Caudate nucleus-dependent response strategies in a virtual navigation task are associated with lower basal cortisol and impaired episodic memory.

The present research examined the relationship between endogenous glucocorticoids, navigational strategies in a virtual navigation task, and performance on standard neuropsychological assessments of memory. Healthy young adult participants (N=66, mean age: 21.7) were tested on the 4 on 8 virtual maze (4/8 VM) and standard neuropsychological tests such as the Rey-Osterrieth Complex Figure (RO) and the Rey Auditory Verbal Learning Task (RAVLT), which measure episodic memory. The 4/8 VM differentiates between navigational strategies, where participants either use a hippocampal-dependent spatial strategy by building relationships between landmarks, or a caudate nucleus-dependent stimulus-response strategy by automatizing a pattern of open and closed arms to learn the location of objects within the maze. Degree of stress was assessed by administering the Perceived Stress Scale (PSS) questionnaire. Cortisol samples were taken on two consecutive days upon waking, 30 min after waking, at 11 am, 4 pm, and 9 pm. There was a significant difference in basal levels of cortisol between spatial and response learners. Interestingly, response learners had significantly lower cortisol levels throughout the day. The two groups did not differ in terms of perceived stress as measured with the PSS questionnaire. Moreover, there was no significant correlation between PSS scores and salivary cortisol levels, indicating that the higher cortisol levels in the spatial group were not associated with greater perceived stress. In addition, participants who spontaneously used a spatial strategy performed significantly better on the RAVLT and RO. These data indicate that the cortisol levels in the spatial group may be optimal in terms of episodic memory performance whereas the cortisol levels in the response group may be associated with poorer memory. These results are suggestive of an inverted U-shaped curve describing the effects of basal levels of circulating cortisol on memory in young adults.

Case Discussions in Advanced Care Planning.

BACKGROUND: Advanced care planning (ACP) provides an opportunity for individuals to explore and document their values concerning medical care decisions prior to an acute event. This manuscript explores the value of ACP and compares and contrasts 2 ACP models currently in practice. METHODS: This hypothetical case describes an elderly, frail patient with end-stage chronic obstructive pulmonary disease who is also a high user of health care resources. A new palliative care-led outpatient ACP clinic model is described using this example. RESULTS: Using the ACP clinic model in this case reveals how different a patient's end of life experience may be when proper, proactive planning measures are in place. With proper education and discussion around this patient and family's wishes pertaining to the end of his life, this man was able to change his plan of care from aggressive resuscitation treatment in hospital to a peaceful palliative experience at home. CONCLUSIONS: In this case description, the valuable role of ACP in preserving quality of life for patients, increasing satisfaction with care, and decreasing distress among family members during a medical event is demonstrated.

Comparison of remote and in-clinic follow-up after methotrexate/misoprostol abortion.

OBJECTIVE: This study compared adherence to follow-up and clinical outcomes between standard in-clinic and remote follow-up after methotrexate/misoprostol abortion. STUDY DESIGN: This nonrandomized trial recruited women requesting medical abortion at two sexual health clinics in Toronto, Canada. Women received methotrexate 50 mg/m(2) followed 3-7 days later by 800 mcg of misoprostol self-administered vaginally. For Day 15, follow-up participants could choose standard in-clinic follow-up with ultrasound and assessment or remote telephone follow-up with serum ß-hCG performed at a community laboratory and symptom checklist. Standard and remote follow-up groups were compared for adherence, defined as completing follow-up within 7 days of the scheduled time, and clinical outcomes. Characteristics associated with adherence were assessed using multivariable logistic regression. RESULTS: Of 129 women, 86 (67%) chose remote follow-up. Nonadherence rates for remote (28%) and standard (23%) follow-up groups did not differ in univariate (p=.57) or multivariable analysis (odds ratio: 1.09, 95% confidence interval: 0.39-3.01). Rates of emergency/hospital visits were 3% and 9% for remote and standard groups, respectively (p=.22), and complete loss to follow was 6% and 14% in remote and standard groups (p=.18). Nonadherent women were more likely to be undecided about their contraception (65% vs. 28%; p=.002), and this difference persisted in the multivariable analysis. CONCLUSION: Given a choice of remote or in-clinic follow-up after methotrexate/misoprostol abortion, most women chose remote follow-up. Rates of adherence to follow-up, adverse outcomes and complete loss to follow-up were similar for women choosing remote and standard follow-up. IMPLICATIONS STATEMENT: Since standard and remote follow-up after methotrexate/misoprostol abortion are associated with similar adherence to follow-up and similar safety profiles, women should be offered their choice of follow-up method.