Modulation of Trust in Borderline Personality Disorder by Script-Based Imaginal Exposure to Betrayal.

Interpersonal and trust-related difficulties are central features of borderline personality disorder (BPD). In this study, we applied script-driven betrayal imagery to evoke mistrustful behavior in a social reinforcement learning task. In 21 BPD and 20 healthy control (HC) participants, we compared this approach to the standard confederate paradigm used in research studies. The script-driven imagery evoked a transient increase in negative affect and also decreased trusting behavior to a similar degree in both groups. Across conditions, we also replicated previously reported between-group differences in negative affect (increased in BPD) and task behavior (more sensitive to social cues in BPD). These results support the validity of script-driven imagery as an alternative social task stimulus. This script-driven imagery approach is appealing for clinical research studies on reinforcement learning because it eliminates deception, scales easily, and evokes disorder-specific states of social difficulty.

Lanthanum masquerading as foreign body ingestion in a critically ill patient with end-stage renal disease.

PURPOSE: Medication use may affect imaging results. In this case study, we report a case of lanthanum ingestion resulting in imaging consistent with ingested metallic foreign bodies. SUMMARY: Hyperphosphatemia affects most patients with end-stage renal disease (ESRD) and is associated with morbidity and mortality. Lanthanum carbonate reduces daily phosphate absorption and is indicated as a non-calcium-based phosphate binder in patients with ESRD. A 58-year-old man with a medical history of stage 5 chronic kidney disease was admitted to the intensive care unit (ICU) for hyperkalemia and acute respiratory failure after a missed dialysis session. He required vasopressors, intubation, and continuous renal replacement therapy. Admission imaging demonstrated several ingested metallic foreign bodies within the colon. There was consideration of colorectal surgery and gastroenterology consultation. On the initial medication reconciliation, no medications that would have the radiographic appearance of ingested metallic foreign bodies were identified. On further review of prescription data available through the electronic medical record, it was noted that the patient had recently filled a prescription for lanthanum despite its apparent discontinuation on a previous admission. After interviewing the patient's wife, it was confirmed that the patient had continued taking lanthanum and that he was swallowing it whole and not chewing it. No consultations or interventions were performed, and the metallic foreign bodies were no longer present on further imaging after a period of 35 days. CONCLUSION: Escalation of care was avoided in this patient due to the performance of diligent medication reconciliation and recognition of the impact of lanthanum ingestion on imaging.

Granular cell tumor in the pulmonary tree.

Granular cell tumors are often benign growths of the tongue, dermis, and subcutaneous tissues. Rarely, we see production in the pulmonary system. These schwannian and histiocyte origin tumors in the lungs are called pulmonary granulocyte tumors. While granular cell tumors are rare, pulmonary granulocyte tumors are even rarer, with less than eighty-five cases described since the 1930s. Herein, we introduce these rare growths and provide a review of known epidemiological evidence and pathophysiology.

Accountable Care Organizations during Covid-19: Routine care for older adults with multiple chronic conditions.

The COVID-19 pandemic threatens the health and well-being of older adults with multiple chronic conditions. To date, limited information exists about how Accountable Care Organizations (ACOs) are adapting to manage these patients. We surveyed 78 Medicare ACOs about their concerns for these patients during the pandemic and strategies they are employing to address them. ACOs expressed major concerns about disruptions to necessary care for this population, including the accessibility of social services and long-term care services. While certain strategies like virtual primary and specialty care visits were being used by nearly all ACOs, other services such as virtual social services, home medication delivery, and remote lab monitoring were far less commonly accessible. ACOs expressed that support for telehealth services, investment in remote monitoring capabilities, and funding for new, targeted care innovation initiatives would help them better care for vulnerable patients during this pandemic.

Atranorin, an antimicrobial metabolite from lichen Parmotrema rampoddense exhibited in vitro anti-breast cancer activity through interaction with Akt activity.

Atranorin (ATR), lichenized secondary metabolite and depside molecule with several biological potentials such as antimicrobial, anticancer, anti-inflammatory, antinociceptive, wound healing and photoprotective activities. Cytotoxic reports of ATR are documented in several cancer cells and in vivo models but its molecular interaction studies are poorly understood. Therefore, in this present investigation, we have used the in silico studies with biological validation of the molecular targets for the anti-breast cancer mechanism of ATR. The molecular docking studies with the breast cancer oncoproteins such as Bcl-2, Bax, Akt, Bcl-w and Bcl-xL revealed the highest interaction was observed with the Akt followed by Bax, Bcl-xL and Bcl-2 & least with the Bcl-w proteins. The cytotoxicity studies showed ATR selectively inhibited MDA MB-231 and MCF-7 breast cancer cells in differential and dose-dependent manner with the IC50 concentration of 5.36 ± 0.85 µM and 7.55 ± 1.2 µM respectively. Further mechanistic investigations revealed that ATR significantly inhibited ROS production and significantly down-regulated the anti apoptotic Akt than Bcl-2, Bcl-xL and Bcl-w proteins with a significant increase in the Bax level and caspases-3 activity in the breast cancer cells when comparison with Akt inhibitor, ipatasertib. In vitro biological activities well correlated with the molecular interaction data suggesting that atranorin had higher interaction with Akt than Bax and Bcl-2 but weak interaction with Bcl-w and Bcl-xL. In this present study, the first time we report the interactions of atranorin with molecular targets for anti-breast cancer potential. Hence, ATR represents the nature-inspired molecule for pharmacophore moiety for design in targeted therapy.Communicated by Ramaswamy H. Sarma.

Boredom in Borderline Personality Disorder: A Lost Criterion Reconsidered.

Difficulty with boredom was eliminated from the formal diagnostic criteria for borderline personality disorder (BPD) in 1994 based on significantly limited, unpublished data. However, it is apparent in clinical practice that boredom remains relevant to BPD. This review synthesizes empirical research, with consideration of theoretical accounts, to critically examine the relevance of boredom to BPD. We first briefly review issues in defining and measuring boredom and offer an expanded conceptualization for BPD, which includes the notion of boredom reactivity, before turning to boredom's differentiation from and overlap with feelings of emptiness, with which it was paired prior to its removal from the DSM. We then discuss perspectives on boredom's significance in BPD, briefly touching on its relevance in other personality disorders. We propose a Boredom Cascade Model that articulates how boredom and boredom reactivity interact with identity disturbance and chronic emptiness to create escalating patterns of behavioral dysregulation and make recommendations for research and treatment.

How Accountable Care Organizations Use Population Segmentation to Care for High-Need, High-Cost Patients.

Issue: New payment and care delivery models such as accountable care organizations (ACOs) have prompted health care delivery systems to better meet the requirements of their high-need, high-cost (HNHC) patients. Goal: To explore how a group of mature ACOs are seeking to match patients with appropriate interventions by segmenting HNHC populations with similar needs into smaller subgroups. Methods: Semistructured telephone interviews with 34 leaders from 18 mature ACOs and 10 national experts knowledgeable about risk stratification and segmentation. Key Findings and Conclusions: ACOs use a range of approaches to segment their HNHC patients. Although there was no consistent set of subgroups for HNHC patients across ACOs, there were some common ones. Respondents noted that when primary care clinicians were engaged in refining segmentation approaches, there was an increase in both the clinical relevance of the results as well as the willingness of frontline providers to use them. Population segmentation results informed ACOs' understanding of program needs, for example, by helping them better understand what skill sets and staff were needed to deliver enhanced care management. Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches.

Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action.

Health care delivery systems, including academic medical centers (AMCs), are increasingly focused on improving care for vulnerable, high-need, high-cost patients, in part because value-based payment models offer the promise of financial returns, or the avoidance of losses, for doing so. AMCs and other providers that have participated in Medicare and Medicaid demonstrations and value-based payment programs have important insights to offer about the features of successful and promising programs for high-need, high-cost patients. As more AMCs embrace value-based payment, they may have greater flexibility to provide services that address the medical and nonmedical needs of clinically complex patients and thereby reduce avoidable health care utilization. AMCs have many opportunities to create high-performing health systems, establish operational evidence for how to transform delivery systems, and train the next generation of providers to better address the care of high-need, high-cost individuals.

How High-Need Patients Experience Health Care in the United States. Findings from the 2016 Commonwealth Fund Survey of High-Need Patients.

Issue: Health care costs are highly concentrated among people with multiple chronic conditions, behavioral health problems, and those with physical limitations or disabilities. With a better understanding of these patients' challenges, health care systems and providers can address patients' complex social, behavioral, and medical needs more effectively and efficiently. Goal: To investigate how the challenges faced by this population affect their experiences with the health care system and examine potential opportunities for improvement. Methods: Analysis of the 2016 Commonwealth Fund Survey of High-Need Patients, June­September 2016. Key findings and conclusions: The health care system is currently failing to meet the complex needs of these patients. High-need patients have greater unmet behavioral health and social issues than do other adults and require greater support to help manage their complex medical and nonmedical requirements. Results indicate that with better access to care and good patient­provider communication, high-need patients are less likely to delay essential care and less likely to go to the emergency department for nonurgent care, and thus less likely to accrue avoidable costs. For health systems to improve outcomes and lower costs, they must assess patients' comprehensive needs, increase access to care, and improve how they communicate with patients.

High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? A Population-Based Comparison of Demographics, Health Care Use, and Expenditures.

Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. Methods: Analysis of data from the 2009­2011 Medical Expenditure Panel Survey. Key findings: High-need adults differed notably from adults with multiple chronic diseases but no functional limitations. They had average annual health care expenditures that were nearly three times higher­and which were more likely to remain high over two years of observation­and out-of-pocket expenses that were more than a third higher, despite their lower incomes. Rates of hospital use for high-need adults were more than twice those for adults with multiple chronic conditions only; high-need adults also visited the doctor more frequently and used more home health care. Costs and use of services also varied widely within the high-need group. Conclusion: These findings suggest that interventions should be targeted and tailored to high-need individuals most likely to benefit.

Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences.

Issue: Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients--those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs--those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks--to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009--2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient-provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured high-need adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study's findings highlight the importance of tailoring interventions to address their needs.

Impact on Primary Care Access Post-Disaster: A Case Study From the Rockaway Peninsula.

OBJECTIVE: Assess Hurricane Sandy's impact on primary care providers' services in the Rockaways. METHODS: In-person surveys were conducted in 2014. A list of 46 health care sites in the area of interest was compiled and each site was called to offer participation in our survey. Respondents included physicians and practice administrators who remained familiar with Sandy-related operational challenges. RESULTS: Of the 40 sites that opted in, most had been in their current location for more than 10 years (73%) and were a small practice (1 or 2 physicians) before Hurricane Sandy (75%). All but 2 (95%) had to temporarily close or relocate. All sites experienced electrical problems that impacted landline, fax, and Internet. Less than one-quarter (n = 9) reported having a plan for continuity of services before Hurricane Sandy, and 43% reported having a plan poststorm. The majority (80%) did not report coordinating with other primary care stakeholders or receiving support from government agencies during the Sandy response. CONCLUSIONS: Hurricane Sandy significantly disrupted access to primary care in the Rockaways. Severe impact to site operations and infrastructure forced many practices to relocate. Greater emergency response and recovery planning is needed, including with government agencies, to minimize disruptions of access to primary care during disaster recovery. (Disaster Med Public Health Preparedness. 2016;10:492-495).

Case studies from three states: breaking down silos between health care and criminal justice.

The jail-involved population-people with a history of arrest in the previous year-has high rates of illness, which leads to high costs for society. A significant percentage of jail-involved people are estimated to become newly eligible for coverage through the Affordable Care Act's expansion of Medicaid, including coverage of substance abuse treatment and mental health care. In this article we explore the need to break down the current policy silos between health care and criminal justice, to benefit both sectors and reduce unnecessary costs resulting from lack of coordination. To draw attention to the hidden costs of the current system, we review three case studies, from Washington State, Los Angeles County in California, and New York City. Each case study addresses different aspects of care needed by or provided to the jail-involved population, including mental health and substance abuse, emergency care, and coordination of care transitions. Ultimately, bending the cost curve for health care and criminal justice will require greater integration of the two systems.

Simulation training in central venous catheter insertion: improved performance in clinical practice.

PURPOSE: To determine whether simulation training of ultrasound (US)-guided central venous catheter (CVC) insertion skills on a partial task trainer improves cannulation and insertion success rates in clinical practice. METHOD: This prospective, randomized, controlled, single-blind study of first- and second-year residents occurred at a tertiary care teaching hospital from January 2007 to September 2008. The intervention group (n = 90) received a didactic and hands-on, competency-based simulation training course in US-guided CVC insertion, whereas the control group (n = 95) received training through a traditional, bedside apprenticeship model. Success at first cannulation and successful CVC insertion served as the primary outcomes. Secondary outcomes included reduction in technical errors and decreased mechanical complications. RESULTS: Blinded independent raters observed 495 CVC insertions by 115 residents over a 21-month period. Successful first cannulation occurred in 51% of the intervention group versus 37% of the control group (P = .03). CVC insertion success occurred for 78% of the intervention group versus 67% of the control group (P = .02). Simulation training was independently and significantly associated with success at first cannulation (odds ratio: 1.7; 95% confidence interval: 1.1-2.8) and with successful CVC insertion (odds ratio: 1.7; 95% confidence interval: 1.1-2.8)--both independent of US use, patient comorbidities, or resident specialty. No significant differences related to technical errors or mechanical complications existed between the two groups. CONCLUSIONS: Simulation training was associated with improved in-hospital performance of CVC insertion. Procedural simulation was associated with improved residents' skills and was more effective than traditional training.