Management of opioid use disorders among veterans in subacute rehab: Use of an interdisciplinary task force to address an emerging concern.

There is both rapidly growing need, and limited evidence-based guidelines, for the management of opioid use disorders in subacute rehab and other nonaddiction medical settings. Following 2 unintentional opioid overdoses within the Community Living Center (CLC), a VA (Veterans Administration) subacute rehab setting, an interdisciplinary CLC Addictions Task Force was created to address a critical issue: how to best meet the combined neuropsychiatric and medical needs of the opiate use disorder patient through a multifaceted treatment approach. The goals of the task force were to develop and institute educational initiatives for providers; create patient care guidelines; increase safety on the unit; improve provider confidence when caring for this high-risk population; and mitigate the risk of unintentional overdose. The task force divided into 4 working groups to meet these aims. Process and outcomes are discussed. We found that in-services by addiction specialists improved clinician comfort in caring for this high-risk patient group. Specific areas that yielded the greatest clinician satisfaction ratings included didactics on how to identify at-risk patients and techniques on how to manage the patient in a general rehab setting. Utilizing an interdisciplinary approach, and an iterative process, at all stages was critical to the success of the CLC Addictions Task Force, as it improved buy-in and motivation from all disciplines. Improvements have been made to enhance patient safety, improve communication amongst providers, and provide a foundation to improve patient outcomes. Our preliminary work to enhance the identification and management of opioid use disorders at our CLC is an important first step towards a standardized curriculum that could be applied to other VA and non-VA subacute rehab settings.

Written content indicators of problematic approach behavior toward political officials.

Those charged with assessing and managing threatening communications must utilize risk factors that are behavioral, operational, and reasonably attainable during investigations. This project examined 326 written correspondence cases of an inappropriate, disruptive, or threatening nature that targeted political officials, with the specific goal of identifying written content indicators of problematic approach behavior. Results revealed that subjects who engaged in problematic approach activity toward their targets had more criminal history, past threat assessment activity, familiarity with firearms, past substance use, and indicators of serious mental illness. Approachers were more likely to engage in multiple contact methods, target dispersion, more overall contacts, and prior contact with their target. Numerous content themes were associated with future problematic approach, including longer handwritten correspondence, referencing specific events, making demands, mentioning stressors, focus on personal themes, feeling their rights were violated, and expressing an intention to approach. Harassing, insulting, and threatening language was not related to approach behavior. The implications of these findings are wide-ranging for the practice of threat assessment.

A comparison of email versus letter threat contacts toward members of the United States Congress.

To better understand inappropriate correspondence sent to public officials, 301 letter cases and 99 email cases were randomly selected from the United States Capitol Police investigative case files and compared. Results indicate that letter writers were significantly more likely than emailers to exhibit indicators of serious mental illness (SMI), engage in target dispersion, use multiple methods of contact, and make a problematic approach toward their target. Emailers were significantly more likely than letter writers to focus on government concerns, use obscene language, and display disorganization in their writing. Also, letter writers tended to be significantly older, have more criminal history, and write longer communications. A multivariate model found that disorganization, SMI symptoms, problematic physical approach, and target dispersion significantly differentiated between the correspondence groups. The group differences illuminated by this study reveal that letter writers are engaging in behavior that is higher risk for problematic approach than are emailers.

Direct effects of interleukin-13 on epithelial cells cause airway hyperreactivity and mucus overproduction in asthma.

Asthma is an increasingly common disease that remains poorly understood and difficult to manage. This disease is characterized by airway hyperreactivity (AHR, defined by exaggerated airflow obstruction in response to bronchoconstrictors), mucus overproduction and chronic eosinophilic inflammation. AHR and mucus overproduction are consistently linked to asthma symptoms and morbidity. Asthma is mediated by Th2 lymphocytes, which produce a limited repertoire of cytokines, including interleukin-4 (IL-4), IL-5, IL-9 and IL-13. Although each of these cytokines has been implicated in asthma, IL-13 is now thought to be especially critical. In animal models of allergic asthma, blockade of IL-13 markedly inhibits allergen-induced AHR, mucus production and eosinophilia. Furthermore, IL-13 delivery to the airway causes all of these effects. IL-13 is thus both necessary and sufficient for experimental models of asthma. However, the IL-13-responsive cells causing these effects have not been identified. Here we show that mice lacking signal transducer and activator of transcription 6 (STAT6) were protected from all pulmonary effects of IL-13. Reconstitution of STAT6 only in epithelial cells was sufficient for IL-13-induced AHR and mucus production in the absence of inflammation, fibrosis or other lung pathology. These results demonstrate the importance of direct effects of IL-13 on epithelial cells in causing two central features of asthma.