What Should Health Professions Students Know About Countertransference in Inpatient Psychiatric Environments?

Inpatient psychiatric units are heavily regulated physical environments designed around the twin aims of treatment and containment. Less formally regulated but no less important are emotional norms and tones that also contribute significantly to psychiatric care environments. Inpatient psychiatric units are co-created by patients and clinicians, but clinicians have authority that patients do not. This means that clinicians' management of their own transference and reactions is clinically and ethically important. This article defines transference reactions and draws on case examples to canvass how positive and negative transference reactions can influence inpatient care of patients who are suicidal.

The pulse: transient fMRI signal increases in subcortical arousal systems during transitions in attention.

Studies of attention emphasize cortical circuits for salience monitoring and top-down control. However, subcortical arousal systems have a major influence on dynamic cortical state. We hypothesize that task-related increases in attention begin with a "pulse" in subcortical arousal and cortical attention networks, which are reflected indirectly through transient fMRI signals. We conducted general linear model and model-free analyses of fMRI data from two cohorts and tasks with mixed block and event-related design. 46 adolescent subjects at our center and 362 normal adults from the Human Connectome Project participated. We identified a core shared network of transient fMRI increases in subcortical arousal and cortical salience/attention networks across cohorts and tasks. Specifically, we observed a transient pulse of fMRI increases both at task block onset and with individual task events in subcortical arousal areas including midbrain tegmentum, thalamus, nucleus basalis and striatum; cortical-subcortical salience network regions including the anterior insula/claustrum and anterior cingulate cortex/supplementary motor area; in dorsal attention network regions including dorsolateral frontal cortex and inferior parietal lobule; as well as in motor regions including cerebellum, and left hemisphere hand primary motor cortex. The transient pulse of fMRI increases in subcortical and cortical arousal and attention networks was consistent across tasks and study populations, whereas sustained activity in these same networks was more variable. The function of the transient pulse in these networks is unknown. However, given its anatomical distribution, it could participate in a neuromodulatory surge of activity in multiple parallel neurotransmitter systems facilitating dynamic changes in conscious attention.

Clinical uses of cannabis and cannabinoids in the United States.

The role of cannabis in medicine is rapidly evolving. Medical cannabis is now legal in a majority of states, and THC and CBD, the prominent cannabinoids found in cannabis, have both been utilized in the development of FDA-approved drugs. Due to the complicated legal status of cannabis and cannabinoids, as well as regulations that vary from state to state, the appropriate use of these substances for both patients as well as clinicians is often unclear. Advancements in the understanding of the pharmacology of cannabis have led to numerous proposed uses of these drugs, including as antidepressant or analgesic agents. However, clinical trial data for these substances suggests that many purported indications of cannabis and cannabinoids are not supported by good clinical data. Furthermore, cannabis and several cannabinoid-based medications have potentially concerning side effect profiles that may limit their use in certain patient populations. As the legal status and clinical database of these medications continue to evolve, physicians will need to continue to balance the real potential of these compounds with their limitations and adverse effects.

Trends and factors affecting the US adult hematology workforce: a mixed methods study.

The current demand for adult hematologists in the United States is projected to exceed the existing supply. However, no national study has systematically evaluated factors affecting the adult hematology workforce. In collaboration with the American Society of Hematology (ASH), we performed a mixed methods study consisting of surveys from the annual ASH In-Service Exam for adult hematology/oncology fellows from 2010 to 2016 (8789 participants); interviews with graduating or recently graduated adult hematology/oncology fellows in a single training program (8 participants); and 3 separate focus groups for hematology/oncology fellowship program directors (12 participants), fellows (12 participants), and clinicians (10 participants) at the 2016 ASH annual meeting. In surveys, the majority of fellows favored careers combining hematology and oncology, with more fellows identifying oncology, rather than hematology, as their primary focus. In interviews with advanced-year fellows, mentorship emerged as the single most important career determinant, with mentorship opportunities arising serendipitously, and oncology faculty perceived as having greater availability for mentorship than hematology faculty. In focus group discussions, hematology, particularly benign hematology, was viewed as having poorer income potential, research funding, job availability, and job security than oncology. Focus group participants invariably agreed that the demand for clinical care in hematology, particularly benign hematology, exceeded the current workforce supply. Single-subspecialty fellowship training in hematology and the creation of new clinical care models were offered as potential solutions to these workforce problems. As a next step, ASH is conducting a national, longitudinal study of the adult hematology workforce to improve recruitment and retention in the field.

Increased lymphocyte activation and atherosclerosis in CD47-deficient mice.

CD47, also known as integrin-associated protein (IAP), is a transmembrane protein with multiple biological functions including regulation of efferocytosis and leukocyte trafficking. In this study we investigated the effect of CD47-deficiency on atherosclerosis using a model of adeno-associated virus (AAV)-induced hypercholesterolemia. We observed increased plaque formation in CD47 null mice compared to wild-type controls. Loss of CD47 caused activation of dendritic cells, T cells and natural killer (NK) cells, indicating an important role for CD47 in regulating immunity. In particular, Cd47 deficiency increased the proportion of IFN-γ producing CD90+ NK cells. Treatment with depleting anti-NK1.1 monoclonal antibody (mAb), but not depleting anti-CD4/CD8 mAbs, equalized atherosclerotic burden, suggesting NK cells were involved in the enhanced disease in Cd47 deficient mice. Additional studies revealed that levels of CD90+ and IFN-γ+ NK cells were expanded in atherosclerotic aorta and that CD90+ NK cells produce more IFN-γ than CD90- NK cells. Finally, we demonstrate that anti-CD47 (MIAP410) causes splenomegaly and activation of DCs and T cells, without affecting NK cell activation. In summary, we demonstrate that loss of CD47 causes increased lymphocyte activation that results in increased atherosclerosis.

IL-23R Deficiency Does Not Impact Atherosclerotic Plaque Development in Mice.

BACKGROUND: Interleukin-23 (IL-23) has been implicated in inflammatory and autoimmune diseases by skewing CD4+ T helper cells towards a pathogenic Th17 phenotype. In this study we investigated the presence of IL-23 receptor (IL-23R)-expressing cells in the atherosclerotic aorta and evaluated the effect of IL-23R deficiency on atherosclerosis development in mice. METHODS AND RESULTS: We used heterozygous Ldlr-/-Il23reGFP/WT knock-in mice to identify IL-23R-expressing cells by flow cytometry and homozygous Ldlr-/-Il23reGFP/eGFP (Ldlr-/-Il23r-/- ) mice to investigate the effect of lack of IL-23R in atherosclerosis. We demonstrate the presence of relatively rare IL-23R-expressing cells in lymphoid tissue and aorta (≈0.1-1% IL23R+ cells of all CD45+ leukocytes). After 10 weeks on a high-fat diet, production of IL-17, but not interferon-γ, by CD4+ T cells and other lymphocytes was reduced in Ldlr-/-Il23r-/- compared with Ldlr-/- controls. However, Ldlr-/- and Ldlr-/-Il23r-/- mice had equivalent amounts of aortic sinus and descending aorta lesions. Adoptive transfer of IL-23R-deficient CD4+ T cells to lymphopenic Ldlr-/-Rag1-/- resulted in dramatically reduced IL-17-producing T cells but did not reduce atherosclerosis, compared with transfer of IL-23R-sufficient CD4+ T cells. CONCLUSIONS: These data demonstrate that loss of IL-23R does not affect development of experimental atherosclerosis in LDLr-deficient mice, despite a role for IL-23 in differentiation of IL-17-producing T cells.

Controversies Regarding the Diagnosis and Management of Ductal Carcinoma In Situ.

Ductal carcinoma in situ (DCIS) is a premalignant condition, whose incidence is increasing in the current era of widespread screening mammography. While eminently treatable, there are innumerable controversies that surround this disease in terms of its diagnosis and treatment. We discuss these issues and review the data to date regarding this condition which affects roughly 20 per cent of all patients presenting with breast cancer.

No Time for Silence: An Urgent Need for Political Activism Among the Medical Community.

Despite being a major stakeholder in the U.S. health care system, the medical community has remained relatively mute in the debate over the future of the Patient Protection and Affordable Care Act (ACA). If the ACA were repealed, tens of millions of Americans would be in danger of losing their insurance, resulting in a significant increase in mortality. Because misinformation about the ACA is rampant, it is imperative that health care providers explain to the public what exactly the ACA is and how repeal will affect patients. Traditionally, many in the medical community have abstained from political advocacy for multiple reasons, including compromising the doctor-patient relationship, financial incentives, lack of experience with activism due to an absence of training in that area, and fear of political retaliation. Encouragingly, there are indications that the medical community is beginning to become more vocal. Medical students are one example, having formed a grassroots response to repeal. However, students need more guidance and support from experienced mentors to most effectively serve as patient advocates. This is no time for silence: On this life-or-death issue, the medical community cannot afford to remain mute.

Discrepancy Between Patient Health Literacy Levels and Readability of Patient Education Materials from an Electronic Health Record.

Limited health literacy is associated with worse health outcomes. It is standard practice in many primary care clinics to provide patients with written patient education materials (PEM), which often come directly from an electronic health record (EHR). We compared the health literacy of patients in a primary care residency clinic with EHR PEM readability by grade level. We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine-Short Form (REALM-SF), and determined grade level readability for the PEM distributed for the five most common clinical diagnoses using the Simple Measure of Gobbledygook (SMOG) and Flesch-Kincaid metrics. Among 175 participants, health literacy was ≥9th grade for 76 patients (43.4%), 7th to 8th grade for 66 patients (37.7%), and ≤6th grade for 30 patients (17.1%). Average standard PEM readability by SMOG was grade 9.2 and easy-to-read PEM readability was grade 6.8. These findings suggest a discrepancy between the health literacy of most patients who were surveyed and standard PEM readability. Despite national guidelines encouraging clinicians to provide PEM at an appropriate reading level, our results indicate that PEM from EHR may not be readable for many patients. [Health Literacy Research and Practice. 2017;1(4):e203-e207.].

A Cdc42 activation cycle coordinated by PI 3-kinase during Fc receptor-mediated phagocytosis.

Fcgamma Receptor (FcR)-mediated phagocytosis by macrophages requires phosphatidylinositol 3-kinase (PI3K) and activation of the Rho-family GTPases Cdc42 and Rac1. Cdc42 is activated at the advancing edge of the phagocytic cup, where actin is concentrated, and is deactivated at the base of the cup. The timing of 3' phosphoinositide (3'PI) concentration changes in cup membranes suggests a role for 3'PIs in deactivation of Cdc42. This study examined the relationships between PI3K and the patterns of Rho-family GTPase signaling during phagosome formation. Inhibition of PI3K resulted in persistently active Cdc42 and Rac1, but not Rac2, in stalled phagocytic cups. Patterns of 3'PIs and Rho-family GTPase activities during phagocytosis of 5- and 2-mum-diameter microspheres indicated similar underlying mechanisms despite particle size-dependent sensitivities to PI3K inhibition. Expression of constitutively active Cdc42(G12V) increased 3'PI concentrations in plasma membranes and small phagosomes, indicating a role for Cdc42 in PI3K activation. Cdc42(G12V) inhibited phagocytosis at a later stage than inhibition by dominant negative Cdc42(N17). Together, these studies identified a Cdc42 activation cycle organized by PI3K, in which FcR-activated Cdc42 stimulates PI3K and actin polymerization, and the subsequent increase of 3'PIs in cup membranes inactivates Cdc42 to allow actin recycling necessary for phagosome formation.