How Using Generative Learning Strategies Improved Medical Student Self-Competency in End-of-Life Care.

During a mandatory fourth-year core geriatric medicine rotation at our medical school, we discovered that our medical students were struggling with end-of-life (EOL) issues both personally and professionally. We implemented curriculum changes to assist them in developing emotional awareness about death and dying, and to help develop their ability to respond personally and professionally to patients and their families during EOL experiences.In our new curriculum, a seasoned ethicist at our university conducts 2 educational sessions addressing EOL issues. Students complete self-study content before the first session, in which they have a discussion about their own experience with death and dying. Our ethicist facilitates these discussions with a small group (10-14 medical students), allowing the students to explore their own experiences, case studies, and others' experiences in EOL. Before the second session, students prepare a self-reflective narrative essay about an EOL experience. Our facilitator, by using a generative learning strategy, has a rich interaction that attempts to connect previous experiences, present training, and how the student physicians may need to adjust behaviors in order to be advocates for their patients in EOL situations in the future. Students complete a pre- and post-self-assessment in the didactic. Results show significant improvement in their perceived competence in EOL issues. In addition, the students' self-reflection essays reveal intriguing themes for future study.

Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis and rifampicin resistance: a prospective multicentre diagnostic accuracy study.

BACKGROUND: The Xpert MTB/RIF assay is an automated molecular test that has improved the detection of tuberculosis and rifampicin resistance, but its sensitivity is inadequate in patients with paucibacillary disease or HIV. Xpert MTB/RIF Ultra (Xpert Ultra) was developed to overcome this limitation. We compared the diagnostic performance of Xpert Ultra with that of Xpert for detection of tuberculosis and rifampicin resistance. METHODS: In this prospective, multicentre, diagnostic accuracy study, we recruited adults with pulmonary tuberculosis symptoms presenting at primary health-care centres and hospitals in eight countries (South Africa, Uganda, Kenya, India, China, Georgia, Belarus, and Brazil). Participants were allocated to the case detection group if no drugs had been taken for tuberculosis in the past 6 months or to the multidrug-resistance risk group if drugs for tuberculosis had been taken in the past 6 months, but drug resistance was suspected. Demographic information, medical history, chest imaging results, and HIV test results were recorded at enrolment, and each participant gave at least three sputum specimen on 2 separate days. Xpert and Xpert Ultra diagnostic performance in the same sputum specimen was compared with culture tests and drug susceptibility testing as reference standards. The primary objectives were to estimate and compare the sensitivity of Xpert Ultra test with that of Xpert for detection of smear-negative tuberculosis and rifampicin resistance and to estimate and compare Xpert Ultra and Xpert specificities for detection of rifampicin resistance. Study participants in the case detection group were included in all analyses, whereas participants in the multidrug-resistance risk group were only included in analyses of rifampicin-resistance detection. FINDINGS: Between Feb 18, and Dec 24, 2016, we enrolled 2368 participants for sputum sampling. 248 participants were excluded from the analysis, and 1753 participants were distributed to the case detection group (n=1439) and the multidrug-resistance risk group (n=314). Sensitivities of Xpert Ultra and Xpert were 63% and 46%, respectively, for the 137 participants with smear-negative and culture-positive sputum (difference of 17%, 95% CI 10 to 24); 90% and 77%, respectively, for the 115 HIV-positive participants with culture-positive sputum (13%, 6·4 to 21); and 88% and 83%, respectively, across all 462 participants with culture-positive sputum (5·4%, 3·3 to 8·0). Specificities of Xpert Ultra and Xpert for case detection were 96% and 98% (-2·7%, -3·9 to -1·7) overall, and 93% and 98% for patients with a history of tuberculosis. Xpert Ultra and Xpert performed similarly in detecting rifampicin resistance. INTERPRETATION: For tuberculosis case detection, sensitivity of Xpert Ultra was superior to that of Xpert in patients with paucibacillary disease and in patients with HIV. However, this increase in sensitivity came at the expense of a decrease in specificity. FUNDING: Government of Netherlands, Government of Australia, Bill & Melinda Gates Foundation, Government of the UK, and the National Institute of Allergy and Infectious Diseases.

Evaluation of a Rapid Molecular Drug-Susceptibility Test for Tuberculosis.

BACKGROUND: Fluoroquinolones and second-line injectable drugs are the backbone of treatment regimens for multidrug-resistant tuberculosis, and resistance to these drugs defines extensively drug-resistant tuberculosis. We assessed the accuracy of an automated, cartridge-based molecular assay for the detection, directly from sputum specimens, of Mycobacterium tuberculosis with resistance to fluoroquinolones, aminoglycosides, and isoniazid. METHODS: We conducted a prospective diagnostic accuracy study to compare the investigational assay against phenotypic drug-susceptibility testing and DNA sequencing among adults in China and South Korea who had symptoms of tuberculosis. The Xpert MTB/RIF assay and sputum culture were performed. M. tuberculosis isolates underwent phenotypic drug-susceptibility testing and DNA sequencing of the genes katG, gyrA, gyrB, and rrs and of the eis and inhA promoter regions. RESULTS: Among the 308 participants who were culture-positive for M. tuberculosis, when phenotypic drug-susceptibility testing was used as the reference standard, the sensitivities of the investigational assay for detecting resistance were 83.3% for isoniazid (95% confidence interval [CI], 77.1 to 88.5), 88.4% for ofloxacin (95% CI, 80.2 to 94.1), 87.6% for moxifloxacin at a critical concentration of 0.5 µg per milliliter (95% CI, 79.0 to 93.7), 96.2% for moxifloxacin at a critical concentration of 2.0 µg per milliliter (95% CI, 87.0 to 99.5), 71.4% for kanamycin (95% CI, 56.7 to 83.4), and 70.7% for amikacin (95% CI, 54.5 to 83.9). The specificity of the assay for the detection of phenotypic resistance was 94.3% or greater for all drugs except moxifloxacin at a critical concentration of 2.0 µg per milliliter (specificity, 84.0% [95% CI, 78.9 to 88.3]). When DNA sequencing was used as the reference standard, the sensitivities of the investigational assay for detecting mutations associated with resistance were 98.1% for isoniazid (95% CI, 94.4 to 99.6), 95.8% for fluoroquinolones (95% CI, 89.6 to 98.8), 92.7% for kanamycin (95% CI, 80.1 to 98.5), and 96.8% for amikacin (95% CI, 83.3 to 99.9), and the specificity for all drugs was 99.6% (95% CI, 97.9 to 100) or greater. CONCLUSIONS: This investigational assay accurately detected M. tuberculosis mutations associated with resistance to isoniazid, fluoroquinolones, and aminoglycosides and holds promise as a rapid point-of-care test to guide therapeutic decisions for patients with tuberculosis. (Funded by the National Institute of Allergy and Infectious Diseases, National Institutes of Health, and the Ministry of Science and Technology of China; ClinicalTrials.gov number, NCT02251327 .).

Preoperative and Intraoperative Predictive Factors of Immediate Extubation After Neonatal Cardiac Surgery.

BACKGROUND: We sought to identify preoperative and intraoperative predictors of immediate extubation (IE) after open heart surgery in neonates. The effect of IE on the postoperative intensive care unit (ICU) length of stay (LOS), cost of postoperative ICU care, operating room turnover, and reintubation rates was assessed. METHODS: Patients younger than 31 days who underwent cardiac surgery with cardiopulmonary bypass (January 2010 to December 2013) at a tertiary-care children's hospital were studied. Immediate extubation was defined as successful extubation before termination of anesthetic care. Data on preoperative and intraoperative variables were compared using descriptive, bivariate, and multivariate statistics to identify the predictors of IE. Propensity scores were used to assess effects of IE on ICU LOS, the cost of ICU care, reintubation rates, and operating room turnover time. RESULTS: One hundred forty-eight procedures done at a median age of 7 days resulted in 45 IEs (30.4%). The IE rate was 22.2% with single-ventricle heart disease. Independent predictors of IE were the absence of the need for preoperative ventilatory assistance, higher gestational age, anesthesiologist, and shorter cardiopulmonary bypass. Immediate extubation was associated with shorter ICU LOS (8.3 versus 12.7 days; p < 0.0001) and lower cost of ICU care (mean postoperative ICU charges, $157,449 versus $198,197; p < 0.0001) with no significant difference in the probability of reintubation (p = 0.7). Immediate extubation was associated with longer operating room turnover time (38.4 versus 46.7 minutes; p = 0.009). CONCLUSIONS: Immediate extubation was accomplished in 30.4% of neonates undergoing open heart surgery involving cardiopulmonary bypass. Immediate extubation was associated with lesser ICU LOS, postoperative ICU costs, and minimal increase in operating room turnover time, but without an increase in reintubation rates. Low gestational age, preoperative ventilatory support requirement, and prolonged cardiopulmonary bypass time were inversely associated with the ability to accomplish IE.

Decreased adrenomedullary function in infants with classical congenital adrenal hyperplasia.

CONTEXT: Classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can cause life-threatening adrenal crises as well as severe hypoglycemia, especially in very young children. Studies of CAH patients 4 years old or older have found abnormal morphology and function of the adrenal medulla and lower levels of epinephrine and glucose in response to stress than in controls. However, it is unknown whether such adrenomedullary abnormalities develop in utero and/or exist during the clinically high-risk period of infancy and early childhood. OBJECTIVE: The objective of the study was to characterize adrenomedullary function in infants with CAH by comparing their catecholamine levels with controls. Design/Settings: This was a prospective cross-sectional study in a pediatric tertiary care center. MAIN OUTCOME MEASURES: Plasma epinephrine and norepinephrine levels were measured by HPLC. RESULTS: Infants with CAH (n = 9, aged 9.6 ± 11.4 d) had significantly lower epinephrine levels than controls [n = 12, aged 7.2 ± 3.2 d: median 84 [(25th; 75th) 51; 87] vs 114.5 (86; 175.8) pg/mL, respectively (P = .02)]. Norepinephrine to epinephrine ratios were also significantly higher in CAH patients than controls (P = .01). The control infants had primary hypothyroidism, but pre- and posttreatment analyses revealed no confounding effects on catecholamine levels. CONCLUSIONS: This study demonstrates for the first time that infants with classical CAH due to 21-hydroxylase deficiency have significantly lower plasma epinephrine levels than controls, indicating that impaired adrenomedullary function may occur during fetal development and be present from birth. A longitudinal study of adrenomedullary function in CAH patients from infancy through early childhood is warranted.

Novel probe-based confocal laser endomicroscopy criteria and interobserver agreement for the detection of dysplasia in Barrett's esophagus.

OBJECTIVES: Probe-based confocal laser endomicroscopy (pCLE) is an imaging technique that allows real-time in vivo histological assessment of Barrett's esophagus (BE). The objectives of this study were to create and test novel pCLE criteria for dysplastic BE (phase I), and to evaluate accuracy, interobserver variability, and learning curve in dysplasia prediction (phase II) using these criteria. METHODS: In phase I, using 50 pCLE videos, a pCLE expert and gastrointestinal pathologist formulated new BE criteria by consensus. These criteria were tested and refined in an independent set of 30 pCLE videos. In phase II, a formal training session for all assessors (three each experts/trainees) was conducted. Finally, using 75 testing videos, each video was interpreted as dysplasia (high-grade dysplasia (HGD)/cancer) vs. no dysplasia and the assessors' confidence in interpretation was noted. Interobserver agreement and accuracy (95% confidence interval (CI)) were determined for BE histology prediction. RESULTS: Of multiple pCLE criteria tested (phase I), only those with ≥70% sensitivity or specificity were included in the final set: epithelial surface: saw-toothed; cells: enlarged; cells: pleomorphic; glands: not equidistant; glands: unequal in size and shape; goblet cells: not easily identified. Overall accuracy in diagnosing dysplasia was 81.5% (95% CI: 77.5-81), with no difference between experts vs. non-experts. Accuracy of prediction was significantly higher when endoscopists were "confident" about their diagnosis (98% (95-99) vs. 62% (54-70), P<0.001). Accuracy of dysplasia prediction for the first 30 videos was not different from the last 45 (93 vs. 81%, P=0.51). Overall agreement of the criteria was substantial, κ=0.61 (0.53-0.69), with no difference between experts and non-experts. CONCLUSIONS: We demonstrate the development and validation of new pCLE criteria for the prediction of HGD/cancer in BE patients. Using these criteria, this study demonstrated that overall accuracy in predicting dysplasia was high with substantial interobserver agreement. After a structured teaching session, accuracy and agreement between experienced and non-experienced observers was not different, suggesting a short learning curve.

Colorectal cancer screening, perceived discrimination, and low-income and trust in doctors: a survey of minority patients.

BACKGROUND: Completion of colorectal cancer (CRC) screening testing is lower among low-income and minority groups than the population as a whole. Given the multiple cancer screening health disparities known to exist within the U.S., this study investigated the relationship between perceived discrimination, trust in most doctors, and completion of Fecal Occult Blood Testing (FOBT) among a low-income, minority primary care population in an urban setting. METHODS: We recruited a convenience sample of adults over age 40 (n = 282) from a federally qualified community health center (70% African American). Participants completed a survey which included measures of trust in most doctors, perceived discrimination, demographics and report of cancer screening. RESULTS: Participants reported high levels of trust in most doctors, regardless of sex, race, education or income. High trust was associated with low perceived discrimination (p < 0.01). The trend was for older participants to express more trust (p = 0.09) and less perceived discrimination (p < 0.01). Neither trust nor discrimination was associated with race or education. Trust was higher among participants over 50 who were up-to-date on FOBT screening vs. those who were not (31 vs. 29 (median), p < 0.05 by T-test). Among those over 50, up-to-date FOBT screening was nearly associated with high trust (p < 0.06; 95% CI 0.99, 1.28) and low perceived discrimination (p < 0.01; 95% CI 0.76, 0.96). Nevertheless, in multivariate-modeling, age and income explained FOBT completion better than race, trust and discrimination. CONCLUSION: Perceived discrimination was related to income, but not race, suggesting that discrimination is not unique to minorities, but common to those in poverty. Since trust in most doctors trended toward being related to age, FOBT screening could be negatively influenced by low trust and perceived discrimination in health care settings. A failure to address these issues in middle-aged, low income individuals could exacerbate future disparities in CRC screening.

The impact of socioeconomic status on perceived barriers to colorectal cancer testing.

PURPOSE: Colorectal cancer (CRC) screening is effective, but only one-half of age-eligible adults adhere to national guidelines. Lower socioeconomic status (SES) groups are less likely to be screened. METHODS: Baseline data from a prospective study were, used to examine the associations among CRC screening screening barriers, and SES. A convenience sample of adults (N = 291) aged 40 years and older was recruited from a federally qualified health center. Questionnaires were administered orally and included demographics, health, health behavior, and screening barriers. RESULTS: In logistic regression, having health insurance was associated with greater odds of screening Bivariate analyses detected few differences in fecal occult blood test (FOBT) barriers, but several endoscopy barriers were more common among the lowest SES groups. For example, fear of injury from endoscopy was more likely among low-income and uninsured participants. DISCUSSION: The impact of SES on cancer screening is complex, but low-SES participants more often reported certain barriers than their higher-SES counterparts. This was more evident for endoscopy than for FOBT. Programs targeted at low-SES patients may need to focus on barriers that are not fully addressed in traditional promotion efforts.

Comparison of body perceptions between obese primary care patients and physicians: implications for practice.

OBJECTIVE: To compare the body image and weight perceptions of primary care patients and their physicians as a first step toward identifying a potential tool to aid physician-patient communication. METHODS: Patients with a body mass index (BMI)> or =30 (n=456, 66% female) completed body image and weight status measures after office visits; physicians (n=29) rated the body figures and weight status of these same patients after office visits. RESULTS: Controlling for BMI, female patients and their physicians showed little or no difference in body figure selection or weight status classification, whereas male patients were significantly less likely than their physicians to self-identify with larger body figures (z=3.74, p<0.01) and to classify themselves as obese or very obese (z=4.83, p<0.0001). CONCLUSION: Findings reveal that physicians and female patients have generally concordant views of the patient's body size and weight status, whereas male patients perceive themselves to be smaller than do their physicians. The discrepancy between male patient and physician views is especially evident at increasingly larger body figure/weight status categories. PRACTICE IMPLICATIONS: When counseling male patients on weight loss, it could be helpful to assess body image and use this information to raise patient awareness of their size and to facilitate communication about weight.

Dopamine alleviation of diaphragm contractile dysfunction and reduction of deoxyribonucleic acid damage in rats.

BACKGROUND: Weaning difficulties from mechanical ventilation are associated with diaphragm fatigue and reduced respiratory muscle endurance capacity. Often the work of breathing is increased during the weaning process as a result of inspiratory resistance loading (IRL). IRL produces increased free radical formation that contributes to deoxyribonucleic acid (DNA) damage. The purpose of this study was to determine whether dopamine reduced nuclei DNA damage when the work of breathing was increased. We hypothesized that the administration of low-dose dopamine (2 microg/kg/min) during IRL decreases myonuclei DNA damage associated with free radical formation. METHODS: In this in vivo study, 30 male Sprague-Dawley rats were divided into three groups: (1) the sham group receiving no IRL or no intravenous fluids, (2) IRL with administration intravenous saline, and (3) IRL with intravenous low-dose dopamine (2 microg/kg/min). All rats from the same breed and similar colonies were purchased from one laboratory facility to ensure homogeneity. The animals were anesthetized and tracheotomized, and an ultrasonic sensor was attached to the right hemidiaphragm to measure diaphragm shortening. Diaphragm fatigue was produced by IRL. Dopamine (2 microg/kg/min) was infused intravenously before and during loading. The diaphragms were excised, and myonuclei DNA damage was measured using the fluorescent dyes ethidium bromide and acridine orange and comet analyses as indices of free radical injury. RESULTS: In rats receiving saline, diaphragm shortening decreased by 37% after 45 minutes of IRL (P = .002) compared with baseline. In contrast, rats infused with dopamine exhibited a 31% increase in diaphragm shortening after 45 minutes of IRL (P = .037). With the use of differential dye uptake, in the saline group 59% of the nuclei were apoptotic, and 18% were necrotic. However, in the dopamine group there was significantly less apoptotic nuclei (16%, P < .001) and necrotic nuclei (7%, P = .005). Myonuclei DNA damage, measured by comet analyses, was associated with tail length and tail olive moment, which were 37% and 60% greater, respectively, in the saline group than in the dopamine group (P < .05). CONCLUSION: These data support the hypothesis that low-dose dopamine during IRL reduced myonuclei DNA damage as measured by the fluorescent dyes and comet analysis. In addition, diaphragm fatigue was prevented by the administration of dopamine during IRL.

Discussing weight with obese primary care patients: physician and patient perceptions.

OBJECTIVE: To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits. DESIGN: Post-visit survey assessments of patients and providers. PARTICIPANTS: Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits. MEASUREMENTS AND MAIN RESULTS: Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement. CONCLUSIONS: Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis.

We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = -0.48, 95% CI -0.89, -0.07), but significant heterogeneity was found (I(2) = 85.9%, P < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.

Comparison of a low carbohydrate and low fat diet for weight maintenance in overweight or obese adults enrolled in a clinical weight management program.

BACKGROUND: Recent evidence suggests that a low carbohydrate (LC) diet may be equally or more effective for short-term weight loss than a traditional low fat (LF) diet; however, less is known about how they compare for weight maintenance. The purpose of this study was to compare body weight (BW) for participants in a clinical weight management program, consuming a LC or LF weight maintenance diet for 6 months following weight loss. METHODS: Fifty-five (29 low carbohydrate diet; 26 low fat diet) overweight/obese middle-aged adults completed a 9 month weight management program that included instruction for behavior, physical activity (PA), and nutrition. For 3 months all participants consumed an identical liquid diet (2177 kJ/day) followed by 1 month of re-feeding with solid foods either low in carbohydrate or low in fat. For the remaining 5 months, participants were prescribed a meal plan low in dietary carbohydrate (~20%) or fat (~30%). BW and carbohydrate or fat grams were collected at each group meeting. Energy and macronutrient intake were assessed at baseline, 3, 6, and 9 months. RESULTS: The LC group increased BW from 89.2 +/- 14.4 kg at 3 months to 89.3 +/- 16.1 kg at 9 months (P = 0.84). The LF group decreased BW from 86.3 +/- 12.0 kg at 3 months to 86.0 +/- 14.0 kg at 9 months (P = 0.96). BW was not different between groups during weight maintenance (P = 0.87). Fifty-five percent (16/29) and 50% (13/26) of participants for the LC and LF groups, respectively, continued to decrease their body weight during weight maintenance. CONCLUSION: Following a 3 month liquid diet, the LC and LF diet groups were equally effective for BW maintenance over 6 months; however, there was significant variation in weight change within each group.

Ecologic correlates of obesity in rural obese adults.

OBJECTIVE: We examined relationships of individual and environmental factors with obesity and trying to lose weight in rural residents. METHODS: The joint contributions of individual and environmental factors on obesity status (obese vs. morbidly obese) and trying to lose weight (yes vs. no) were evaluated using generalized estimating equations. Patients at 29 clinics in rural areas (N = 414, M age 55.0 years (SD = 15.4), 66.3% female) completed anthropometric assessments of weight and height along with survey assessments of individual sociodemographics and trying to lose weight. Rural environments were assessed on aggregated physician access, and sociodemographic context. RESULTS: Most participants (70%, M BMI = 38.3) were obese and 30% morbidly obese. A majority (73%, n = 302) of the sample was trying to lose weight. Compared to obese, morbidly obese participants were more likely to be younger, disproportionately female, not have private insurance, have more comorbid conditions, and rate themselves in worse health in comparison to their obese peers. Compared to not trying to lose weight, trying to lose weight participants were more likely to be younger, disproportionately female, have fewer comorbid conditions, and have attempted to lose weight more times through exercise. Few relationships were seen between environmental variables and obesity or trying to lose weight. CONCLUSIONS: There was no consistent pattern of relationships between environment factors and obesity or trying to lose weight was seen. Unique aspects of rural living may not be captured by traditionally available neighborhood measures.

The influence of calcium consumption on weight and fat following 9 months of exercise in men and women.

BACKGROUND: There is some evidence that calcium consumption improves weight loss during energy restriction but the effects of calcium consumption in conjunction with chronic exercise are unknown. OBJECTIVE: The purpose of the study was to determine the degree to which calcium consumption influences weight and fat weight change as a result of 9 months of verified supervised exercise in the absence of energy restriction. METHODS: Participants were 50 previously sedentary, overweight and moderately obese men (n=20) and women (n=30). Exercise of moderate intensity was performed for 45 min/d, 5 d/wk, under supervision. Diet intake was ad libitum and was measured for energy, macronutrient and micronutrient composition at baseline, 4 and 9 months by use of observer recorded weighed plate waste and multiple-pass 24-h dietary recall procedures. RESULTS: Average calcium consumption was 987 +/- 389 mg/day for men and 786 +/- 276 mg/day for women. Weight change over the 9 months was -4.6 +/- 4.6 kg for men and 0.2 +/- 3.3 kg for women. Calcium consumption was associated with weight change (r =-0.47, p<0.05) in men. The calcium to protein ratio was associated with weight change (r=0.56) and fat weight change (r=-0.53) in men. There was no observed association between calcium and weight or fat weight change in women. CONCLUSION: Weight and fat weight loss as a result of nine months of moderate intensity exercise may be improved by increased calcium consumption in men but was not observed in women.

A feasibility trial of narrow band imaging endoscopy in patients with gastroesophageal reflux disease.

BACKGROUND AND AIMS: Narrow band imaging (NBI) endoscopy system enhances visualization of microvasculature and mucosal patterns. This study assessed the utility of NBI in patients with gastroesophageal reflux disease (GERD) symptoms. METHODS: Patients with and without GERD symptoms completed 2 validated GERD questionnaires prior to enrollment. The distal esophagus was examined by standard white light endoscopy followed by NBI. The features seen only by NBI were compared between GERD patients and controls. RESULTS: Overall, 80 patients (50 GERD, 30 controls) were eligible for final analysis (mean age, 58.4 years; males, 93.7%; white, 82.5%). A significantly higher proportion of patients with GERD had increased number (OR, 12.6; 95% CI: 3.7-42; P < .0001), dilatation (OR, 20; 95% CI: 6.1-65.3; P < .0001), tortuosity of intrapapillary capillary loops (IPCLs) (OR, 6.9; 95% CI: 2.5-19; P < .0001), presence of microerosions (P < .0001), and increased vascularity at the squamocolumnar junction (OR, 9.3; 95% CI: 1.9-43.6; P = .001) compared with controls. On multivariate analysis, increased number (OR, 5.5; 95% CI: 1.4-21.6) and dilatation (OR, 11.3; 95% CI: 3.2-39.9) of IPCLs were the best predictors for diagnosing GERD. The maximum, minimum, and average number of IPCLs/field were significantly greater in the GERD group compared with controls (P < .0001). Although the interobserver agreement for the various NBI findings was very good, the intraobserver agreement was modest. CONCLUSIONS: NBI endoscopy may represent a significant improvement over standard endoscopy for the diagnosis of GERD. These preliminary findings including inter- and intraobserver agreement need to be evaluated in future prospective, controlled, and blinded GERD trials.

Objective documentation of traumatic brain injury subsequent to mild head trauma: multimodal brain imaging with MEG, SPECT, and MRI.

OBJECTIVE: To determine to what extent magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), and magnetoencephalography (MEG) can provide objective evidence of brain injury in adult patients with persistent (>1 year) postconcussive symptoms following mild blunt head trauma. DESIGN: A retrospective and blind review of imaging data with respect to the presence of specific somatic, psychiatric, and cognitive complaints. SETTING/PARTICIPANTS: Thirty complete data sets (with MRI, SPECT, MEG, and neuropsychological testing results) were collected between 1994 and 2000 from the MEG programs at the Albuquerque VAMC and the University of Utah. MAIN OUTCOME MEASURES: MRI data were evaluated for focal and diffuse structural abnormalities, SPECT data for regions of hypoperfusion, and resting MEG data for abnormal dipolar slow wave activity (DSWA) and epileptiform transients. RESULTS: Structural MRI was abnormal for 4 patients. SPECT showed regions of hypoperfusion in 12 patients, while MEG showed abnormal activity in 19 patients. None of the imaging methods produced findings statistically associated with postconcussive psychiatric symptoms. A significant association was found between basal ganglia hypoperfusion and postconcussive headaches. For patients with cognitive complaints, abnormalities were more likely to be detected by MEG (86%) than either SPECT (40%) or MRI (18%) (P<.01). MEG also revealed significant (P<.01) associations between temporal lobe DSWA and memory problems, parietal DSWA and attention problems, and frontal DSWA and problems in executive function. CONCLUSIONS: Functional brain imaging data collected in a resting state can provide objective evidence of brain injury in mild blunt head trauma patients with persistent postconcussive somatic and/or cognitive symptoms. MEG proved to be particularly informative for patients with cognitive symptoms.

Patterns of smoking and methadone dose in drug treatment patients.

Cigarette smoking prevalence is very high, and cessation rates are very low, among people in methadone treatment. This may in part be due to interactions between methadone administration and cigarette smoking. The present study explores relationships between methadone dose timing and smoking rates. Twenty methadone patients, over a period of 19 days, used electronic cigarette packs to record their smoking patterns and called a voice mailbox daily to report their methadone dose and timing. The average proportion of daily cigarettes smoked was calculated for 2-hr blocks preceding and following methadone dose administration. For all participants, peak smoking rates occurred after methadone administration. Participants smoked a greater proportion of cigarettes in their first 2-hr block after methadone dosing (M = 0.368, SD = 0.135) than during their first 2-hr block of smoking of the day (M = 0.245, SD = 0.010; S = 85.5, p < .0001). The proportion of cigarettes smoked increased by 0.02 from more than 2 hr before methadone to the 2-hr time block before methadone, by 0.04 from the 2-hr time block before methadone to the 2-hr time block after methadone, and by 0.015 from the 2-hr time block after methadone to the next 2-hr time block. From this time block (2-4 hr after methadone), smoking decreased by 0.02 in the 4-plus hr postmethadone dose. All of these changes were statistically significant. Future research should use experimental designs to better examine whether a causal relationship exists and examine the impact of other types of opioid maintenance medications on smoking patterns.

Indicators of mania in depressed outpatients: a retrospective analysis of data from the Kansas 1500 study.

OBJECTIVE: Previous prospective studies have shown that unipolar depressed patients often switch to a manic episode. Some of these studies have reported that the conversion to bipolar disorder is predicted by an early onset of depression, a positive family history for mania, and psychotic symptoms. The present study examines the strength of the relationship between these 3 indicators, both alone and in combination, and the presence of mania in a large retrospective analysis. METHOD: 1458 consecutive admissions to a large, Midwestern university outpatient clinic between 1981 and 1986 were interviewed, and 1002 patients met DSM-III inclusive criteria for major depressive disorder. Of these, information about age at onset of depression, family history of mania, and psychotic symptoms was available on 744 outpatients. Two structured interviews were used to assess the 3 indicators. RESULTS: In this large depressed outpatient sample, the incidence of lifetime mania was 27%. Each of the 3 indicators was significantly associated with the report of mania (p < .0001 for all 3 indicators). The rates of mania increased as the number of indicators increased. Psychotic symptoms were the strongest indicator, followed by a family history of mania and an early age at onset of depression. CONCLUSION: Depressed patients with 1 or more of these 3 indicators should be monitored for the presence of bipolar disorder. Patients with 2 or more of these indicators are especially at risk to develop mania.

Characteristics of social smoking among college students.

Social smoking is a newly identified phenomenon in the young adult population that is poorly understood. We investigated differences in social smoking (smoking most commonly while partying or socializing) and other smoking within a convenience sample of college smokers (n = 351) from a large midwestern university. Results revealed that 70% of 351 current (past 30-day) smokers reported social smoking. No significant difference was found in motivation to quit between smoking groups. However, a significant difference was found between groups in confidence to quit, the number of days smoked, and the number of cigarettes smoked on those days. More social smokers than expected did not perceive themselves as smokers. Logistic regression analysis revealed that lower physical and psychological dependence and higher social support scores predicted social smoking.