Training physicians for the real world of medicine: administration-based learning.

Tired of outdated teaching formats like case-based learning (CBL), problem-based learning (PBL) and team-based learning (TBL)? We wanted something fresh for our medical school, something that would prepare our graduates for the modern practice of medicine, something that would satisfy regulatory agencies and our deans. After doing an extensive needs assessment, which we ignored, we decided to replace basic science in our curriculum with something more practical: administration-based learning (ABL). We taught students how to fix fax machines, how to deal with angry team members, and how to maximise revenue in private practice - lessons that were well received and were more consistent with what physicians really need to learn to be effective practitioners. Educational outcomes have been positive, and although more research is needed, we call on other schools to add ABL tracks to their own curricula.

Prospective longitudinal course of aggression among adults with bipolar disorder.

OBJECTIVES: Bipolar disorder (BP) has been associated with increased aggressive behaviors. However, all existing studies are cross-sectional and include forensic or inpatient populations and many do not take into account the effects of comorbid conditions. The goal of this study was to evaluate the longitudinal course of aggression among adult outpatients with BP compared with non-BP patients and healthy controls. METHODS: Subjects with bipolar I disorder (BP-I)/bipolar II disorder (BP-II) (n = 255), those with non-BP psychopathology (n = 85), and healthy controls (n = 84) (average 38.9 years, 78.7% female, and 84.9% Caucasian) were evaluated at intake and after two and four years of follow-up. Aggression was self-rated using the Aggression Questionnaire (AQ). Comparisons were adjusted for any significant demographic and clinical differences and for multiple comparisons. For subjects with BP, associations of AQ with subtype of BP, current versus past mood episodes, polarity and severity of the current episode, psychosis, and current pharmacological treatment were evaluated. RESULTS: In comparison with subjects with non-BP psychiatric disorders and healthy controls, subjects with BP showed persistently higher total and subscale AQ scores (raw and T-scores) during the four-year follow-up. There were no effects of BP subtype, severity or polarity of the current episode, psychosis, and current pharmacological treatments. Subjects in an acute mood episode showed significantly higher AQ scores than euthymic subjects. CONCLUSIONS: BP, particularly during acute episodes, is associated with increased self-reported verbal and physical aggression, anger, and hostility. These results provide further evidence of the need for treatments to prevent mood recurrences and prompt treatment of acute mood episodes in subjects with BP.

Reduction of Postdischarge Suicidal Behavior Among Adolescents Through a Telephone-Based Intervention.

OBJECTIVE: Brief telephone follow-up for a patient with suicidal tendencies after he or she has been discharged from an emergency room or hospital has been shown to decrease subsequent suicide attempts. However, despite the high rate of suicidal behavior in adolescents, this intervention has not been examined in this population. As part of a quality improvement intervention, postdischarge telephone contacts were used to attempt to reduce suicidal behavior and inpatient rehospitalizations among adolescents. METHODS: Adolescents who were hospitalized for suicidal ideation or attempt (N=142) were randomly assigned to one of two telephone interventions delivered over a 90-day period: either a single call intervention (SCI) or a multiple calls intervention (MCI). The intervention consisted of assessment of suicidality, review of safety plan, and discussion of medication and weapon safety, with up to six telephone contacts in the MCI and up to one contact in the SCI. Primary outcome measures included suicidal behavior and inpatient rehospitalizations; secondary outcome measures included adolescents' confidence in their safety plan. RESULTS: Adolescents receiving the MCI had a significantly lower rate of suicidal behavior (6%) compared with adolescents receiving SCI (17%; odds ratio [OR]=0.28, p=0.037); results persisted while the analysis controlled for relevant covariates (OR=0.25, p=0.032). Similarly, adolescents receiving the MCI reported significantly greater confidence in their safety plan at 90 days (95%vs. 74%; p=0.001), which, in turn, was associated with a lower rate of suicidal behavior (OR=0.95, p=0.019). CONCLUSIONS: A telephone-based intervention for providing recurrent follow-up soon after discharge is feasible in the adolescent population and may be effective in reducing postdischarge suicidal behavior.

Effects of m-CPP in altering neuronal function: blocking depolarization in invertebrate motor and sensory neurons but exciting rat dorsal horn neurons.

The compound m-chlorophenylpiperazine (m-CPP) is used clinically to manipulate serotonergic function, though its precise mechanisms of actions are not well understood. m-CPP alters synaptic transmission and neuronal function in vertebrates by non-selective agonistic actions on 5-HT(1) and 5-HT(2) receptors. In this study, we demonstrated that m-CPP did not appear to act through a 5-HT receptor in depressing neuronal function in the invertebrates (crayfish and Drosophila). Instead, m-CPP likely decreased sodium influx through voltage-gated sodium channels present in motor and primary sensory neurons. Intracellular axonal recordings showed that m-CPP reduced the amplitude of the action potentials in crayfish motor neurons. Quantal analysis of excitatory postsynaptic currents, recorded at neuromuscular junctions (NMJ) of crayfish and Drosophila, indicated a reduction in the number of presynaptic vesicular events, which produced a decrease in mean quantal content. m-CPP also decreased activity in primary sensory neurons in the crayfish. In contrast, serotonin produces an increase in synaptic strength at the crayfish NMJ and an increase in activity of sensory neurons; it produces no effect at the Drosophila NMJ. In the rat spinal cord, m-CPP enhances the occurrence of spontaneous excitatory postsynaptic potentials with no alteration in evoked currents.

Disruptive mood dysregulation disorder and chronic irritability in youth at familial risk for bipolar disorder.

OBJECTIVE: Disruptive mood dysregulation disorder (DMDD) is a new diagnosis in the DSM-5. Youth with a family history of bipolar disorder (BD) are at increased risk for BD and non-bipolar psychopathology. No studies to date have examined rates of DMDD among offspring of parents with BD. This study examines the risk for DMDD in offspring of parents with BD compared to community controls and considers rates of chronic irritability (independent of a DMDD diagnosis) across diagnoses in youth with parents with BD. METHOD: Modified DMDD criteria were applied post hoc to 375 offspring of parents with BD and 241 offspring, aged 6 to 17 years, of community control parents. We calculated odds ratios using generalized linear mixed models. In addition, we explored associations with a severe chronic irritability phenotype and various diagnoses in the high-risk cohort. RESULTS: Offspring of parents with BD were more likely to meet criteria for DMDD than were the offspring of community control parents (Odds ratio [OR] = 8.3, 6.7% vs. 0.8%), even when controlling for demographic variables and comorbid parental diagnoses (OR = 5.4). They also had higher rates of chronic irritability compared to community controls (12.5% vs. 2.5%, χ(2) = 18.8, p < .005). Within the offspring of parents with BD, the chronic irritability phenotype was frequently present in offspring with diagnoses of BD, depression, attention-deficit/hyperactivity disorder, and disruptive behavior disorders. CONCLUSIONS: Like other non-BD diagnoses, family history of BD increases the risk for DMDD. Severe chronic irritability and temper tantrums are the core features of DMDD, and are associated with mood and behavioral disorders in youth at risk for BD.

Sensitivity and specificity of a procedure for early human screening of novel smoking cessation medications.

BACKGROUND AND AIM: It is important to find economical methods in early Phase 2 studies to screen drugs potentially useful to aid smoking cessation. A method has been developed that detects efficacy of varenicline and nicotine patch. This study aimed to evaluate whether the method would detect the efficacy of bupropion and identify correctly the lack of efficacy of modafinil. DESIGN: Using a within-subject double cross-over design, smokers attempted to quit during each treatment, with bupropion (150 mg b.i.d.), modafinil [100 mg twice daily (b.i.d.)] or placebo (double-blind, counterbalanced order). In each of three medication periods, all smoked with no drug on week 1 (baseline or washout), began dose run-up on week 2, and tried to quit every day during week 3. SETTING: A university research center in the United States. PARTICIPANTS: Forty-five adult smokers high in quit interest. MEASUREMENTS: Abstinence was verified daily each quit week by self-report of no smoking over the prior 24 hours and carbon monoxide (CO) < 5 parts per million. FINDINGS: Compared with placebo, bupropion did (F(1,44) = 6.98, P = 0.01), but modafinil did not (F(1,44) = 0.29, P = 0.60), increase the number of abstinent days. Also, bupropion (versus placebo) significantly increased the number of those able to maintain continuous abstinence on all 5 days throughout the quit week (11 versus four), Z = 2.11, P < 0.05, while modafinil did not (six). CONCLUSIONS: Assessing days abstinent during 1 week of use of medication versus placebo in a cross-over design could be a useful early Phase 2 study design for discriminating between medications useful versus not useful in aiding smoking cessation.