Defining the role of corticotropin releasing factor binding protein in alcohol consumption.

The corticotropin releasing factor (CRF) exerts its effects by acting on its receptors and on the binding protein (CRFBP), and has been implicated in alcohol use disorder (AUD). Therefore, identification of the exact contribution of each protein that mediates CRF effects is necessary to design effective therapeutic strategies for AUD. A series of in vitro/in vivo experiments across different species were performed to define the biological discrete role of CRFBP in AUD. First, to establish the CRFBP role in receptor signaling, we developed a novel chimeric cell-based assay and showed that CFRBP full length can stably be expressed on the plasma membrane. We discovered that only CRFBP(10 kD) fragment is able to potentiate CRF-intracellular Ca2+ release. We provide evidence that CRHBP gene loss increased ethanol consumption in mice. Then, we demonstrate that selective reduction of CRHBP expression in the center nucleus of the amygdala (CeA) decreases ethanol consumption in ethanol-dependent rats. CRFBP amygdalar downregulation, however, does not attenuate yohimbine-induced ethanol self-administration. This effect was associated with decreased hemodynamic brain activity in the CRFBP-downregulated CeA and increased hemodynamic activity in the caudate putamen during yohimbine administration. Finally, in alcohol-dependent patients, genetic variants related to the CRFBP(10 kD) fragment were associated with greater risk for alcoholism and anxiety, while other genetic variants were associated with reduced risk for anxiety. Taken together, our data provide evidence that CRFBP may possess both inhibitory and excitatory roles and may represent a novel pharmacological target for the treatment of AUD.

The Alcohol Intervention Mechanisms Scale (AIMS): Preliminary Reliability and Validity of a Common Factor Observational Rating Measure.

The present work provides an overview, and pilot reliability and validity for the Alcohol Intervention Mechanisms Scale (AIMS). The AIMS measures therapist interventions that occur broadly across modalities of behavioral treatment for alcohol use disorder. It was developed based on identified commonalities in the function rather than content of therapist interventions in observed therapy sessions, as well as from existing observer rating systems. In the AIMS, the primary function areas are: explore (four behavior count codes), teach (five behavior count codes), and connect (three behavior count codes). Therapist behavior counts provide a frequency rating of occurrence (i.e., adherence). The three functions (explore, teach, connect) are then rated on global skillfulness, which provides a quality valence (i.e., competence) to the entire session. In the present study, three independent raters received roughly 30 hours of training on the use of the AIMS by the first author. Data were a sample of therapy session audio files from a Project MATCH clinical research site. Reliability results showed generally good performance for the measure. Specifically, 2-way mixed intraclass coefficients were 'excellent', ranging from .94 to .99 for function summary scores, while prevalence-adjusted, bias-adjusted kappa for global skillfulness measures were in the 'fair' to 'moderate' range (k=.36 to.40). Internal consistency reliability was acceptable, as were preliminary factor models by behavioral treatment function (i.e., explore, teach, connect). However, confirmatory fit for the subsequent three factor model was poor. In concurrent validity analyses, AIMS summary and skillfulness scores showed associations with relevant Project MATCH criterion measures (i.e., MATCH Tape Rating Scale) that were consistent with expectations. The AIMS is a promising and reliable observational measure of three proposed common functions of behavioral alcohol treatment.

Improving colon cancer screening rates in primary care: a pilot study emphasising the role of the medical assistant.

BACKGROUND: Colorectal cancer (CRC) is the third-leading cause of cancer death for both men and women in the USA. Despite consensus recommendations for screening, just over half of eligible adults nationally have undergone screening. We therefore implemented a programme to improve the rate of CRC screening. METHODS: This study was conducted in the Utah Health Research Network and the University of Utah Community Clinics, a 100 000 patient, seven-practice, university-owned system offering primary and secondary care and ancillary services including endoscopy. We focused on patients aged >or=50 who were seen between 1 January 2003 and 31 October 2006, and who were not current for CRC screening at the time of the visit. The study included a three-phase INTERVENTION: electronic medical record (EMR) reminders, physician and medical assistant (MA) education about CRC screening guidelines, and redesign of patient visit workflow with an expanded role for MAs to review patients' CRC screening status and recommend testing when appropriate. With patient agreement, the MA entered a preliminary order in the EMR, and the physician confirmed or rejected the order. The primary outcome measure was the rate of screening colonoscopy ordered for eligible patients. RESULTS: The baseline colonoscopy referral rate was 6.0%. Provider education and electronic reminders had minimal immediate impact on screening rates. Addition of the expanded MA role was associated with a sustained increase in colonoscopy referral order rate to 13.4%, a relative improvement of 123%. CONCLUSIONS: The MA can play a key role in improving CRC screening rates as part of a redesigned system of primary care.

High rates of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin use and intrafamilial transmission.

OBJECTIVE: Streptococcus pneumoniae is one of the most clinically significant pathogens with emerging antibiotic resistance. We performed a surveillance study in isolated rural populations of healthy children to estimate the prevalence of pneumococcal resistance and to contrast factors that predict pneumococcal carriage with those that specifically predict resistant pneumococcal carriage. METHODS: The study was conducted in 1998 in 2 rural communities in Utah. Families were recruited directly for participation through community canvassing. Surveillance nasopharyngeal cultures were obtained from children who were younger than 8 years. Antibiotic usage and information on other potential risk factors were obtained from questionnaires and local pharmacy records. Resistance was determined by testing isolates for susceptibility to penicillin, cefaclor, trimethoprim-sulfamethoxazole, erythromycin, ceftriaxone, and trovafloxacin. Selected resistant isolates were characterized further by serotyping, pulsed field gel electrophoresis, and Southern blot with DNA probes specific for the pneumococcal lytA gene and for antibiotic resistance genes. RESULTS: In April 1998, surveillance nasopharyngeal cultures were obtained from 368 children aged

Integrating public health into medical education: community health projects in a Primary Care Preceptorship.

Physicians must integrate care of populations with the care of individual patients to function optimally in today's health care environment. With this understanding, medical school curricula are increasingly addressing the skills and knowledge of public health along with those of clinical medicine. The University of Utah School of Medicine in 1997 revised its four-year curriculum to increase the teaching of topics needed by future physicians, including public health. This report describes one course in the curriculum, the Primary Care Preceptorship (PCP), a fourth-year, six-week required rotation that assists students in learning about the health needs of a community along with providing primary care for its individual residents. Students in the PCP spend approximately 60% of their time in clinical primary care and 40% completing a community health project. In the first year of the PCP, 32 students completed projects on clinical problems, 27 on community health needs assessment, 26 on patient education, and 15 on epidemiology.

What opportunities have we missed, and what bad deals have we made?

In addition to its many accomplishments, family medicine has inevitably made some choices that have not worked out as well. Respectful consideration of where we may have done so can help inform future decision making. This paper suggests some decisions that in retrospect appear to be bad deals, good deals gone bad, or missed opportunities. Bad deals include the limiting effects of our specialty's name and of our go-it-alone philosophy. Good deals gone bad include our affinity for a permanent counterculture role, our persistent belief that big is better, and limited evolution of our residency family practice centers. We have missed opportunities to lead development of a new model of patient-responsive health care, to change the system of payment for care, to maximize the strength of our discipline by links between university and community family physicians, and to build a powerful program of family medicine research.

1,4-Anthraquinone: an anticancer drug that blocks nucleoside transport, inhibits macromolecule synthesis, induces DNA fragmentation, and decreases the growth and viability of L1210 leukemic cells in the same nanomolar range as daunorubicin in vitro.

1,4-Anthraquinone (AQ) was synthesized and shown to prevent L1210 leukemic cells from synthesizing macromolecules and growing in vitro. In contrast, its dihydroxy-9,10anthraquinone precursor, quinizarin, was inactive. The antitumor activity of AQ was compared to that of daunorubicin (DAU), which is structurally different from AQ but also contains a quinone moiety. AQ is equipotent to DAU against L1210 tumor cell proliferation (IC50: 25 nM at day 2 and 9 nM at day 4) and viability (IC50: 100 nM at day 2 and 25 nM at day 4), suggesting that its cytostatic and cytotoxic activities are a combination of drug concentration and duration of drug exposure. Since AQ does not increase but rather decreases the mitotic index of L1210 cells at 24 h, it is not an antitubulin drug but might arrest early stages of cell cycle progression. Like DAU, a 1.5-3 h pretreatment with AQ is sufficient to inhibit the rates of DNA, RNA and protein syntheses (IC50: 2 microM) determined over 30-60 min periods of pulse-labeling in L1210 cells in vitro. In contrast to DAU, which is inactive, a 15 min pretreatment with AQ has the advantage of also inhibiting the cellular transport of both purine and pyrimidine nucleosides (IC50: 2.5 microM) over a 30 s period in vitro. Hence, AQ may prevent the incorporation [3H]thymidine into DNA because it rapidly blocks the uptake of these nucleosides by the tumor cells. After 24 h, AQ induces as much DNA cleavage as camptothecin and DAU, two anticancer drugs producing DNA strand breaks and known to, respectively, inhibit topoisomerase I and II activities. However, the concentration-dependent induction of DNA cleavage by AQ, which peaks at 1.6-4 microM and disappears at 10-25 microM, resembles that of DAU. The mechanism by which AQ induces DNA cleavage is inhibited by actinomycin D, cycloheximide and aurintricarboxylic acid, suggesting that AQ activates endonucleases and triggers apoptosis. The abilities of AQ to block nucleoside transport, inhibit DNA synthesis and induce DNA fragmentation are irreversible upon drug removal, suggesting that this compound may rapidly interact with various molecular targets in cell membranes and nuclei to disrupt the functions of nucleoside transporters and nucleic acids, and trigger long-lasting antitumor effects which persist after cessation of drug treatment. Because of its potency and dual effects on nucleoside transport and DNA cleavage, the use of bifunctional AQ with antileukemic activity in the nM range in vitro might provide a considerable advantage in polychemotherapy to potentiate the action of antimetabolites and sensitize multidrug-resistant tumor cells.

Triptycenes: a novel synthetic class of bifunctional anticancer drugs that inhibit nucleoside transport, induce DNA cleavage and decrease the viability of leukemic cells in the nanomolar range in vitro.

In contrast to their inactive parent compound triptycene (code name TT0), several triptycene (TT) analogs (code names TT1 to TT13), most of them new compounds, were synthesized and shown to prevent L1210 leukemic cells from synthesizing macromolecules and growing in vitro. The most potent rigid tetracyclic quinones synthesized so far are TT2 and its C2-brominated derivative, TT13. The antitumor activity of TT2 has been compared to that of daunomycin (DAU), a clinically valuable anthracycline antibiotic which is structurally different from TT2 but also contains a quinone moiety. TT2 inhibits the proliferation (IC50: 300 nM at day 2 and 150 nM at day 4) and viability (IC50: 250 nM at day 2 and 100 nM at day 4) of L1210 cells to the same maximal degree as DAU, suggesting that the cytostatic and cytotoxic activities of TT2 are a combination of drug concentration and duration of drug exposure. Since TT2 does not increase the mitotic index of L1210 cells at 24 h like vincristine, it is unlikely to be an antimitotic drug that disrupts microtubule dynamics. Like DAU, a 1.5-3 h pretreatment with TT2 is sufficient to inhibit the rates of DNA, RNA and protein syntheses determined over 30-60 min periods of pulse-labeling in L1210 cells in vitro (IC50: 6 microM). In contrast to DAU, which is inactive, a 15 min pretreatment with TT2 has the advantage of also inhibiting the cellular transport of nucleosides occuring over a 30 s period in vitro (IC50: 6 microM), suggesting that TT2 prevents the incorporation of [3H]thymidine into DNA because it rapidly blocks the uptake of [3H]thymidine by the tumor cells. After 24 h, TT2 induces as much DNA cleavage as camptothecin and DAU, two anti-cancer drugs producing DNA strand breaks and known to respectively inhibit DNA topoisomerase I and II activities. Interestingly, the abilities of TT2 to block nucleoside transport, inhibit DNA synthesis and induce DNA fragmentation are irreversible upon drug removal, suggesting that this compound may rapidly interact with various molecular targets in cell membranes and nuclei to disrupt the functions of nucleoside transporters and nucleic acids, and trigger long-lasting antitumor effects which persist after cessation of drug treatment. Because inhibition of nucleoside transport is highly unusual among DNA-damaging drugs, the use of bifunctional TTs with antileukemic activity in the nM range in vitro might provide a considerable advantage in polychemotherapy to potentiate the action of antimetabolites and sensitize multidrug-resistant tumor cells.

Tricyclic pyrone analogs: a new synthetic class of bifunctional anticancer drugs that inhibit nucleoside transport, microtubule assembly, the viability of leukemic cells in vitro and the growth of solid tumors in vivo.

Tricyclic pyrones (TPs) may represent a novel synthetic class of microtubule (MT) de-stabilizing anticancer drugs previously shown by us to inhibit macromolecule synthesis, tubulin polymerization, and the proliferation of leukemic and mammary tumor cells in vitro. A linear skeleton with a N-containing aromatic ring attached at C3 of the top A-ring, a central pyran B-ring and a six-membered bottom C-ring with no alkylation at C7 are required for the antitumor activities of the lead compounds, a 3-pyridyl benzopyran (code name H10) and its somewhat weaker 2-pyridyl regioisomer (code name H19). Increasing concentrations of H10 do not alter the binding of [3H]vinblastine and [3H]GTP to tubulin but mimic the ability of unlabeled colchicine (CLC) to reduce the amount of [3H]CLC bound to tubulin, suggesting that TPs may interact with the CLC binding site to inhibit tubulin polymerization. Exogenous Mg2+ cations absolutely required for the binding of GTP to tubulin and MT assembly cannot overcome the antitubulin action of H10. H10 reduces the viability of L1210 cells in vitro (IC50: 0.5 microM) but its antitumor activity may be related to its ability to inhibit tubulin polymerization and rapidly increase the mitotic index rather than to induce DNA cleavage and apoptosis. The anticancer potential of TPs in vivo is demonstrated by the fact that i.p. injections of the water-soluble H10-HCl decrease the growth of solid tumors in mice inoculated s.c. with Lewis lung carcinoma. A critical finding is that the antimitotic H10 is a bifunctional anticancer drug, which also blocks the cellular transport of nucleosides (IC50: 6 microM) to inhibit DNA synthesis. Since few CLC site-binding antimitotic agents are active in solid tumor models in vivo, the ability of these new MT destabilizing TPs to totally block nucleoside transport might be valuable in polychemotherapy to arrest tumor cells at several phases of their cycle, potentiate the action of antimetabolites and sensitize multidrug-resistant tumor cells.

Medicine and public health. Whose agenda?

My grandfather was a general practitioner in a rural midwestern town during the first half of this century. His office consisted of a single examining room in the family home, a tiny waiting area, and little envelopes in which he dispensed medications. Patient hours were in the evening, no appointment necessary. Mostly, folks chatted in the living room with my grandmother while waiting to see "Grandpa Doc." My grandfather's nights often included trips to neighbors' kitchens to deliver babies. Days were time to serve as the county health officer, student health director for the local college, and organizer of the town's free clinic for indigent patients, based in the Presbyterian church.

Multiple chemical sensitivity syndrome.

Multiple chemical sensitivity (MCS) is a syndrome in which multiple symptoms reportedly occur with low-level chemical exposure. Several theories have been advanced to explain the cause of MCS, including allergy, toxic effects and neurobiologic sensitization. There is insufficient scientific evidence to confirm a relationship between any of these possible causes and symptoms. Patients with MCS have high rates of depression, anxiety and somatoform disorders, but it is unclear if a causal relationship or merely an association exists between MCS and psychiatric problems. Physicians should compassionately evaluate and care for patients who have this distressing condition, while avoiding the use of unproven, expensive or potentially harmful tests and treatments. The first goal of management is to establish an effective physician-patient relationship. The patient's efforts to return to work and to a normal social life should be encouraged and supported.