A Planning Checklist for Interprofessional Consultations for Women in Midwifery Care.

Team-based, interprofessional models of maternity care can allow women to receive personalized care based on their health needs and personal preferences. However, involvement of multiple health care providers can fragment care and increase communication errors, which are a major cause of preventable maternal morbidity and mortality. In order to improve communication within one health system, a community-engaged approach was used to develop a planning checklist for the care of women who began care with midwives but developed risks for poor perinatal outcomes. The planning checklist was constructed using feedback from women, nurses, midwives, and physicians in one interprofessional, collaborative network. In feasibility testing during 50 collaborative visits, the planning checklist provided a prompt to generate a comprehensive plan for maternity care and elucidate the rationale for interventions to women and future health care providers. In interviews after implementation of the checklist within a new collaborative format of prenatal physician consultations, women were pleased with the information received, and nurses, midwives, and physicians were positive about improved communication. This tool, developed with stakeholder input, was easy to implement and qualitatively beneficial to satisfaction and health system function. This article details the creation, implementation, and qualitative evaluation of the planning checklist. The checklist is provided and can be modified to meet the needs of other health systems.

The feasibility of brief dog-assisted therapy on university students stress levels: the PAwS study.

BACKGROUND: Pet therapy is becoming increasingly popular and is used in a variety of ways from encouraging communication in older adults to improving wellbeing in those with serious mental illness. Increasingly Universities have been offering pet therapy to students in an effort to reduce stress. However, little evidence currently exists to support the effectiveness of reducing measurable stress levels after a standalone drop-in unstructured session. The University of Sheffield's Counselling Service works in partnership with Guide Dogs for the Blind to give students access to calm, well-trained animals for informal group stress relief. AIMS: To assess the feasibility of implementing and evaluating unstructured group interventions with a Guide Dog in training within the university student population. METHODS: One hundred and thirty-one students who attended pet therapy at the University Counselling Service were recruited on a voluntary basis to take part in the research. Stress, measured on the state trait anxiety inventory, and blood pressure were taken before and after a 15-min intervention. RESULTS: All measures showed a statistically significant reduction immediately after the intervention. CONCLUSION: Short interactions with a Guide Dog in training appear to reduce stress in University students. A controlled study is required to investigate further.

Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive Health? An Anthropological Assessment in the Context of U.S. Health Reform.

Chronic conditions associated with lifestyle and modifiable behaviors are the leading causes of morbidity and mortality in the United States. The implementation of the Affordable Care Act offers an historic opportunity to consider novel approaches to addressing the nation's public health concerns. We adopt an anticipatory anthropological perspective to consider lifestyle behavior change as common ground shared by practitioners of both biomedicine and common forms of complementary and alternative medicine (CAM). At issue is whether CAM practitioners might play a more proactive and publicly endorsed role in delivering preventive and promotive health services to address these needs. Recognizing that this is a contentious issue, we consider two constructive roles for engaged medical anthropologists: (1) as culture brokers helping to facilitate interprofessional communities of preventive and promotive health practice and (2) in collaboration with health service researchers developing patient-near evaluations of preventive and promotive health services on patient well-being and behavior change.

Hypocretin (orexin) facilitates reward by attenuating the antireward effects of its cotransmitter dynorphin in ventral tegmental area.

Hypocretin (orexin) and dynorphin are neuropeptides with opposing actions on motivated behavior. Orexin is implicated in states of arousal and reward, whereas dynorphin is implicated in depressive-like states. We show that, despite their opposing actions, these peptides are packaged in the same synaptic vesicles within the hypothalamus. Disruption of orexin function blunts the rewarding effects of lateral hypothalamic (LH) stimulation, eliminates cocaine-induced impulsivity, and reduces cocaine self-administration. Concomitant disruption of dynorphin function reverses these behavioral changes. We also show that orexin and dynorphin have opposing actions on excitability of ventral tegmental area (VTA) dopamine neurons, a prominent target of orexin-containing neurons, and that intra-VTA orexin antagonism causes decreases in cocaine self-administration and LH self-stimulation that are reversed by dynorphin antagonism. Our findings identify a unique cellular process by which orexin can occlude the reward threshold-elevating effects of coreleased dynorphin and thereby act in a permissive fashion to facilitate reward.

Surface electromyograph activity of submental muscles during swallowing and expiratory muscle training tasks in Huntington's disease patients.

INTRODUCTION: Huntington's disease (HD) patients have difficulty in swallowing, leading to aspiration pneumonia, which is a major cause of death. It seems possible that submental muscles that are crucial for preventing an escape of a bolus into the airway, are affected by HD, but no previous studies have investigated this. OBJECTIVE: To assess surface electromyograph (sEMG) activity of submental muscles during swallowing and expiratory muscle training (EMT) tasks in HD patients in comparison to healthy volunteers. METHODS: sEMG activities of submental muscles during saliva, water swallowing, EMT tasks performed at 25% and 75% of maximum expiratory pressure were recorded and normalised by the sEMG activity during an effortful swallow in 17 early to mid stage HD patients and 17 healthy volunteers. RESULTS: sEMG activity was greater (p<0.05) during EMT tasks than saliva and water swallowing, but was not significantly different between groups for saliva, water swallowing and EMT at 25%. HD patients had lower sEMG activity for EMT at 75% (p<0.05). CONCLUSION: Decreases in submental muscle activity were not evident in HD patients except during EMT at 75%. This suggests that relative submental muscle weakness is observed only during a high intensity task in early to mid stage HD patients.

Developing a patient-centered outcome measure for complementary and alternative medicine therapies II: refining content validity through cognitive interviews.

BACKGROUND: Available measures of patient-reported outcomes for complementary and alternative medicine (CAM) inadequately capture the range of patient-reported treatment effects. The Self-Assessment of Change questionnaire was developed to measure multi-dimensional shifts in well-being for CAM users. With content derived from patient narratives, items were subsequently focused through interviews on a new cohort of participants. Here we present the development of the final version in which the content and format is refined through cognitive interviews. METHODS: We conducted cognitive interviews across five iterations of questionnaire refinement with a culturally diverse sample of 28 CAM users. In each iteration, participant critiques were used to revise the questionnaire, which was then re-tested in subsequent rounds of cognitive interviews. Following all five iterations, transcripts of cognitive interviews were systematically coded and analyzed to examine participants' understanding of the format and content of the final questionnaire. Based on this data, we established summary descriptions and selected exemplar quotations for each word pair on the final questionnaire. RESULTS: The final version of the Self-Assessment of Change questionnaire (SAC) includes 16 word pairs, nine of which remained unchanged from the original draft. Participants consistently said that these stable word pairs represented opposite ends of the same domain of experience and the meanings of these terms were stable across the participant pool. Five pairs underwent revision and two word pairs were added. Four word pairs were eliminated for redundancy or because participants did not agree on the meaning of the terms. Cognitive interviews indicate that participants understood the format of the questionnaire and considered each word pair to represent opposite poles of a shared domain of experience. CONCLUSIONS: We have placed lay language and direct experience at the center of questionnaire revision and refinement. In so doing, we provide an innovative model for the development of truly patient-centered outcome measures. Although this instrument was designed and tested in a CAM-specific population, it may be useful in assessing multi-dimensional shifts in well-being across a broader patient population.

Fixed-dose rasburicase 6 mg for hyperuricemia and tumor lysis syndrome in high-risk cancer patients.

BACKGROUND: Rasburicase is indicated for the initial management of plasma uric acid levels in adults receiving anticancer therapy who are at risk for acute tumor lysis syndrome (TLS) and subsequent hyperuricemia. The labeled dose is 0.2 mg/kg/day administered intravenously over 30 minutes for up to 5 days. Our institutional adult guidelines recommend rasburicase 6 mg for uric acid levels >8 mg/dL in most adults with TLS, or 4-8 mg/dL in high-risk patients. Repeat dosing is indicated for uric acid levels >4 mg/dL determined ≥12 hours following the initial dose. OBJECTIVE: To determine the efficacy of a single dose of rasburicase 6 mg per institutional adult TLS guidelines to decrease uric acid levels to <4 mg/dL by day 3, as well as to determine the effect on serum creatinine and phosphorus concentrations. The secondary objectives were to evaluate the appropriateness of our institutional guidelines and identify TLS risk factors. METHODS: The study was approved by the University of Maryland Medical Center Institutional Review Board. A retrospective review of all adults between July 2008 and February 2009 who received at least one 6-mg dose of rasburicase, with redosing, if indicated, before day 3, was conducted. Subsequent TLS monitoring over 7 days after initial dosing was recorded. Patients were excluded if dosing did not adhere to institutional guidelines. RESULTS: We observed a decline in median uric acid levels from 9.2 mg/dL (interquartile range 8.1-10.4) on day 1 to between 1.8 (1.0-3.8) on day 3 and 3.8 mg/dL (2.1-4.4) on day 7 (p < 0.0001) with 2 patients requiring repeat dosing before day 3 (n = 34). The majority of the population was hyperuricemic (>8 mg/dL; 76%) or at high risk for TLS (85%). CONCLUSIONS: A 6-mg dose of rasburicase effectively decreased uric acid to <4 mg/dL by day 3, rarely requiring repeat dosing, in a high-risk population.

Effects of dietary calcium compared with calcium supplements on estrogen metabolism and bone mineral density.

BACKGROUND: High calcium intake has been associated with both high bone mineral density (BMD) and high urinary estrogen metabolites. However, the role of dietary calcium and calcium supplements on estrogen metabolism and BMD remains unknown. OBJECTIVE: The objective was to investigate the importance of the source of calcium intake on estrogen metabolism and BMD. DESIGN: The average total daily calcium intake from supplements and diet, urinary estrogen metabolites, and spine and proximal femur BMD were studied in 168 healthy postmenopausal white women. RESULTS: Women who obtained calcium primarily from the diet or from both the diet and supplements had significantly (P=0.03) lower ratios of nonestrogenic to estrogenic metabolites (2-hydroxyestrone 1/16 alpha-hydroxyestrone) than did those who obtained calcium primarily from supplements. Adjusted BMD z scores were significantly greater in the subjects who obtained calcium primarily from the diet or from both the diet and supplements than in those who obtained calcium primarily from calcium supplements at the spine (P=0.012), femoral neck (P=0.02), total femur (P=0.003), and intertrochanter (P=0.005). This difference was evident especially in those who obtained calcium primarily from the diet, whose total calcium intake was lower than that in those who obtained calcium primarily from supplements. CONCLUSION: Calcium from dietary sources is associated with a shift in estrogen metabolism toward the active 16 alpha-hydroxyl metabolic pathway and with greater BMD and thus may produce more favorable effects in bone health in postmenopausal women than will calcium from supplements.

The compliance paradox: what we need to know about "real-world" dietary supplement use in the United States.

Current research on dietary supplements (primarily survey-based prevalence studies and clinical trials of safety and efficacy) is inadequate for understanding how consumers use supplements in the real world. Analyzing interview data from formative research with dietary supplement users (N=60), we observed skepticism in the way our informants interpret scientific information about supplements, trust in referrals from those they feel are like them, and experimentation with products in order to tailor them to their bodies and needs. We stress the need for qualitative research focusing on patterns of supplement use in context (rather than as isolated supplements in fixed doses), the network effect of supplement use, and the way information about supplements is translated and transmitted. Furthermore, we urge clinicians to pay careful attention not only to whether patients are taking dietary supplements, but also how supplements are being used alone and in combination with other supplements, pharmaceuticals, and over-the-counter (OTC) medications.

For my wellness, not just my illness: North Americans' use of dietary supplements.

Passage of the DSHEA in 1994 created a new "liminal" category for the FDA: dietary supplements are regulated as neither food nor drugs. However, there appears to be a significant disconnect between the "official" discourse surrounding dietary supplements and supplement users' actual practices. Despite this discrepancy, and the inadequacy of surveys to capture the dynamics of pharmaceutical practice, there is little ethnographic information available on the ways that Americans think about or use dietary supplements. We offer some preliminary observations from a pilot ethnographic study of Americans' use of dietary supplements in which we consider not only the reasons why people are using supplements, but how they are using them, and how their experimentation has been influenced by the information they seek and receive from a variety of sources. We illustrate how anthropological studies of supplement related practice can help us better understand Americans' attraction to and use of dietary supplements, and suggest that anthropology can contribute to a more balanced perspective on supplement use-one that moves the study of supplements beyond surveys and randomized controlled studies of efficacy to considerations of patterns of use in context, user expectations, and measures of perceived effectiveness.

Graft-vs-host disease: nutrition therapy in a challenging condition.

Graft-vs-host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation. Both acute and chronic forms of GVHD are challenging to manage medically and nutritionally. Patients with advanced GVHD commonly become depleted nutritionally, with loss of lean body mass (LBM) and functional status. We present 2 case reports of patients who developed GVHD and subsequent nutrition decline. Although both patients were candidates for specialized nutrition support (SNS), only 1 was able to receive enteral and parenteral nutrition due to GVHD complications preventing access for provision of SNS. Fortunately, the patients have remained in remission from their hematologic malignancy, but they continue to cope with chronic GVHD and its consequences. These cases exhibit the complexity of managing a patient with extensive GVHD and nutrition interventions for clinicians to consider to optimize outcomes.

Auditory lexical decision, categorical perception, and FM direction discrimination differentially engage left and right auditory cortex.

Recent neuroimaging and neuropsychological data suggest that speech perception is supported in bilaterally auditory areas. We evaluate this issue building on well-known behavioral effects. While undergoing positron emission tomography (PET), subjects performed standard auditory tasks: direction discrimination of frequency-modulated (FM) tones, categorical perception (CP) of consonant-vowel (CV) syllables, and word/non-word judgments (lexical decision, LD). Compared to rest, the three conditions led to bilateral activation of the auditory cortices. However, lateralization patterns differed as a function of stimulus type: the LD task generated stronger responses in the left, the FM task a stronger response in the right hemisphere. Contrasts between either words or syllables versus FM were associated with significantly greater activity bilaterally in superior temporal gyrus (STG) ventro-lateral to Heschl's gyrus. These activations extended into the superior temporal sulcus (STS) and the middle temporal gyrus (MTG) and were greater in the left. The same areas were more active in the LD than the CP task. In contrast, the FM task was associated with significantly greater activity in the right lateral-posterior STG and lateral MTG. The findings argue for a view in which speech perception is mediated bilaterally in the auditory cortices and that the well-documented lateralization is likely associated with processes subsequent to the auditory analysis of speech.