggressive actions and a strategic, sustainable approach are urgently needed to address declining enrollment.

Addressing Unmet Patient Care Needs Through Curricular Development of Student Pharmacist Leadership and Entrepreneurial Skills

Objective. To develop, deliver, and evaluate an innovative curriculum designed to increase student pharmacists' skills and confidence in addressing unmet patient care needs and the Institute for Healthcare Improvement's (IHI) Triple Aim goals in the community pharmacy setting. Methods. Course modules developed collaboratively between the University of Washington and Washington State University focused on student pharmacist exposure to and direct application of leadership theory in addressing real world challenges. Both programs delivered the curriculum to all second-year student pharmacists during the fall 2015 and fall 2016 semesters. Student teams were asked to identify a new or enhanced service for a community pharmacy based on a needs assessment and the IHI's Triple Aim goals. Students completed precourse, postcourse, and retrospective assessments of their confidence, comfort level in leadership theory application, and project implementation. Effectiveness of the project pitch and team dynamics were assessed. Precourse, postcourse, and retrospective assessments of individual student progress in leadership, innovation, self-awareness, and professionalism also were completed. Results. For all confidence questions, a significant relationship was found between mean precourse and postcourse scores. A comparison of students' postcourse scores and their retrospective reflection scores indicated an increase in confidence to lead. At the conclusion of the course, the students reported improved confidence in their ability to communicate decisions (73%), create a vision (64%), and form a guiding coalition (55%). Conclusion. A five-module curriculum with corresponding project proposal successfully increased the confidence and comfort level of student pharmacists' in their leadership skillset.

Aggregation of Markov flows I: theory

A Markov flow is a stationary measure, with the associated flows and mean first passage times, for a continuous-time regular jump homogeneous semi-Markov process on a discrete state space. Nodes in the state space can be eliminated to produce a smaller Markov flow which is a factor of the original one. Some improvements to the elimination methods of Wales are given. The main contribution of the paper is to present an alternative, namely a method to aggregate groups of nodes to produce a factor. The method can be iterated to make hierarchical aggregation schemes. The potential benefits are efficient computation, including recomputation to take into account local changes, and insights into the macroscopic behaviour.This article is part of the theme issue 'Hilbert's sixth problem'.

Moving from Novice to Expertise and Its Implications for Instruction

Objective: To address the stages of expertise development, what differentiates a novice from an expert, and how the development and differences impact how we teach our classes or design the curriculum. This paper will also address the downside of expertise and discuss the importance of teaching expertise relative to domain expertise. Summary: Experts develop through years of experience and by progressing from novice, advance beginner, proficient, competent, and finally expert. These stages are contingent on progressive problem solving, which means individuals must engage in increasingly complex problems, strategically aligned with the learner's stage of development. Thus, several characteristics differentiate experts from novices. Experts know more, their knowledge is better organized and integrated, they have better strategies for accessing knowledge and using it, and they are self-regulated and have different motivations.

Using Collaborative Drug Therapy Agreements to Train Student Pharmacists to Provide Clinical Patient Care Services

Objective. To assess the impact of a new course designed to train student pharmacists to provide clinical patient care services delivered through collaborative drug practice agreements. Design. An intensive two-credit, one-week course with a combined self-study and interactive pedagogical approach was developed. Content from the online Washington State Pharmacy Association Clinical Community Pharmacist training program was integrated with a live, eight-hour seminar. Assessment. Student-pharmacist learning, effectiveness of content presented, and perceived value of the material were evaluated. Scores on quizzes, a knowledge assessment, a patient-case examination, pre- and post-seminar surveys, and voluntary student certification rate were collected and analyzed. Of 132 student pharmacists enrolled in the course, 121 students met competency on their first attempt at completing the knowledge assessment and 126 students met competency on their first attempt at completing the practical examination. A pre- and post-training survey found that student pharmacists were significantly more comfortable performing and recommending implementation of services after completing the course. Conclusions. Training student pharmacists who are competent and comfortable providing clinical patient care services can improve access to care and reduce the impact of the impending physician shortage.

Management of Refractory Intracranial Pressure

Patients with refractory intracranial pressure represent a challenge to the multidisciplinary critical care team. Myriad diagnoses: traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke, are among the causes commonly seen in patients with elevated intracranial pressure. Clinicians tasked with caring for these patients must be aware of available interventions and management strategies to improve outcomes. Nurses as the bedside clinician most frequently assessing these patients are ideally situated to detect changes and act efficiently to lower refractory intracranial pressure.

A tool to assess student performance in a Clostridium difficile infection simulation scenario

OBJECTIVE

To develop and validate an evaluation tool to assess student pharmacists' performance in a simulation scenario involving a patient with Clostridium difficile infection (CDI).

METHODS

The authors used an expert panel review process to establish content validity of the tool. Four faculty members used the tool to evaluate student pharmacist groups during 2011 and tested a modified version of the tool in 2012. The authors analyzed the results for each year to determine internal consistency and inter-rater reliability.

RESULTS

The 2011 tool demonstrated sound internal consistency, but several items had poor inter-rater agreement. The revised 2012 tool demonstrated acceptable internal consistency and good to excellent inter-rater agreement for all items except one.

CONCLUSIONS

The tool facilitated reliable assessment of student pharmacists' clinical decision-making during simulation performance involving a patient with CDI.

Can a new ultra-long-acting insulin analogue improve patient care? Investigating the potential role of insulin degludec

The basal-bolus concept of delivering insulin to diabetic patients makes physiological sense, as it mimics normal insulin release in people without diabetes. In line with this concept, a major effort put forth by insulin manufacturers has been to develop the ideal exogenous basal insulin product. The perfect basal insulin product would be injected into subcutaneous tissue without causing irritation, release insulin continuously at a constant rate for at least 24 hours, be stable, not contribute to weight gain, have a low risk of allergic reactions and, very importantly, minimize the risk of hypoglycaemia. While the perfect insulin has not yet been discovered, advancements are still being made. Insulin degludec is an ultra-long-acting basal insulin analogue that possesses a flat, stable glucose-lowering effect in patients with type 1 or type 2 diabetes mellitus. Insulin degludec achieves these pharmacokinetic properties by forming soluble multihexamers upon subcutaneous injection, resulting in the formation of a depot in the subcutaneous tissue that is slowly released and absorbed into circulation. Insulin degludec has been associated with slightly less weight gain and fewer nocturnal hypoglycaemic episodes when compared with insulin glargine in some, but not all, clinical studies. This article briefly reviews current evidence for the use of insulin degludec in patients with type 1 or type 2 diabetes mellitus and discusses the potential impact of this new basal insulin on clinical practice.

Using human patient simulation to prepare student pharmacists to manage medical emergencies in an ambulatory setting

OBJECTIVE

To implement a simulation-based educational experience focused on medical emergencies in an ambulatory pharmacy setting.

DESIGN

Second-year student pharmacists were assigned randomly to groups and played the role of pharmacists in a community pharmacy setting in which a simulated patient experienced 1 of 5 emergency scenarios: medication-related allergic reaction, acute asthma attack, hypoglycemia, myocardial infarction, and stroke. The students were expected to use patient assessment techniques to determine which emergency the simulated patient was experiencing and the appropriate intervention. Following each simulation, a debriefing session was conducted.

ASSESSMENT

Eighty-two student pharmacists completed the simulation activity. Ninety-three percent of student groups correctly identified the emergency. A post-activity survey instrument was administered, and 83% of responders indicated this activity was effective or very effective.

CONCLUSION

Simulation of emergencies seen in an ambulatory pharmacy setting allowed students to assert knowledge, practice communication skills, apply assessment techniques, and work as a team in a low-risk environment.

Diabetes mellitus, inflammation, obesity: proposed treatment pathways for current and future therapies

OBJECTIVE

To review the pathophysiology, pharmacology, and current or future therapies under study for use in treating diabetes mellitus, inflammation associated with diabetes mellitus, and/or obesity related to diabetes mellitus, through 1 of 4 investigational pathways: adiponectin, ghrelin, resveratrol, or leptin.

DATA SOURCES

A literature search using MEDLINE (1966-December 12, 2009), PubMed (1950-December 12, 2009), Science Direct (1994-December 12, 2009), and International Pharmaceutical Abstracts (1970-December 12, 2009) was performed using the terms adiponectin, ghrelin, resveratrol, leptin, inflammation, obesity, and diabetes mellitus. English-language, original research, and review articles were examined, and citations from these articles were assessed as well.

STUDY SELECTION AND DATA EXTRACTION

Clinical studies and in vitro studies were included in addition to any Phase 1, 2, or 3 clinical trials.

DATA SYNTHESIS

Mechanistic pathways regarding adiponectin, ghrelin, resveratrol, and leptin are of interest as future treatment options for diabetes mellitus. Each of these pathways has produced significant in vitro and in vivo clinical data warranting further research as a possible treatment pathway for diabetes-related inflammation and/or obesity reduction. While research is still underway to determine the exact effects these pathways have on metabolic function, current data suggest that each of these compounds may be of interest for future therapies.

CONCLUSIONS

While several pathways under investigation may offer additional benefits in the treatment of diabetes mellitus and associated impairments, further investigation is necessary for both investigational and approved therapies to ensure that the impact in new pathways does not increase risks to patient safety and outcomes.

Disposition of [s]-heparin in the rat

[(35)S]-Heparin is rapidly taken up by tissues after intraperitoneal injection andrapidly degraded. Skin, aorta and lung showed an especially high affinity for[(35)S]-heparin. In these organs, as well as in adrenal gland, stomach, heart and brain,the isotope was found preponderantly as dialysable metabolite(s) of heparin. Another group of tissues (large intestine, fat, kidney and liver) was characterized by a smaller proportion of dialysable material. Tissues that showed a high affinity for exogenous heparin appeared to catabolize it rapidly. It is also noted that some of the radioactive material present in tissues after the injection of [(35)S]-heparin could come from the uptake of [(35)S]-sulphate resulting from the degradation of [(35)S]-heparin. The incorporation of [(35)S]-sulphate into the sulphomucopolysaccharides of some tissues is recorded.

Blood levels of flupenthixol in patients with acute and chronic schizophrenia

Plasma levels of flupenthixol were estimated by three methods in 30 patients with acute schizophrenia and 29 patients with chronic schizophrenia. These levels were related to clinical response, anterior pituitary hormone secretion, platelet monoamine oxidase activity, the effects of the concurrent administration of anticholinergic drugs, and body weight. No clearcut relationships between plasma flupenthixol levels and any of these variables were demonstrated. The practical clinical value of the estimation of plasma flupenthixol is limited at the present time.

The DRD2 TaqI-B polymorphism and its relationship to smoking abstinence and withdrawal symptoms

The dopamine receptor D2 (DRD2) gene has polymorphisms that have been linked to regulation of the dopamine system and to an increased prevalence of smoking. The present study examined the relationship of the DRD2 TaqI-A and -B polymorphisms with short-term clinical outcome (abstinence and withdrawal symptoms), collected from daily (14 pre-quit and 42 post-quit) diary data among smokers (n=116) treated with the nicotine patch plus either venlafaxine or placebo. The results showed that B1/B1 or B1/B2 smokers were slightly less likely to be abstinent on a given day than those homozygous for the TaqI-B2 allele. Significant DRD2 TaqI-B x time interactions were found for several of the withdrawal scales, indicating that those smokers with the B1/B1 or B1/B2 genotypes tended to report more symptoms over time compared to those with the B2/B2 genotype. No interactions or main effects were found for the DRD2 TaqI-A polymorphism. The findings demonstrate that smokers homozygous for the TaqI-B2 allele experience progressive improvement in self-reported withdrawal symptoms while smokers with the TaqI-B1 allele showing little change.

Healthcare providers' sun-protection promotion and at-risk clients' skin-cancer-prevention outcomes

BACKGROUND

This study aims to determine whether healthcare providers' (HCPs') communication dealing with sun-protection (i.e., counseling) is associated with clients' skin-cancer-related prevention practices, detection self-efficacy, and knowledge.

METHODS

Secondary analysis of two surveys of 1,469 randomly sampled farmers and soccer participants from southeast and coastal Georgia.

RESULTS

Farmers and soccer participants who report ever having been counseled by a HCP about how to protect their skin from the sun report being more likely to wear sunscreen (P < 0.05), get clinical exams of their skin (P < 0.001), be certain that they can recognize unhealthy changes in their skin (P < 0.001), be certain that they know how to perform a skin exam (P < 0.001), and be knowledgeable about skin cancer prevention (P < 0.05 and P < 0.001, respectively); soccer participants are additionally more likely to wear protective headgear (P < 0.05) and perform monthly self-exams of their skin (P < 0.001). All analyses incorporated three control variables: participants' prior history of skin cancer, age, and non-HCP-derived skin-cancer awareness.

CONCLUSIONS

Findings suggest that HCPs' counseling can positively shape skin-cancer-related prevention practices, detection self-efficacy, and knowledge. Additional research is needed on HCPs' actual communication about skin cancer and sun protection and its influence on client outcomes.

Closing medical encounters: two physician practices and their implications for the expression of patients' unstated concerns

When patients visit primary-care physicians, they frequently have more than one concern. Patients' first concerns are solicited by physicians at the beginnings of encounters. A challenge to health care is how to get patients' additional concerns raised as topics of discussion. If patients' additional concerns are addressed, it tends to occur at the end of encounters. Using the methodology of conversation analysis, this article identifies and describes the interactional organization of two physician-initiated communication practices that are used to negotiate the closure of the business of encounters and a transition into the activity of closing encounters themselves. These practices have different implications for the topicalization of patients' additional concerns.

The time course of emotional and attentional modulation of the startle eyeblink reflex during imagery

Two studies were conducted to examine the time course of attentional and emotional processing using the startle eyeblink reflex. Forty-eight participants listened to a series of 1500-ms tones that occurred every 6 s. The tones signaled participants to generate emotional images that were positive or negative in valence and high or low in arousal. Auditory startle probes occurred 120 ms, 1400 ms, or 4000 ms after tone onset. Startle inhibition was seen 120 ms after tone onset and startle facilitation was found at 1400 ms, compared to startles elicited 4000 ms after tone onset. Startle inhibition was greater at 120 ms when the tone signaled imagery, indicating an attentional effect. A second experiment found that this effect was not caused by the comparative rarity of the tones signaling imagery. Startle magnitude was also smaller at 1400 ms when the tone signaled imagery compared to no-imagery tones. The type of imagery did not modulate the startle response 120 ms after tone onset, but negative valence imagery enhanced startle magnitude at 1400 ms and 4000 ms after tone onset, and high arousal also enhanced startle magnitude at 4000 ms. Thus, attention and emotion followed different time courses in affecting the startle reflex response during imagery.

Women's health problems in soap operas: a content analysis

A content analysis of women's health problems in network daytime serials is reported. Results indicate a preponderance of such problems as substance abuse, falls resulting in death or injury, comas or unconsciousness, mental health concerns (most notably represented by amnesia and multiple personality), concerns about AIDS, automobile accidents, being drugged, fainting, pregnancy problems, and violent acts resulting in harm. Such concerns as breast and cervical cancer and heart disease are less frequently portrayed.

Experimental Characterization of the Higher Vibrationally Excited States of HCO(+): Determination of omega(2), x(22), g(22), and B(030)

Analyses of high Rydberg series of HCO converging to the (030) vibrational state of the cation establish rovibrational state-detailed thresholds for HCO(+). UV-visible laser double resonance isolates series for assignment. Strongly vertical Rydberg-Rydberg transitions from photoselected N' = 0 and N' = 2 rotational levels of the Sigma(-) Renner-Teller vibronic component of the 3ppi (2)Pi (030) complex define individual series converging to rotational levels, N(+) = 1 through 5 and 3 through 5 of the HCO(+) vibrational states (03(1)0) and (03(3)0), respectively. Extrapolation of autoionizing series locates the positions of these rovibrational states to within +/-0.01 cm(-1). The use of this information combined with precise ionization limits for lower vibrational states determined from earlier Rydberg extrapolations and spectroscopic information available from infrared absorption measurements enables an estimate of the force-field parameters for HCO(+) bending. These parameters include the harmonic bending frequency, omega(2) = 842.57 cm(-1), the vibrational angular momentum splitting constant, g(22) = 3.26 cm(-1), and the diagonal bending anharmonicity, x(22) = -2.53 cm(-1), separated from the off-diagonal contribution, x(12), by reference to ab initio calculations. Results of experiment on the higher vibrationally excited states of HCO(+) are compared with recent theoretical predictions. Copyright 2000 Academic Press.

Transient kinetics of substrate binding to Na+/K(+)-ATPase measured by fluorescence quenching

This paper examines the transient kinetics of substrate binding to the Na+/K(+)-ATPase labelled with iodoacetamidofluorescein (IAF) using fluorescence quenching by trinitrophenyl-ATP (TNP-ATP). Earlier work (E.H. Hellen, P.R. Pratap, 1996, Fluorescence quenching of IAF-Na+/K(+)-ATPase via energy transfer to TNP-labelled nucleotide, Proceedings of the VIIIth International Conference on the Na+/K(+)-ATPase, in press) has shown that TNP-nucleotide binds to specific sites (from which unlabelled nucleotide can displace it) and nonspecific sites (from which unlabelled nucleotide cannot displace it). Under stopped-flow conditions, quenching of IAF-enzyme fluorescence was well described by a stretched exponential (F(t) = F infinity + delta F exp[-Bt alpha]). Physically, this function may be interpreted in terms of its inverse Laplace transform phi (k), which describes a distribution of rate-constants; alpha reflects the width of this distribution. As TNP-ATP concentration increased, alpha decreased, reflecting TNP-ATP binding to sites with higher energy barriers. alpha decreased by about the same amount with increasing [TNP-ATP] in the presence of saturating ATP, indicating that the distribution of rate-constants is largely associated with the nonspecific binding sites. However, alpha was significantly less than 1 for ATP-induced fluorescence recovery in the presence of TNP-ATP, indicating that rate-constants associated with specific binding site are also distributed. The distribution of rate-constants for binding to the specific site indicates a distribution in the energy of the transition state for substrate binding. These results suggest that the specific binding site (in either the empty or the full state) may exist in a series of conformations separated by small energy barriers. However, the energy barriers for binding associated with these conformations are significantly distributed.

Iodine insufficiency and neonatal hyperthyrotropinaemia in Hong Kong

OBJECTIVES

23% of the neonatal hypothyroidism in Hong Kong is transient. The present study aims to evaluate iodine excretion in healthy pregnant women in Hong Kong and to determine whether iodine insufficiency may occur in the local population to account for the type of neonatal thyroid dysfunction seen in our screening programme.

SUBJECTS

Pilot screening of urinary iodine excretion was determined in 253 healthy pregnant women between 32 and 36 weeks gestation. Fetal and maternal thyroid function in relation to urinary iodine excretion was evaluated in another 55 pregnant women who had given birth to infants with cord blood TSH > or = 16 mIU/I (95th percentile of the cord blood TSH screening programme) and the results were compared to a control group of 160 healthy women whose infants had cord blood TSH < 16 mIU/I.

RESULTS

Using a cut-off value of 0.79 mumol/l, a level as defined by WHO as iodine deficiency, we found that 35.8% of the pregnant women had urinary iodine concentrations below this cut off value. We demonstrated that the existence of borderline iodine supply affected the maternal and fetal thyroid function as evidenced by (i) a negative correlation between maternal TSH and urinary iodine concentration, (ii) higher cord blood TSH in those infants whose mothers had a low urinary iodine concentration as compared to those in whose mothers it was normal, (iii) women who had given birth to infants with cord blood TSH > or = 16 mIU/I had lower urinary iodine concentrations and serum fT4 levels as compared to mothers who had given birth to infants with normal cord TSH levels, and their offspring also had higher cord blood thyroglobulin levels.

CONCLUSION

Although Hong Kong is not a goitrous area, borderline iodine deficiency exists. Iodization of salt in our community could obviate the necessity for iodine supplements in pregnant women and other at-risk groups.

Kinetics of conformational changes associated with potassium binding to and release from Na+/K(+)-ATPase

The Na+/K(+)-ATPase functions in cells to couple energy from the hydrolysis of ATP to the transport Na+ out and K+ in. The fluorescent probe IAF (iodoacetamidofluorescein) covalently binds to this enzyme, reporting conformational changes without inhibiting enzyme activity. This paper describes experiments using dog kidney enzyme labeled with IAF to examine kinetics of conformational changes resulting from added Na+ and K+, measured in terms of steady-state and stopped-flow fluorescence changes. Kinetics of these fluorescence changes were examined as a function of temperature from two initial conditions: (a) enzyme in the high-fluorescence form (E(high)) was rapidly mixed with varying [K+]; and (b) enzyme in the low-fluorescence form (E(low)) was rapidly mixed with varying [ATP]. These experiments showed: (1) The rate constant for the fluorescence change from E(high) to E(low) was much larger than that for the opposite transition, E(low) to E(high); (2) the apparent free energy of activation (Ea(app)) for the two transitions were different (as estimated from Arrhenius plots); (3) under steady-state conditions, IAF fluorescence did not change when ATP was added to E(low)(K+) in the absence of Na+; (4) the apparent free energy of activation was independent of [K+] for the E(high) to E(low) transition (at 16.4 kcal/mol) but increased with [ATP] for the E(low) to E(high) transition; (5) Ea(app) for the E(low) to E(high) transition with 1 mM ATP was approximately the same as that in the absence of ATP (34 kcal/mol). These results can be interpreted as: (i) in the transition from E(low) to E(high), IAF reported a conformational change that occurred after K+ release to the intracellular side and which is involved in Na+ binding; (ii) Ea(app) increased with [ATP], while increasing the entropy of the transition state. Thus, ATP appeared to destabilize the enzyme during the transition from E(low) to E(high).

Existence of iodine deficiency in Hong Kong--a coastal city in southern China

OBJECTIVE

Iodine deficiency is a serious public health problem worldwide which is associated with mental retardation and cretinism. In view of a high incidence of transient neonatal hypothyroidism and a relatively high mean cord blood thyrotropin (TSH) concentration, a pilot study was carried out to analyse the urine iodine excretion in Hong Kong, a coastal city in the southern part of China.

DESIGN

Early morning urine was collected from healthy volunteers including children (n = 104), adults (n = 112) and elderly subjects (n = 349). A semi-quantitative questionnaire survey on the pattern of food intake was conducted in the adults and elderly.

RESULTS

45.3% of the children, 51.7% of the adults and 55.3% of the elderly had urine iodine concentration below the criteria for iodine sufficiency (< 0.79 mumol/l). Iodine content in the drinking water and salt was low. A dietary survey revealed that seafood was not commonly consumed. 50-80% of the subjects never consumed high-iodine containing food such as seaweed, kelp or laver, and only 50% consumed seawater fish daily.

CONCLUSION

We confirmed that although Hong Kong is a non-goitrous area, iodine insufficiency exists. It is unsafe to assume that iodine deficiency does not exist in coastal urban areas.

The Howard University Hospital Transplant and Dialysis Support Group: twenty years and going strong

This article discusses group therapy as part of a multidisciplinary approach to the management of the various psychological and physical rehabilitation concerns posed by kidney and liver transplant candidates and recipients at Howard University Hospital in Washington, DC. The group's history, format, intervention foci, and roles of clinicians and patients attending the group are described and evaluated. Given the relative paucity of research literature in this area, the authors offer recommendations for empirical evaluation of the benefits of multidisciplinary group psychotherapy in ameliorating physical and emotional suffering and prolonging life among transplant patients.

Rapid kinetic analyses of the Na+/K(+)-ATPase distinguish among different criteria for conformational change

The Na+/K(+)-ATPase couples the hydrolysis of ATP to the transport of Na+ and K+ via a phosphorylated intermediate and conformational changes. In order to identify these conformational changes, we have probed the sequence of steps from EP(3Na+ in) to EP + 3Na+ out with three fluorescent probes (IAF: 5-iodoacetamidofluorescein; BIPM: N-[p-(2-benzimidazolyl)phenyl]maleimide; and RH421) and the sensitivity of their fluorescence change to oligomycin and divalent cations (Ca2+ and Mn2+). The magnitude (% delta F) and rate constant (k(obs)) of ATP-induced fluorescence changes were measured on a fluorescence stopped-flow apparatus, and yielded the following results. (a) With RH421, k(obs) and % delta F varied with [Na+] (maximal k(obs) = 100 s-1, K1/2 = 6 mM; % delta Fmax = 6%, K1/2 = 1 mM); these values are comparable to those previously reported using IAF-labeled enzyme (Pratap, P.R., Robinson, J.D. and Steinberg, M.I. (1991) Biochim. Biophys. Acta 1069, 288-298). (b) With BIPM-labeled enzyme k(obs) did not vary with [Na+] over the range tested, and was twice as high as the maximum k(obs) for RH421. (c) Treatment with oligomycin reduced k(obs) for all three probes to about the same level (approximately 1-2 s-1) while % delta Fmax was largely unaffected. (d) Replacing Mg2+ with Ca2+ had similar effects to treatment with oligomycin. (e) RH421 fluorescence change was completely abolished in the presence of oligomycin and Ca2+. (f) Replacing Mg2+ with Mn2+ decreased IAF fluorescence, i.e., put the enzyme in an E2-like form, reduced k(obs), and rendered oligomycin less effective in reducing k(obs). From these results, we conclude: (a) the release of the second/third Na+ is the rate-limiting step for the conformational change measured by IAF and charge transfer measured with RH421; (b) BIPM indicates an earlier step, either the deocclusion of Na+ and/or the release of the first Na+; (c) oligomycin blocks Na+ deocclusion, and this step is sensitive to the divalent cation used to activate enzyme phosphorylation; and (d) Ca2+ slows the step reported by IAF as well. These experiments indicate that a simple model with two conformations (E1 and E2) is insufficient to explain transient kinetic data.

Improved mammography with a reduced radiation dose

A 2-cm-high focused air-interspaced grid with a 7:1 ratio and eight lamellae per inch was devised. The grid is arc-shaped and pivots on its focal point, the anode-cathode axis. Milliamperage was 35% less for breast phantom radiographs obtained with the new grid versus those obtained with a conventional 5:1 mammographic grid. In a comparison study of five mammograms, each evaluated for five parameters, the images obtained with the new grid were judged to be of equal or better quality than those obtained with a conventional grid in 17 of 20 comparisons.

The requirement of low calcium dialysate in patients on continuous ambulatory peritoneal dialysis receiving calcium carbonate as a phosphate binder

In the present study we investigated the requirement of low calcium dialysate in 35 patients on continuous ambulatory peritoneal dialysis (CAPD) receiving calcium carbonate as the sole phosphate binder over a 12-month period. Patients with corrected serum calcium > or = 2.85 mmol/L after switching to oral calcium carbonate were given 1 to 3 2-litre exchanges of 2.5 mEq/L calcium dialysate. Serum phosphate level dropped from the pretreatment value of 2.95 +/- 0.62 to a level of between 1.70 +/- 0.41 to 2.03 +/- 0.44 mmol/L 2 weeks after therapy. Corrected serum calcium level increased significantly from 2 weeks onwards. Serum alkaline phosphatase rose initially at 2 and 6 weeks and decreased from 3 months onwards. Serum parathyroid hormone level dropped significantly from a mean pretreatment level of 569 to 320 pg/ml after 12 months (p < 0.001). Serum aluminum decreased significantly from a mean of 1.04 to 0.65 umol/L (p < 0.01). Daily calcium carbonate requirement fluctuated but tended to increase till 8 months and plateaued and ranged from 2.61 +/- 0.57 to 3.98 +/- 2.11 gm. The daily requirement of low calcium dialysate followed a similar trend with approximately three-quarters of patients ultimately requiring at least 1 bag of low calcium dialysate. Eight patients did not require low calcium dialysate. Patients who required low calcium dialysate were significantly older, had a significantly lower pretreatment serum parathyroid hormone and higher serum aluminum levels than those who did not.(ABSTRACT TRUNCATED AT 250 WORDS)

Lovastatin in glomerulonephritis patients with hyperlipidaemia and heavy proteinuria

Lovastatin, a 3-hydroxy-3-methylglutaryl coenzyme A inhibitor, was given to 14 patients with unremittent nephrotic syndrome (heavy proteinuria with hyperlipidaemia) for 6 months. Treatment was started at an initial dose of 20 mg/day, increasing to a maximum of 80 mg/day. Treatment was well tolerated except in two patients: one developed rhabdomyolysis and one severe hypertriglyceridaemia requiring an additional antihyperlipidaemic agent. Lovastatin was effective in reducing serum cholesterol, LDL-C and apolipoprotein B in the remaining 12 patients. Cholesterol was reduced by 31% from 8.24 +/- 0.49 mmol/l (mean +/- SEM) to 5.7 +/- 0.18 mmol/l after 6 months (P less than 0.001). LDL-C was normalized to 3.26 +/- 0.21 mmol/l from a pretreatment value of 5.76 +/- 0.48 mmol/l (P less than 0.001), a decrease of 43%. Serum apolipoprotein B was also normalized to 1.11 +/- 0.09 g/l from a basal level of 1.51 +/- 0.10 g/l (P less than 0.05). Triglyceride, HDL-C and apolipoprotein A1 concentrations were unchanged. Proteinuria as well as renal albumin clearance were unchanged. GFR by plasma radioisotope Cr-EDTA clearance for the whole group was unaltered by treatment. However, among those with relatively good pretreatment renal function (GFR greater than 70 ml/min per 1.73 m2), GFR increased at the end of 6 months' treatment (118.2 +/- 15 ml/min per 1.73 m2 versus 77.6 +/- 8.4 ml/min per 1.73 m2 in wash-out phase).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of choline on Na(+)- and K(+)-interactions with the Na+/K(+)-ATPase

Choline chloride, 100 mM, stimulates Na+/K(+)-ATPase activity of a purified dog kidney enzyme preparation when Na+ is suboptimal (9 mM Na+ and 10 mM K+) and inhibits when K+ is suboptimal (90 mM Na+ and 1 mM K+), but has a negligible effect at optimal concentrations of both (90 mM Na+ and 10 mM K+). Stimulation occurs at low Na+ to K+ ratios, but not at those same ratios when the actual Na+ concentration is high (90 mM). Stimulation decreases or disappears when incubation pH or temperature is increased or when Li+ is substituted for K+ or Rb+. Choline+ also reduces the Km for MgATP at the low ratio of Na+ to K+ but not at the optimal ratio. In the absence of K+, however, choline+ does not stimulate at low Na+ concentrations: either in the Na(+)-ATPase reaction or in the E1 to E2P conformational transition. Together, these observations indicate that choline+ accelerates the rate-limiting step in the Na+/K(+)-ATPase reaction cycle, K(+)-deocclusion; consequently, optimal Na+ concentrations reflect Na+ accelerating that step also. Thus, the observed K0.5 for Na+ includes high-affinity activation of enzyme phosphorylation and low-affinity acceleration of K(+)-deocclusion. Inhibition of Na+/K(+)-ATPase and K(+)-nitrophenylphosphatase reactions by choline+ increases as the K(+)-concentration is decreased; the competition between choline+ and K+ may represent a similar antagonism between conformations selected by choline+ and by K+.

The reaction sequence of the Na+/K(+)-ATPase: rapid kinetic measurements distinguish between alternative schemes

Conformational changes between E1 and E2 enzyme forms of a dog kidney Na+/K(+)-ATPase preparation labeled with 5-iodoacetamidofluorescein were followed with a stopped-flow fluorimeter, in terms of the rate constant, kobs, and the steady-state magnitude, % delta F of fluorescence change. On rapid mixing of enzyme plus Mg2+ plus Na+ with saturating (0.5 mM) ATP in the absence of K+, kobs varied with Na+ concentration in the range 0-155 mM, with a K1/2 of 10 mM, while % delta F was relatively insensitive to Na+, with a K1/2 of 0.5 mM. Oligomycin reduced kobs by 98-99% for Na+ greater than or equal to 10 mM, but only by 50% for Na+ = 1 mM; % delta F was reduced at most by 20%. At 155 mM Na+, both kobs and % delta F changed if K+ was present with the enzyme. kobs decreased by 50% when K+ was increased from 0 to 0.2 mM, but increased when K+ was varied in the range 0.2-5 mM. K+ increased % delta F by a factor of 3 with a K1/2 of 0.3-0.5 mM as measured in both stopped-flow and steady-state experiments. These data are considered in terms of the derived presteady-state equations for two alternate schemes for the enzyme, with the E1P to E2P conformational change either preceding (Albers-Post) or following (Nørby-Yoda-Skou) Na+ transport and release. The analysis indicates that: (i) Na+ must be released before the conformational transition, from an E1 form; (ii) the step in which the second and/or third Na+ is released is rate-limiting, but this release is accelerated by Na+; and (iii) the release is also accelerated by K+ acting with low affinity (possibly at extracellular sites).

Na+/K(+)-ATPase: modes of inhibition by Mg2+

Adding 15 mM free Mg2+ decreased Vmax of the Na+/K(+)-ATPase reaction. Mg2+ also decreased the K0.5 for K+ activation, as a mixed inhibitor, but the increased inhibition at higher K+ concentrations diminished as the Na+ concentration was raised. Inhibition was greater with Rb+ but less with Li+ when these cations substituted for K+ at pH 7.5, while at pH 8.5 inhibition was generally less and essentially the same with all three cations: implying an association between inhibition and ion occlusion. On the other hand, Mg2+ increased the K0.5 for Na(+)-activation of the Na+/K(+)-ATPase and Na(+)-ATPase reactions, as a mixed inhibitor. Changing incubation pH or temperature, or adding dimethylsulfoxide affected inhibition by Mg2+ and K0.5 for Na+ diversely. Presteady-state kinetic studies on enzyme phosphorylation, however, showed competition between Mg2+ and Na+. In the K(+)-phosphatase reaction catalyzed by this enzyme Mg2+ was a (near) competitor toward K+. Adding Na+ with K+ inhibited phosphatase activity, but under these conditions 15 mM Mg2+ stimulated rather than inhibited; still higher Mg2+ concentrations then inhibited with K+ plus Na+. Similar stimulation and inhibition occurred when Mn2+ was substituted for Mg2+, although the concentrations required were an order of magnitude less. In all these experiments no ionic substitutions were made to maintain ionic strength, since alternative cations, such as choline, produced various specific effects themselves. Kinetic analyses, in terms of product inhibition by Mg2+, require Mg2+ release at multiple steps. The data are accommodated by a scheme for the Na+/K(+)-ATPase with three alternative points for release: before MgATP binding, before K+ release and before Na+ binding. The latter alternatives necessitate two Mg2+ ions bound simultaneously to the enzyme, presumably to divalent cation-sites associated with the phosphate and the nucleotide domains of the active site.