Exploring the Effect of Adding an Interactive Lecture to a Standardized Patient Curriculum on the Attitudes of Third-Year Medical Students About Patients With Obesity: A Quasi-Experimental Study.

OBJECTIVES: Anti-obesity bias is pervasive among medical professionals, students, and trainees. Stigmatization of patients leads to suboptimal care and clinical outcomes. Educational strategies in medical training are needed to reverse these attitudes. The aim of this study was to evaluate the effect of an innovative didactic intervention and a standardized patient (SP) exercise on attitudes towards patients with obesity among medical students. METHODS: In 2016, a quasi-experimental study design was used at a US medical school. The class was divided into 2 groups according to a pre-determined protocol based on their clinical schedule, one assessed after exposure to a SP group and the other after exposure to the SP and an interactive lecture (IL + SP group) with real patients. The Attitudes about Treating Patients with Obesity and The Perceived Causes of Obesity questionnaires measured changes in several domains. A generalized estimating equations model was used to estimate the effect of the interventions both within and between groups. RESULTS: Both groups showed improvements in negative and positive attitudes, although the reduction in scores for the negative attitude domain did not reach statistical significance in the IL + SP group (for the SP group, P = .01 and < .001, respectively; for the IL + SP group, P = .15 and .01, respectively). For perceived causes of obesity, there were no statistically significant changes for pre-post survey measures within each group, except for the physiologic causes domain in the SP group (P = .03). The addition of an IL to a SP curriculum did not result in any changes for any domain in between-group analyses. CONCLUSIONS: Although adding a novel intervention utilizing real patients to a SP curriculum failed to show an additional educational benefit, our study showed that it is possible to influence attitudes of medical students regarding patients with obesity.

Depressive symptoms in asymptomatic stage B heart failure with Type II diabetic mellitus.

BACKGROUND: The presence of concomitant Type II diabetic mellitus (T2DM) and depressive symptoms adversely affects individuals with symptomatic heart failure (HF). HYPOTHESIS: In presymptomatic stage B HF, this study hypothesized the presence of greater inflammation and depressive symptoms in T2DM as compared to non-T2DM Stage B patients. METHODS: This cross-sectional study examined clinical parameters, inflammatory biomarkers, and depressive symptoms in 349 T2DM and non-T2DM men with asymptomatic stage B HF (mean age 66.4 years ±10.1; range 30-91). RESULTS: Fewer diabetic HF patients had left ventricular (LV) systolic dysfunction (P < .05) although more had LV diastolic dysfunction (P < .001). A higher percentage of T2DM HF patients were taking ACE-inhibitors, beta-blockers, calcium channel blockers, statins, and diuretics (P values < .05). T2DM HF patients had higher circulating levels of interleukin-6 (IL-6) (P < .01), tumor necrosis factor-alpha (P < .01), and soluble ST2 (sST2) (P < .01) and reported more somatic/affective depressive symptoms (Beck Depression Inventory II) (P < .05) but not cognitive/affective depressive symptoms (P = .20). Among all patients, in a multiple regression analysis predicting presence of somatic/affective depressive symptoms, sST2 (P = .026), IL-6 (P = .010), B-type natriuretic peptide (P = .016), and sleep (Pittsburgh Sleep Quality Index [P < .001]) were significant predictors (overall model F = 15.39, P < .001, adjusted R2 = .207). CONCLUSIONS: Somatic/affective but not cognitive/affective depressive symptoms are elevated in asymptomatic HF patients with T2DM patients. Linkages with elevated inflammatory and cardiac relevant biomarkers suggest shared pathophysiological mechanisms among T2DM HF patients with somatic depression, and these conditions are responsive to routine interventions, including behavioral. Copyright © 2019 John Wiley & Sons, Ltd.

The Role of Gratitude in Spiritual Well-being in Asymptomatic Heart Failure Patients.

Spirituality and gratitude are associated with wellbeing. Few if any studies have examined the role of gratitude in heart failure (HF) patients or whether it is a mechanism through which spirituality may exert its beneficial effects on physical and mental health in this clinical population. This study examined associations bet ween gratitude, spiritual wellbeing, sleep, mood, fatigue, cardiac-specific self-efficacy, and inflammation in 186 men and women with Stage B asymptomatic HF (age 66.5 years ±10). In correlational analysis, gratitude was associated with better sleep (r=-.25, p<0.01), less depressed mood (r=-.41, p<0.01), less fatigue (r=-.46, p<0.01), and better self-efficacy to maintain cardiac function (r=.42, p<0.01). Patients expressing more gratitude also had lower levels of inflammatory biomarkers (r=-.17, p<0.05). We further explored relationships among these variables by examining a putative pathway to determine whether spirituality exerts its beneficial effects through gratitude. We found that gratitude fully mediated the relationship between spiritual wellbeing and sleep quality (z=-2.35, SE=.03, p=.02) and also the relationship between spiritual wellbeing and depressed mood (z=-4.00, SE=.075, p<.001). Gratitude also partially mediated the relationships between spiritual wellbeing and fatigue (z=-3.85, SE=.18, p<.001), and between spiritual wellbeing and self-efficacy (z=2.91, SE=.04, p=.003). In sum, we report that gratitude and spiritual wellbeing are related to better mood and sleep, less fatigue, and more self-efficacy, and that gratitude fully or partially mediates the beneficial effects of spiritual wellbeing on these endpoints. Efforts to increase gratitude may be a treatment for improving wellbeing in HF patients' lives and be of potential clinical value.

Depressive symptoms and spiritual wellbeing in asymptomatic heart failure patients.

Depression adversely predicts prognosis in individuals with symptomatic heart failure. In some clinical populations, spiritual wellness is considered to be a protective factor against depressive symptoms. This study examined associations among depressive symptoms, spiritual wellbeing, sleep, fatigue, functional capacity, and inflammatory biomarkers in 132 men and women with asymptomatic stage B heart failure (age 66.5 years ± 10.5). Approximately 32 % of the patients scored ≥10 on the Beck Depression Inventory, indicating potentially clinically relevant depressive symptoms. Multiple regression analysis predicting fewer depressive symptoms included the following significant variables: a lower inflammatory score comprised of disease-relevant biomarkers (p < 0.02), less fatigue (p < 0.001), better sleep (p < 0.04), and more spiritual wellbeing (p < 0.01) (overall model F = 26.6, p < 0.001, adjusted R square = 0.629). Further analyses indicated that the meaning (p < 0.01) and peace (p < 0.01) subscales, but not the faith (p = 0.332) subscale, of spiritual wellbeing were independently associated with fewer depressive symptoms. Interventions aimed at increasing spiritual wellbeing in patients lives, and specifically meaning and peace, may be a potential treatment target for depressive symptoms asymptomatic heart failure.

Mitotically active cellular luteinized thecoma of the ovary and luteinized thecomatosis associated with sclerosing peritonitis: case studies, comparison, and review of the literature.

In this study, we distinguish two clinical and pathological entities that are similarly named: luteinized thecoma and luteinized thecoma associated with sclerosing peritonitis. Ovarian luteinized thecoma lacks definitive criteria for malignancy. Based on our case study of a mitotically active neoplasm without nuclear atypia in which the patient was living and well 19 years after operation and comparison with prior studies of luteinized thecoma and the closely related entity of cellular fibroma, we propose presumptive criteria for malignancy for this rare neoplasm. Increased mitotic activity in luteinized thecoma without significant nuclear atypia is not an indication of malignant behavior, and such cases should therefore be referred to as mitotically active cellular luteinized thecoma. We also contrast neoplasms in the luteinized thecoma category with the entity originally reported as luteinized thecoma associated with sclerosing peritonitis. In the latter, the ovarian stromal proliferations are typically bilateral, can have an exceedingly high mitotic rate as was seen in our illustrative case, often incorporate non-neoplastic ovarian structures at their periphery, and are responsive to medical therapy. In our patient with sclerosing peritonitis, both the ovarian masses and peritoneal sclerosis underwent complete regression following treatment with gonadotropin-releasing hormone agonist and high doses of steroids, and an ovarian biopsy taken 2 months after therapy showed a histologically normal ovary. The patient subsequently became pregnant and delivered a normal infant. This is, to our knowledge, the first case of successful medically conservative treatment of a young patient with this entity that led to complete relief of symptoms and allowed preservation of fertility. Because recent observations support the non-neoplastic nature of the ovarian stromal proliferations, we advocate use of the previously proposed term luteinized thecomatosis associated with sclerosing peritonitis for this entity.

Polycystic ovary syndrome: a follow-up study on diabetes mellitus, cardiovascular disease and malignancy 15-25 years after ovarian wedge resection.

The aim of the present study was to examine the occurrence of possibly associated diseases in 149 women with polycystic ovary syndrome (PCOS) 15-25 years after ovarian wedge resection. Diabetes mellitus was the only associated disease which showed a significantly increased occurrence. No significant change in cancers specific for the female gender was seen. Likewise, the relative risk of cardiovascular disease was not affected. However, the power of the statistical test was low. This long-term study indicates increased risk of diabetes mellitus in PCOS patients. The study group is too small to give any conclusions about other possibly associated diseases. Family histories, however, revealed that associated diseases are related to genetic disposition rather than to PCOS per se.

Etanercept or intravenous immunoglobulin attenuates expression of genes involved in post-myocardial infarction remodeling.

OBJECTIVE: Persistently elevated levels of inflammatory cytokines such as tumor necrosis factor (TNF)alpha after acute myocardial infarction (MI) may contribute to maladaptive ventricular remodeling. The aim of the present study was to examine the effects of immunomodulatory therapy with recombinant soluble TNF receptor (TNFR:Fc) or intravenous immunoglobulin (IVIg) on left and right ventricular post-MI remodeling in rats. METHODS AND RESULTS: Adult male Sprague-Dawley rats were subjected to MI by left coronary artery ligation and randomized to treatment with vehicle, TNFR:Fc, or IVIg and sacrificed after 7 days. The main findings were that: (i) TNFR:Fc- and IVIg-treated rats developed less right ventricular (RV) hypertrophy compared to vehicle-treated controls. (ii) LV and arterial pressures in post-MI rats were not affected by the TNFR:Fc or IVIg treatment. (iii) As determined by real-time RT-PCR, both treatments reduced the expression of the hypertrophy-related genes, atrial natriuretic peptide and the ratio of beta/alpha-myosin heavy chains, and genes related to extracellular matrix remodeling (i.e., collagens I and III, matrix metalloproteinase [MMP]-2 and its tissue inhibitor TIMP-1) in the non-ischemic segment of LV and, in particular, in the RV. (iv) Treatment with IVIg, but not TNFR:Fc, reduced MMP-2 zymographic activity in the RV and the expression of genes for TNFalpha and monocyte chemoattractant protein-1. CONCLUSION: Therapy targeted directly against TNFalpha (i.e., TNFR:Fc) and a more general immunomodulatory approach (i.e., IVIg) in the acute phase of MI attenuates the cardiac remodeling process and expression of genes that are involved. These findings raise the possibility that initiation of immunomodulatory therapy post-MI could be beneficial in preventing the later development of heart failure.