Suicidality in women with Premenstrual Dysphoric Disorder: a systematic literature review.

Previous research has identified how menstruation is an important factor in both attempted and completed suicides for women. The purpose of this review was to outline (a) the risk profile for suicidality in women who were identified to experience Premenstrual Dysphoric Disorder (PMDD), a condition characterized by severe physical and psychological changes that occur during the luteal menstrual phase, and (b) the implications of these findings for clinical practice. A systematic literature review was conducted using five databases to identify any peer-reviewed articles published between 1989 and 2019. Ten papers eligible for inclusion were identified: three pertaining to suicide cognitions, five to suicide attempts and two to both cognitions and attempts. Findings showed that suicidal thoughts, ideation, plans and attempts were strongly associated with experiences of PMDD and that these findings were independent of psychiatric co-morbidities. However, women with PMDD did not present with more severe risk profiles for suicide attempts (in terms of frequency, impulsivity and lethality) or make more frequent attempts during the luteal menstrual phase compared with suicide attempters without PMDD. Women with PMDD should be considered a high risk group for suicidality; thus, identifying and treating symptoms are vital in reducing suicide attempts. Implications for clinical practice are outlined in the discussion.

Combining spore germination and heat inactivation to decontaminate materials contaminated with Bacillus anthracis spores.

AIMS: To add a spore germination step in order to reduce decontamination temperature and time requirements compared to the current hot, humid air decontamination parameters, which are 75-80°C, ≥72 h, 70-90% RH, down to ≤60°C and ≤24 h total decontamination time. METHODS AND RESULTS: Bacillus anthracis spore germination with l-alanine+inosine+calcium dipicolinate (CaDPA) was quantified at 0-40°C, several time points and spore concentrations of 5-9 log10 per ml. Germination efficiency at 0-40°C was >99% at <8 log10 spores per ml. The temperature optimum was 20°C. Germination efficiency was significantly higher but slower at 0°C compared to ≥30°C at ≥8 log10 spores per ml. A single germinant application followed by 60°C, 1-h treatment consistently inactivated >2 log10 (>99%) of spores. However, a repeat application of germinant was needed to achieve the objective of ≥6 log10 spore inactivation out of a 7 log10 challenge (≥99·9999%) for ≤24 h total decontamination time for nylon and aircraft performance coating. CONCLUSIONS: l-alanine+inosine+CaDPA stimulated germination across wide temperature and spore concentration ranges. SIGNIFICANCE AND IMPACT OF THE STUDY: Germination expands the scope of spore decontamination to include materials from any industry sector that can be sprayed with an aqueous germinant solution.

Hot, humid air decontamination of a C-130 aircraft contaminated with spores of two acrystalliferous Bacillus thuringiensis strains, surrogates for Bacillus anthracis.

AIM: To develop test methods and evaluate survival of Bacillus thuringiensis kurstaki cry(-) HD-1 and B. thuringiensis Al Hakam spores after exposure to hot, humid air inside of a C-130 aircraft. METHODS AND RESULTS: Bacillus thuringiensis spores were either pre-inoculated on 1 × 2 or 2 × 2 cm substrates or aerosolized inside the cargo hold of a C-130 and allowed to dry. Dirty, complex surfaces (10 × 10 cm) swabbed after spore dispersal showed a deposition of 8-10 log10 m(-2) through the entire cargo hold. After hot, humid air decontamination at 75-80°C, 70-90% relative humidity for 7 days, 87 of 98 test swabs covering 0·98 m(2) , showed complete spore inactivation. There was a total of 1·67 log10 live CFU detected in 11 of the test swabs. Spore inactivation in the 98 test swabs was measured at 7·06 log10 m(-2) . CONCLUSIONS: Laboratory test methods for hot, humid air decontamination were scaled for a large-scale aircraft field test. The C-130 field test demonstrated that hot, humid air can be successfully used to decontaminate an aircraft. SIGNIFICANCE AND IMPACT OF THE STUDY: Transition of a new technology from research and development to acquisition at a Technology Readiness Level 7 is unprecedented.

Pressor and intra-renal effects of angiotensins I and II, and noradrenaline, in anaesthetized and conscious sheep. The effects of halothane anaesthesia on pressor sensitivity and electrolyte shifts: the proposed use of angiotensin I in treating septicaemia and septic shock.

The pressor and intra-renal actions and effects of octa - and deca-peptides angiotensins II and I and of the catecholamine noradrenaline, in anaesthetized and conscious sheep, are considered. The halothane anaesthetic substantially lowers pressor sensitivity to both peptides but does not influence their ability to liberate K(+) ions into the circulating plasma. In comparison with angiotensin II, both angiotensin I and noradrenaline -- with direct presentation to the kidney -- are ineffective in decreasing intra-renal blood flow. However, with left ventricular injection, both pressor compounds immediately increase the blood pressure, as does angiotensin II. Combined doses of the decapeptide and catecholamine are thus highly effective in raising the blood pressure while having a minimal effect on blood flow through the kidney. This overall situation could provide a basis for treating clinical shock, especially regarding septicaemia and septic shock. The lowered hind-limb blood flow, with administration of the pressor compounds into the femoral artery, contrasts strongly with the raised flow resulting from intravenous injection. Experimental procedures to establish, or otherwise, relevant hypothetical situations are detailed.

A mechanistic model of the actin cycle.

We have derived a broad, deterministic model of the steady-state actin cycle that includes its major regulatory mechanisms. Ours is the first model to solve the complete nucleotide profile within filaments, a feature that determines the dynamics and geometry of actin networks at the leading edges of motile cells, and one that has challenged investigators developing models to interpret steady-state experiments. We arrived at the nucleotide profile through analytic and numerical approaches that completely agree. Our model reproduces behaviors seen in numerous experiments with purified proteins, but allows a detailed inspection of the concentrations and fluxes that might exist in these experiments. These inspections provide new insight into the mechanisms that determine the rate of actin filament treadmilling. Specifically, we find that mechanisms for enhancing Pi release from the ADP.Pi intermediate on filaments, for increasing the off rate of ADP-bound subunits at pointed ends, and the multiple, simultaneous functions of profilin, make unique and essential contributions to increased treadmilling. In combination, these mechanisms have a theoretical capacity to increase treadmilling to levels limited only by the amount of available actin. This limitation arises because as the cycle becomes more dynamic, it tends toward the unpolymerized state.

Hind-limb/hind-quarter vascular resistance and blood flow changes: possible intrinsic renin--angiotensin system involvement.

For many years there was a general belief that the enzyme renin, having been secreted into the circulation by the kidney in response to appropriate stimuli, initially generates the inactive decapeptide angiotensin I in the bloodstream. This is then converted to the biologically active octapeptide angiotensin II by angiotensin converting enzyme on or near, vascular surface receptors both in the lungs and in the organs supplied by the systemic circulation. The results of various investigations have, however, latterly led to the conclusion that the overall system is widely distributed throughout the vasculature with the local intracellular formation of angiotensin II. In this review the reckoned intrinsic renin-angiotensin activity in hind-limb/hind-quarter is discussed with particular regard to the widespread use of radioimmunoassay, together with a consideration of other factors, more especially ACE inhibition, affecting the relevant regional vascular resistance and blood flow.

Regulation of the actin cycle in vivo by actin filament severing.

Cycling of actin subunits between monomeric and filamentous phases is essential for cell crawling behavior. We investigated actin filament turnover rates, length, number, barbed end exposure, and binding of cofilin in bovine arterial endothelial cells moving at different speeds depending on their position in a confluent monolayer. Fast-translocating cells near the wound edge have short filament lifetimes compared with turnover values that proportionately increase in slower moving cells situated at increasing distances from the wound border. Contrasted with slow cells exhibiting slow actin filament turnover speeds, fast cells have less polymerized actin, shorter actin filaments, more free barbed ends, and less actin-associated cofilin. Cultured primary fibroblasts manifest identical relationships between speed and actin turnover as the endothelial cells, and fast fibroblasts expressing gelsolin have higher actin turnover rates than slow fibroblasts that lack this actin-severing protein. These results implicate actin filament severing as an important control mechanism for actin cycling in cells.

Punishment: a story for medical educators.

The author recounts an incident of cheating by two first-year medical students, and how it was handled. One of the students, George, had waited until the last minute to write what he called a "stupid" paper that was required as the final examination in a health policy course. His classmate Ellen offered to write the paper for him, and other students also offered to help; no one pointed out that this would be unethical. After some hesitation, George was persuaded to accept Ellen's offer, and he turned in the paper as his own. The course director deduced the deception, and when the students were confronted, they immediately admitted what they had done, blamed only themselves, and said they had been "foolish." Subsequent events showed that the faculty saw the incident as a clear-cut case of cheating, whereas many students felt that George and Ellen's transgression was trivial when compared with plagiarizing a research paper or falsifying lab results on a patient's chart. Also, the faculty chose a more severe and long-lasting punishment, one that many students did not agree with. The author believes that the faculty's refusal to give George and Ellen a clean slate after a reasonable time reflected a lack of forgiveness that is antithetical to the compassionate, forgiving role of physician-healer that medical education promotes. She concludes by explaining how this incident illustrates complex generational and cultural differences in moral reasoning and the selection of punishment, and the great emphasis that medical education places on knowing the facts rather than working creatively with ideas.

Differences in curriculum emphasis in US undergraduate and generalist residency education programmes.

OBJECTIVES: Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. DESIGN: Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. SETTING: US allopathic medical schools. SUBJECTS: Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). RESULTS: Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. CONCLUSIONS: The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.

A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee.

The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.

Severe vs. nonsevere firesetters revisited.

The study reported here compares a group of 75 severe firesetters with a group of 105 nonfiresetters and minor firesetters along 32 variables that have been positively correlated with juvenile firesetting behavior. A chisquare analysis of the data revealed that the frequencies observed in the 75 "severe" cases differ significantly from those in the "nonsevere" group. A prediction equation was derived from the 14 most salient variables. This equation can be used to differentiate severe/high-risk from minor/low-risk firesetters 95% of the time.

Occupational exposures to body fluids among medical students. A seven-year longitudinal study.

BACKGROUND: Medical students may be at high risk for occupational exposures to blood. OBJECTIVE: To measure the frequency of medical students' exposure to infectious body substances, to identify factors that affect the probability of such exposure, and to suggest targets for the prevention of such exposure. DESIGN: Review of all exposures reported by medical students at the University of California, San Francisco, School of Medicine. SETTING: Teaching hospitals affiliated with the University of California, San Francisco. PARTICIPANTS: Third- and fourth-year medical students from the classes of 1990 through 1996 at the University of California, San Francisco, School of Medicine. INTERVENTIONS: A needlestick hotline service was instituted at teaching hospitals affiliated with the University of California, San Francisco, and a required course was created to train students in universal precautions and clinical skills before the beginning of the third-year clerkship. MEASUREMENTS: Reports of exposures made to the needlestick hotline service, including type of exposure, training site, clerkship, and time of year. RESULTS: 119 of 1022 medical students sustained 129 exposures. Of these exposures, 82% occurred on four services: obstetrics-gynecology, surgery, medicine, and emergency medicine. The probability of exposure was not related to graduation year, clerkship location, previous clerkship experience, or training site. Surveys of two graduating classes at the beginning and end of the study showed that the percentage of exposures reported increased from 45% to 65% over the 7-year study period. Thus, the reported injury rates represent minimum estimates of actual occurrences. Human immunodeficiency virus infection and hepatitis were not reported, although follow-up was limited. CONCLUSIONS: Instruction in universal precautions and clinical procedures is not sufficient to prevent exposures to blood during medical training. Medical schools must assume greater responsibility for ensuring that students are proficient in the safe conduct of clinical procedures and must develop systems that protect students so that they can report and learn from their mistakes.

"Bimodal" medical schools: excelling in research and primary care.

The authors studied four "bimodal" medical schools--those ranked in the top 20% by the Association of American Medical Colleges both in production of primary care physicians and in receiving research grants from the National Institutes of Health. A descriptive, anthropologic method was used to describe the cultures of these schools and to determine common factors in their success. The four schools are at the University of Washington, the University of North Carolina, the University of California, San Francisco, and the University of California, San Diego. These common factors ranged from characteristics of the schools to characteristics of their external environments. All four are part of large, state-supported universities. They are relatively new schools in areas of the country that have blossomed in biotechnology, aerospace, and computer industries. The schools' missions, admission committees, and educational programs reflect their dual role: to meet the health care needs of their states and to advance basic science knowledge in medicine. Each state has a strong Academy of Family Practice, and the medical schools have been in the forefront of residency training in this specialty. Federal- and state-funded Area Health Education Centers and private foundations have provided seed money for educational programs in community and rural settings that attract medical students to primary care. Research-intensive medical schools can encourage students to enter primary care specialties if they have strong primary care leaders and programs and if they support medical education programs outside the academic, tertiary-care center. A culture of mutual respect and commitment to community service is also essential to achieving this bimodal success.

The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data.

OBJECTIVES: The study reviewed methods for measuring the specialty distribution of the US physician workforce. It was hypothesized that current databases and measurement conventions overestimate the number of generalist physicians. METHODS: A descriptive analysis of the American Medical Association (AMA) Physician Masterfile for California was done with different assumptions about the definition of generalists based on primary and secondary specialty information. RESULTS: A rigorous definition of generalist physician that excludes physicians with secondary practices in specialist fields resulted in an estimate of generalist physicians 25% lower than the number estimated by conventional workforce evaluation methods. Physicians who reported practicing in both generalist and specialist fields were more likely to be older, to be international medical school graduates, and to be in solo or duo practice compared with physicians who listed only generalist or specialist fields. CONCLUSIONS: The actual number of generalist physicians in the United States may be less than previously believed. Although the exact magnitude of the "hidden system" of specialists providing primary care is difficult to measure, at least a portion appear to already be counted as generalist physicians by current conventions.

Factors influencing students' choices of primary care or other specialties.

BACKGROUND: Because of the marked decline in the numbers of U.S. medical school graduates entering the primary care fields of internal medicine, pediatrics, and family medicine, medical educators are increasingly interested in determining the factors that influence students' choices of specialty. METHOD: A few months before graduation, the 142 seniors in the class of 1992 at the University of California, San Francisco, School of Medicine, were surveyed about their choices of first-year residency programs. They were asked to rate various influential factors by using a five-point Likert scale. Chi-square analysis was used to compare the students' responses, by specialty choice (i.e., primary care versus other specialties) and by gender. RESULTS: A total of 102 students responded: 50 who were entering primary care specialties, and 52 who were entering other specialties. Three factors were found to significantly influence the students' choices: future income, opportunities to work with new technology, and faculty advisors. Income and working with new technology were significantly rated factors leading toward the non-primary-care fields (p = .031; p = .000), although a total of only 20 students (15 in non-primary-care) rated income as an important factor. A faculty advisor was a positive influence on the students who were entering residency training in the primary care specialties (p = .000). CONCLUSION: That the influence of a faculty advisor was the significant factor in affecting students' decisions to choose primary care suggests that schools can increase the percentages of their students entering the primary care fields by increasing their students' contact with mentors in these fields.

A peptide family being re-united: the angiotensins coming in from the cold.

The renin-angiotensin-aldosterone system is now considered to be far more complex than previously thought when the vasoconstrictor and other physiological effects of the octapeptide angiotensin II in the circulating blood were emphasized. The reasons for this altered viewpoint, involving angiotensins other than the octapeptide in the regulation of blood pressure, water and electrolyte homeostasis, are briefly advanced and discussed.

Women's attitudes toward careers in academic medicine at the University of California, San Francisco.

In order to identify the concerns and possible barriers for women considering careers in academic medicine, in 1990 the authors surveyed both men and women medical students, housestaff, postdoctoral students, and junior faculty at The University of California, San Francisco (UCSF). The authors achieved a 58% response rate from students and faculty, a 21% response rate from postdoctoral students, and a 15% response rate from housestaff. Results indicated that women at all levels were less interested in academic careers than were their male colleagues. Concerns about balancing family responsibilities, clinical practice, and teaching in addition to the research required of an academic career were mentioned most frequently. Women, especially those among the housestaff and junior faculty, reported fewer mentor relationships and role models. The authors discuss these findings in relation to other studies and describe what they are doing to foster women's interest and success in academic medicine at UCSF.

Receptors for angiotensins I and II: their relevance to renal haemodynamics, blood pressure control and hind-limb blood flow.

The well established differential pulmonary handling of angiotensins I and II indicates the possibility that vascular receptors for the deca- and octa-peptides do not necessarily involve common sites in the renal vasculature either. Experimental findings involving haemodynamic changes within the kidney in anaesthetised and conscious sheep, with utilization of the angiotensins, and also of noradrenaline, are briefly presented; the implications of the intra-renal water and creatinine transfers are discussed, especially as they concern the possible location of angiotensin receptors in the renal blood vessels. Other aspects of the relationships between the peptides are also taken into account particularly with regard to a postulated angiotensin I [NaCl] dependent peritubular capillary antidiuretic action, angiotensin converting enzyme inhibition, Goldblatt clamp induced hypertension and blood flow through the hind-limbs.

Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial.

BACKGROUND: Previous interventions to promote performance of cancer prevention activities have largely targeted physicians in university-based practices. METHODS: We randomly assigned 40 primary care physicians in community-based practices to either (1) Cancer Prevention Reminders, computer-generated lists of overdue screening tests, and smoking and dietary assessment and counseling, supplemented by cancer education materials; or (2) controls. For each physician, we reviewed a random sample of 60 medical records for data about screening test, assessment, and counseling performance during 12-month preintervention and intervention periods. We calculated performance scores as percentage compliance with American Cancer Society and/or National Cancer Institute recommendations. Multiple regression analyses provided estimates of incremental differences in performance scores between intervention and control groups. RESULTS: Controlling for preintervention performance levels, significant incremental differences in performance scores between intervention and control groups (P less than .05) were achieved for nine maneuvers: stool occult-blood test, +14.5; rectal examination, +10.5; pelvic examination, +11.8; Papanicolaou's smear, +30.7; breast examination, +8.7; smoking assessment, +10.2; smoking counseling, +17.3; dietary assessment, +12.3; and dietary counseling, +13.9. Increments for sigmoidoscopy and mammography were not significant. CONCLUSION: Computerized reminders can significantly increase physicians' performance of cancer prevention activities in community-based practices.