Allergen immunotherapy at university health services and allergist's reasons for guidelines nonadherence.

BACKGROUND: Our previous pilot study conducted at the University of Michigan Health Services showed that fewer than 25% of the non-university allergen immunotherapy (AIT) prescribers adhered to AIT labeling guidelines which impacted both patients and healthcare personnel involved in AIT administration. OBJECTIVES: We expand our study to characterize AIT labeling compliance and impact of practice variability at the "Big 10" University Health Services, and investigate prescribers motives for nonadherence to practice parameter guidelines. METHODS: Three online surveys were distributed: AIT Administrator and Manager surveys for healthcare personnel at the "Big 10"; University Health Services and Physician Survey for physician members of the AAAAI. Data were analyzed using frequency/bivariate analysis and logistic regression. RESULTS: 21 AIT administrators from 10 University Health Services responded. 90.4% (20/21) felt labels containing all recommended practice parameter guidelines, components would decrease error; and standardization of labels, buildup and missed dose schedules would increase workflow efficiency (76%; 16/21). 90% (17/19) felt standardized protocols for treatment of systemic reactions would increase patient safety, workflow efficiency and comfort level of administrators. Only 28.6% of AIT extract vial labels at University Health Services were in accordance with practice parameter guidelines. Despite familiarity with the guidelines (91.5%; 697/762), only 64% (488/762) of surveyed physicians had practice parameter adherent AIT extracts labels with higher odds of a complete label when physicians were in group practice (odds ratio 1.51; [95% confidence interval, 1.06-2.15]; P=0.02). Reasons for nonadherence included having personalized labeling systems (55.4%, 174/314), unfamiliarity (14%, 44/314) and disagreement (9%, 29/314) with practice parameter guidelines. CONCLUSION: Poor adherence with AIT practice parameters labeling guidelines is an important concern in nonallergy offices. It is imperative that allergists comply with the highest recommended standards to provide the best clinical outcomes and ensure excellent and efficient care in both allergy and non-allergy offices.

iTunes song-gifting is a low-cost, efficient recruitment tool to engage high-risk MSM in internet research.

This brief report describes methodology and results of a novel, efficient, and low-cost recruitment tool to engage high-risk MSM in online research. We developed an incentivization protocol using iTunes song-gifting to encourage participation of high-risk MSM in an Internet-based survey of HIV status, childhood sexual abuse, and adult behavior and functioning. Our recruitment methodology yielded 489 participants in 4.5 months at a total incentive cost of $1.43USD per participant. The sample comprised a critically high-risk group of MSM, including 71.0 % who reported recent condomless anal intercourse. We offer a "how-to" guide to aid future investigators in using iTunes song-gifting incentives.

Systemic reactions to inhalant immunotherapy using 1:1 target dosing.

BACKGROUND: The 2007 immunotherapy practice parameters advocate maintenance dosing at 1:1 (1:20 maintenance concentrate). There is limited literature exploring the effect of 1:1 dosing on the rate of systemic reactions to subcutaneous immunotherapy (SRITs). OBJECTIVE: To investigate the effects of 1:1 dosing on SRITs in a large, academic practice. METHODS: We conducted a retrospective cohort study of all nonvenom and noncluster SRITs that occurred between 2005 and 2011. SRITs that occurred from August 2008 through December 2011, postparameter dosing (post-PD) was initiated, were compared to SRITs that occurred from January 2005 to July 2008 with preparameter dosing (pre-PD) using 1:50 as a maintenance concentrate. RESULTS: A total of 269 SRITs occurred in a 7-year period. Significantly more post-PD SRITs (131 of 38,548 injections) occurred than pre-PD SRITs (132 of 52,833 injections) (0.34% vs 0.25%, P = .01). However, when excluding 44 SRITs that occurred in established pre-PD patients transitioned to post-PD, there was no significant difference in SRIT rate (0.25% vs 0.22%), World Allergy Organization (WAO) grade, or SRIT time to onset. Nonred (non-1:1) vials accounted for a significantly larger proportion of all post-PD SRITs compared with all pre-PD SRITs (50.7% vs 31.1%, adjusted P = .009). Prior SRITs were reported less frequently among persons with post-PD SRITs (29.2% vs 70.8%, adjusted P = .009). In an adjusted logistic regression model, male sex (odds ratio, 7.9; 95% CI, 2.4-26) and longer time to reaction onset (odds ratio, 0.94; 95% CI, 0.89-0.99) were associated with higher WAO severity grade reactions. CONCLUSION: Pre-PD vs post-PD SRIT rates were not significantly different, adjusting for patients transitioned from established pre-PD to post-PD. This finding suggests that post-PD is as safe as pre-PD. Male sex and faster time to reaction onset were associated with higher WAO grade reactions.

Naturally occurring neoplasms in pigeons in a research colony: a retrospective study.

This study reports the gross and microscopic pathology of naturally occurring neoplasms in adult pigeons that were presented for necropsy at the Indiana Animal Disease Diagnostic Laboratory from 2001 to 2011. The study population consisted of white carneau and mixed-breed pigeons used in behavioral studies in the Department of Psychological Sciences at Purdue University. Twelve types of neoplasms or proliferative disorders were identified in 28 of 83 pigeons (33.7%). Five pigeons had two or three types of neoplasms-proliferative disorders. Of the 83 pigeons, 11 (13.3%) had seminoma, five (6.0%) had thyroid adenoma, four (4.8%) had lymphoma, four (4.8%) had adenocarcinoma of female reproductive tract origin, two (2.4%) had pulmonary carcinoma, and two (2.4%) had cutaneous vascular hamartomas. Also identified were single incidences of dysgerminoma, mesothelioma, liposarcoma, cloacal papilloma, cloacal adenocarcinoma, and gizzard carcinoma. The most frequently occurring tumor was seminoma; 7/11 cases effaced both testicles and 3/11 cases had metastasis to the liver or kidney. The relatively high prevalence of neoplasms in pigeons in the present study is most likely related to the advanced ages of pigeons kept in the research colony.

Web-based versus face-to-face interprofessional team encounters with standardized patients.

BACKGROUND: Challenges exist in developing interprofessional education (IPE) activities including coordinating schedules and obtaining appropriate space for teams to work. Virtual worlds have been explored as a means to overcome some of these challenges. We sought to develop a web-based interprofessional team interaction with a standardized patient (SP), as compared to a face-to-face SP interaction, focusing on the competency area of interprofessional communication. INTERPROFESSIONAL EDUCATION ACTIVITY: Interprofessional teams of students were randomized to complete a web-based or face-to-face SP encounter. The web-based encounter was conducted via video conference that students accessed using their own electronic device. Interprofessional communication was evaluated by faculty observers and the SPs. Participants of the web-based encounter also completed a perceptions questionnaire. DISCUSSION: Interprofessional communication was rated as average/above average by the authors and SPs. Perceptions of the web-based encounter were mixed with not all students willing to complete such an encounter again despite finding it enjoyable and a positive learning experience. The need for adequate preparation was identified, including the opportunity to review the patient case before the encounter. IMPLICATIONS: The web-based SP encounter afforded students the opportunity to utilize communication technology to provide patient-centered care while collaborating as an interprofessional team. Video conferencing presents an opportunity to bypass some logistical challenges in scheduling IPE experiences and can be implemented as a co-curricular activity, avoiding course revisions. Additional studies are needed to further explore student and patient perspectives and clarify when, and with what level of trainees, the experiences are most valuable.

Nursing and Focal Dyscognitive Seizures: A Clinical Update When Managing Risk Using Advanced Nursing Skills.

Focal seizures are divided into simple and dyscognitive, with the latter resulting in the alteration of consciousness. In the ictal and postictal stages, patients may present with confusion, delirium, and psychosis, presenting a risk of safety to themselves and others. This article presents 3 case studies where patients have been admitted for visual and electroencephalographic monitoring. Seizure activity is provoked for the diagnosis and development of a management plan. These cases illustrate the unique nursing implications when caring for patients experiencing focal dyscognitive seizures, highlighting the unique circumstances for the neuroscience nurse regarding risk management, safe administration of radioactive isotopes, detection of subtle seizure manifestation, and use of family as experts in patient-centered care. Through a deliberate onset of seizures, neuroscience nurses are placed in nontypical nursing situations, thus managing risk in unpredictable conditions and displaying advanced and distinctive nursing skills.

Adherence with allergen immunotherapy labeling guidelines.

BACKGROUND: Little is known about the adherence rate to allergen immunotherapy (AIT) labeling guidelines. OBJECTIVE: To assess adherence to labeling guidelines of AIT Practice Parameter 2011 at University of Michigan Health Service. METHODS: AIT vials of 320 patients who received their care at the University of Michigan Health Service were reviewed. Data collected looked at patient identifiers (PI), concentrations in volume/volume (v/v) format, color coding, allergen content, expiration date and instructions about AIT dosing, and systemic reaction treatment. Data were analyzed by using χ(2) test and the Fisher exact test and logistic regression. RESULTS: Of 238 non-university formulated labels, 65% had 2 PIs, 62% had a v/v concentration, 41% had color coding, 71% had the content listed, and 100% had a recorded expiration date. Only 21% had all 5 recommended components. All 82 University vials had 5 components. Labels with 2 PIs were more likely to have a v/v concentration with its corresponding color coding (odds ratio [OR] 3.84 [95% CI, 1.9-7.7]; P < .001). Labels that specified the extract's content were more likely to be color coded or to have a v/v concentration listed (OR 6.3 [95% CI, 3.4-11.8]; P < .001). For all AIT vials, complete labels were significantly more likely to have a clear buildup schedule (OR 9.6 [95% CI, 4.2-23.2]; P < .001), dosing adjustment after a missed dose (OR 8.2 [95% CI, 3.4-19.8]; P < .001) or after a reaction (OR 13.7 [95% CI, 7.8-2.1]; P < .001), and clear systemic reaction treatment instructions (OR 9.7 [95% CI, 7.8-24.1]; P < .001). CONCLUSION: Fewer than 25% of the nonuniversity prescribers adhered to AIT practice parameters 5 years after publication. Recording 2 PIs, the v/v concentration, or the color coding increased the likelihood of having a complete label. Complete label contents were associated with clear instructions about AIT dosing and reaction treatment and/or dose adjustments.

High-frequency voltage oscillations in cultured astrocytes.

Because of their close interaction with neuronal physiology, astrocytes can modulate brain function in multiple ways. Here, we demonstrate a yet unknown astrocytic phenomenon: Astrocytes cultured on microelectrode arrays (MEAs) exhibited extracellular voltage fluctuations in a broad frequency spectrum (100-600 Hz) after electrical stimulation. These aperiodic high-frequency oscillations (HFOs) could last several seconds and did not spread across the MEA. The voltage-gated calcium channel antagonist cilnidipine dose-dependently decreased the power of the oscillations. While intracellular calcium was pivotal, incubation with bafilomycin A1 showed that vesicular release of transmitters played only a minor role in the emergence of HFOs. Gap junctions and volume-regulated anionic channels had just as little functional impact, which was demonstrated by the addition of carbenoxolone (100 µmol/L) and NPPB (100 µmol/L). Hyperpolarization with low potassium in the extracellular solution (2 mmol/L) dramatically raised oscillation power. A similar effect was seen when we added extra sodium (+50 mmol/L) or if we replaced it with NMDG(+) (50 mmol/L). The purinergic receptor antagonist PPADS suppressed the oscillation power, while the agonist ATP (100 µmol/L) had only an increasing effect when the bath solution pH was slightly lowered to pH 7.2. From these observations, we conclude that astrocytic voltage oscillations are triggered by activation of voltage-gated calcium channels and driven by a downstream influx of cations through channels that are permeable for large ions such as NMDG(+). Most likely candidates are subtypes of pore-forming P2X channels with a low affinity for ATP.

Combining computerized social cognitive training with neuroplasticity-based auditory training in schizophrenia.

OBJECTIVE: Social cognitive deficits are an important treatment target in schizophrenia, but it is unclear to what degree they require specialized interventions and which specific components of behavioral interventions are effective. In this pilot study, we explored the effects of a novel computerized neuroplasticity-based auditory training delivered in conjunction with computerized social cognition training (SCT) in patients with schizophrenia. METHODS: Nineteen clinically stable schizophrenia subjects performed 50 hours of computerized exercises that place implicit, increasing demands on auditory perception, plus 12 hours of computerized training in emotion identification, social perception, and theory of mind tasks. All subjects were assessed with MATRICS-recommended measures of neurocognition and social cognition, plus a measure of self-referential source memory before and after the computerized training. RESULTS: Subjects showed significant improvements on multiple measures of neurocognition. Additionally, subjects showed significant gains on measures of social cognition, including the MSCEIT Perceiving Emotions, MSCEIT Managing Emotions, and self-referential source memory, plus a significant decrease in positive symptoms. CONCLUSIONS: Computerized training of auditory processing/verbal learning in schizophrenia results in significant basic neurocognitive gains. Further, addition of computerized social cognition training results in significant gains in several social cognitive outcome measures. Computerized cognitive training that directly targets social cognitive processes can drive improvements in these crucial functions.

Consequences of intratumoral injection of a herbal preparation containing blood root (Sanguinaria canadensis) extract in two dogs.

CASE DESCRIPTION: 2 dogs were referred for surgical removal of cutaneous tumors that had previously been treated by intratumoral injection of a herbal preparation containing blood-root (Sanguinaria canadensis) extract. CLINICAL FINDINGS: 11 days following injection of bloodroot extract into a small dermal tumor, dog 1 developed a large, soft, fluctuant cutaneous mass at the site of injection. Ultrasonographic evaluation of the mass revealed a fluid-filled central cavity with increased echogenicity of the surrounding subcutaneous tissues. Dog 2 had a small dermal tumor under the left mandible that had been treated in similar fashion. However, an exuberant reaction was not observed following injection of bloodroot extract in this dog. TREATMENT AND OUTCOME: Both dogs underwent surgical excision of the cutaneous tumors. Histologic evaluation revealed severe necrosis and inflammation in the excised tissues from dog 1. This dog experienced postsurgical wound complications and had a prolonged postsurgical recovery. Similar, although less severe, histopathologic findings were apparent in the excised tissues from dog 2; this dog recovered without complications. CLINICAL RELEVANCE: Various products containing bloodroot are marketed on the Internet for topical and parenteral treatment of cutaneous neoplasms in domestic animals. However, the antineoplastic properties, therapeutic efficacy, and adverse effects of these products are poorly described in the veterinary literature. Clinicians should be aware of the potential for harm caused by the use of these products.

Can I trust you? Negative affective priming influences social judgments in schizophrenia.

Successful social interactions rely on the ability to make accurate judgments based on social cues as well as the ability to control the influence of internal or external affective information on those judgments. Prior research suggests that individuals with schizophrenia misinterpret social stimuli and this misinterpretation contributes to impaired social functioning. We tested the hypothesis that for people with schizophrenia, social judgments are abnormally influenced by affective information. Twenty-three patients with schizophrenia and 35 healthy control participants rated the trustworthiness of faces following the presentation of neutral, negative (threat-related), or positive affective primes. Results showed that all participants rated faces following negative affective primes as less trustworthy than faces following neutral or positive primes. Importantly, this effect was significantly more pronounced for participants with schizophrenia, suggesting that schizophrenia may be characterized by an exaggerated influence of negative affective information on social judgment. Furthermore, the extent that the negative affective prime influenced trustworthiness judgments was significantly associated with patients' severity of positive symptoms, particularly feelings of persecution. These findings suggest that for people with schizophrenia, negative affective information contributes to an interpretive bias, consistent with paranoid ideation, when judging the trustworthiness of others. This bias may contribute to social impairments in schizophrenia.

Neuroplasticity-based cognitive training in schizophrenia: an interim report on the effects 6 months later.

BACKGROUND: New cognitive treatments for schizophrenia are needed that drive persistent gains in cognition and functioning. Using an innovative neuroplasticity-based cognitive training approach, we report our interim findings on the effects on cognition and functional outcome at 6 months after treatment. METHODS: Thirty-two clinically stable schizophrenia subjects were randomly assigned to either targeted cognitive training (TCT, N = 22) or a computer games (CGs) control condition (N = 10). Twelve TCT subjects completed 50 hours of auditory based training; 10 TCT subjects completed an additional 50 hours of training targeting visual and cognitive control processes. Subjects were assessed on neurocognition and functional outcome after training and at 6-month follow-up. RESULTS: Both TCT subject groups showed significant durable gains at 6 months on measures of verbal learning/memory and cognitive control. Only TCT subjects who completed 100 hours of training showed durable gains on processing speed and global cognition, with nonsignificant improvement in functional outcome. Improved cognition was significantly associated with improved functional outcome at 6 months for TCT subjects. CONCLUSIONS: A total of 50 hours of neuroplasticity-based computerized cognitive training appears sufficient to drive improvements in verbal learning/memory and cognitive control that endure 6 months beyond the intervention, but a higher "dose" and more "broad-spectrum" training may be necessary to drive enduring gains in processing speed and global cognition. Training-induced cognitive improvement is related to enhanced functioning at 6 months. These data suggest that (1) higher and "broader" doses of cognitive training may confer the most benefits for schizophrenia patients; (2) the posttraining period opens a critical window for aggressive adjunctive psychosocial rehabilitation.

Using neuroplasticity-based auditory training to improve verbal memory in schizophrenia.

OBJECTIVE: Impaired verbal memory in schizophrenia is a key rate-limiting factor for functional outcome, does not respond to currently available medications, and shows only modest improvement after conventional behavioral remediation. The authors investigated an innovative approach to the remediation of verbal memory in schizophrenia, based on principles derived from the basic neuroscience of learning-induced neuroplasticity. The authors report interim findings in this ongoing study. METHOD: Fifty-five clinically stable schizophrenia subjects were randomly assigned to either 50 hours of computerized auditory training or a control condition using computer games. Those receiving auditory training engaged in daily computerized exercises that placed implicit, increasing demands on auditory perception through progressively more difficult auditory-verbal working memory and verbal learning tasks. RESULTS: Relative to the control group, subjects who received active training showed significant gains in global cognition, verbal working memory, and verbal learning and memory. They also showed reliable and significant improvement in auditory psychophysical performance; this improvement was significantly correlated with gains in verbal working memory and global cognition. CONCLUSIONS: Intensive training in early auditory processes and auditory-verbal learning results in substantial gains in verbal cognitive processes relevant to psychosocial functioning in schizophrenia. These gains may be due to a training method that addresses the early perceptual impairments in the illness, that exploits intact mechanisms of repetitive practice in schizophrenia, and that uses an intensive, adaptive training approach.

Is serum brain-derived neurotrophic factor a biomarker for cognitive enhancement in schizophrenia?

BACKGROUND: Brain-derived neurotrophic factor (BDNF) plays a critical role in neurodevelopment and plasticity; decreased BDNF functioning may contribute to the pathogenesis of schizophrenia. However, BDNF levels are not static; in animal experiments, brain BDNF increases during spatial learning, and in clinical depression, successful antidepressant treatment raises serum BDNF. We asked: would neuroplasticity-based cognitive training in schizophrenia result in increased serum BDNF? METHODS: Fifty-six schizophrenia outpatients and 16 matched healthy comparison subjects were assessed on baseline cognitive performance and serum BDNF. Schizophrenia subjects were randomly assigned to either 50 hours (10 weeks) of computerized auditory training or a computer game control condition, followed by reassessment of cognition and serum BDNF. RESULTS: At baseline, schizophrenia participants had significantly lower-than-normal serum BDNF. Schizophrenia subjects who engaged in computerized cognitive training designed to improve auditory processing showed significant cognitive gains and a significant increase in serum BDNF compared with subjects who played computer games. This increase was evident after 2 weeks of training, and after 10 weeks in the active condition, subjects "normalized" their mean serum BDNF levels, whereas the control group showed no change. In the active condition, change in BDNF was significantly associated with improved quality of life. CONCLUSIONS: Serum BDNF levels are significantly increased in clinically stable, chronically ill schizophrenia subjects after neuroplasticity-based cognitive training, but not after computer games. Serum BDNF levels may serve as a peripheral biomarker for the effects of intensive cognitive training and may provide a useful tool for the evaluation of cognitive enhancement methods in schizophrenia.

The cognitive cost of anticholinergic burden: decreased response to cognitive training in schizophrenia.

OBJECTIVE: Schizophrenia is treated with medications that raise serum anticholinergic activity and are known to adversely affect cognition. The authors examined the relationship between serum anticholinergic activity and baseline cognitive performance and response to computerized cognitive training in outpatients with schizophrenia. METHOD: Fifty-five patients were randomly assigned to either computerized cognitive training or a computer games control condition. A neurocognitive battery based on the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) initiative was performed at baseline and after the intervention. Serum anticholinergic activity, measured at study entry by radioreceptor assay, was available for 49 patients. RESULTS: Serum anticholinergic activity showed a significant negative correlation with baseline performance in verbal working memory and verbal learning and memory, accounting for 7% of the variance in these measures, independent of age, IQ, or symptom severity. Patients in the cognitive training condition (N=25) showed a significant gain in global cognition compared to those in the control condition, but this improvement was negatively correlated with anticholinergic burden. Serum anticholinergic activity uniquely accounted for 20% of the variance in global cognition change, independent of age, IQ, or symptom severity. CONCLUSIONS: Serum anticholinergic activity in schizophrenia patients shows a significant association with impaired performance in MATRICS-based measures of verbal working memory and verbal learning and memory and is significantly associated with a lowered response to an intensive course of computerized cognitive training. These findings underscore the cognitive cost of medications that carry a high anticholinergic burden. The findings also have implications for the design and evaluation of cognitive treatments for schizophrenia.