Teaching Motivational Interviewing to Medical Students to Improve Behavior Change Counseling Skills - Results of a Pilot Test

BACKGROUND: Patient behavior accounts for half or more of the variance in health, disease, mortality and treatment outcome and costs. Counseling using motivational interviewing (MI) effectively improves the substance use and medical compliance behavior of patients. Medical training should include substantial focus on this key issue of health promotion. The objective of the study is to test the efficacy of teaching MI to medical students. METHODS: Thirteen fourth-year medical students volunteered to participate. Seven days before and after an 8-hour interactive MI training workshop, each student performed a video-recorded interview with two standardized patients: a 60 year-old alcohol dependent female consulting a primary care physician for the first time about fatigue and depression symptoms; and a 50 year-old male cigarette smoker hospitalized for myocardial infarction. All 52 videos (13 students×2 interviews before and after training) were independently coded by two blinded clinicians using the Motivational Interviewing Training Integrity (MITI, 3.0). MITI scores consist of global spirit (Evocation, Collaboration, Autonomy/Support), global Empathy and Direction, and behavior count summary scores (% Open questions, Reflection to question ratio, % Complex reflections, % MI-adherent behaviors). A "beginning proficiency" threshold (BPT) is defined for each of these 9 scores. The proportion of students reaching BPT before and after training was compared using McNemar exact tests. Inter-rater reliability was evaluated by comparing double coding, and test-retest analyses were conducted on a sub-sample of 10 consecutive interviews by each coder. Weighted Kappas were used for global rating scales and intra-class correlations (ICC) were computed for behavior count summary scores. RESULTS: The percent of counselors reaching BPT before and after MI training increased significantly for Evocation (15% to 65%, p<.001), Collaboration (27% to 77%, p=.001), Autonomy/Support (15% to 54%, p=.006), and % Open questions (4% to 38%, p=.004). Proportions increased, but were not statistically significant for Empathy (38% to 58%, p=.18), Reflection to question ratio (0% to 15%, p=.12), % Complex reflection (35% to 54%, p=.23), and % MI-adherent behaviors (8% to 15%, p=.69). There was virtually no change for the Direction scale (92% to 88%, p=1.00). The reliability analyses produced mixed results. Weighted kappas for inter-rater reliability ranged from .14 for Direction to .51 for Collaboration, and from .27 for Direction to .80 for Empathy for test-retest. ICCs ranged from .20 for Complex reflections to .89 for Open questions (inter-rater), and from .67 for Complex reflections to .99 for Reflection to question ratio (test-retest). CONCLUSION: This pilot study indicates that a single 8-hour training in motivational interviewing for voluntary fourth-year medical students results in significant improvement of some MI skills. A larger sample of randomly selected medical students observed over longer periods should be studied to test if MI training generalizes to medical students. Inter-rater reliability and test-retest findings indicate a need for caution when interpreting the present results, as well as for more intensive training to help appropriately capture more dimensions of the process in future studies.

Intravenous pamidronate as treatment for osteoporosis after heart transplantation: a prospective study.

Fractures due to osteoporosis are one of the major complications after heart transplantation, occurring mostly during the first 6 months after the graft, with an incidence ranging from 18% to 50% for vertebral fractures. Bone mineral density (BMD) decreases dramatically following the graft, at trabecular sites as well as cortical sites. This is explained by the relatively high doses of glucocorticoids used during the months following the graft, and by a long-term increase of bone turnover which is probably due to cyclosporine. There is some evidence for a beneficial effect on BMD of antiresorptive treatments after heart transplantation. The aim of this study was to assess prospectively the effect on BMD of a 3-year treatment of quarterly infusions of 60 mg of pamidronate, combined with 1 g calcium and 1000 U vitamin D per day, in osteoporotic heart transplant recipients, and that of a treatment with calcium and vitamin D in heart transplant recipients with no osteoporosis. BMD of the lumbar spine and the femoral neck was measured by dual-energy X-ray absorptiometry in all patients every 6 months for 2 years and after 3 years. Seventeen patients, (1 woman, 16 men) aged 46+/-4 years (mean +/- SEM) received only calcium and vitamin D. A significant decrease in BMD was observed after 6 months following the graft, at the lumbar spine (- 6.6%) as well as at the femoral neck (-7.8%). After 2 years, BMD tended to recover at the lumbar spine, whereas the loss persisted after 3 years at the femoral neck. Eleven patients (1 woman and 10 men) aged 46+/-4 years (mean +/- SEM) started treatment with pamidronate on average 6 months after the graft, because they had osteoporosis of the lumbar spine and/or femoral neck (BMD T-score below -2.5 SD). Over the whole treatment period, a continuous increase in BMD at the lumbar spine was noticed, reaching 18.3% after 3 years (14.3% compared with the BMD at the time of the graft). BMD at the femoral neck was lowered in the first year by -3.4%, but recovered totally after 3 years of treatment. In conclusion, a 3-year study of treatment with pamidronate given every 3 months to patients with existing osteoporosis led to a significant increase in lumbar spine BMD and prevented loss at the femoral neck. However, since some of these patients were treated up to 14 months after the transplant, they may already have passed through the phase of most rapid bone loss. In patients who were not osteoporotic at baseline, treatment with calcium and vitamin D alone was not able to prevent the rapid bone loss that occurs immediately after transplantation.

Application of European accounting standards to the public healthcare sector: a comparative study on the application of the European System of Accounts ESA-95 to healthcare centres in the United Kingdom, France and Germany

This report aims to analyse how European accounting standards (European System of Accounts ESA-95) are interpreted and applied to the public healthcare sector, from the standpoint of comparative law. Specifically, the study focuses on the application of ESA-95 to healthcare centres in the United Kingdom, France and Germany, with the aim of reaching useful conclusions for the Public Companies and Consortia (EPIC, for their initials in Catalan) in the Catalan Public Healthcare System.

A novel approach to characterize clonality and differentiation of human melanoma-specific T cell responses: spontaneous priming and efficient boosting by vaccination.

Despite major progress in T lymphocyte analysis in melanoma patients, TCR repertoire selection and kinetics in response to tumor Ags remain largely unexplored. In this study, using a novel ex vivo molecular-based approach at the single-cell level, we identified a single, naturally primed T cell clone that dominated the human CD8(+) T cell response to the Melan-A/MART-1 Ag. The dominant clone expressed a high-avidity TCR to cognate tumor Ag, efficiently killed tumor cells, and prevailed in the differentiated effector-memory T lymphocyte compartment. TCR sequencing also revealed that this particular clone arose at least 1 year before vaccination, displayed long-term persistence, and efficient homing to metastases. Remarkably, during concomitant vaccination over 3.5 years, the frequency of the pre-existing clone progressively increased, reaching up to 2.5% of the circulating CD8 pool while its effector functions were enhanced. In parallel, the disease stabilized, but subsequently progressed with loss of Melan-A expression by melanoma cells. Collectively, combined ex vivo analysis of T cell differentiation and clonality revealed for the first time a strong expansion of a tumor Ag-specific human T cell clone, comparable to protective virus-specific T cells. The observed successful boosting by peptide vaccination support further development of immunotherapy by including strategies to overcome immune escape.

International Union of Pharmacology. LXI. Peroxisome proliferator-activated receptors.

The three peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors of the nuclear hormone receptor superfamily. They share a high degree of structural homology with all members of the superfamily, particularly in the DNA-binding domain and ligand- and cofactor-binding domain. Many cellular and systemic roles have been attributed to these receptors, reaching far beyond the stimulation of peroxisome proliferation in rodents after which they were initially named. PPARs exhibit broad, isotype-specific tissue expression patterns. PPARalpha is expressed at high levels in organs with significant catabolism of fatty acids. PPARbeta/delta has the broadest expression pattern, and the levels of expression in certain tissues depend on the extent of cell proliferation and differentiation. PPARgamma is expressed as two isoforms, of which PPARgamma2 is found at high levels in the adipose tissues, whereas PPARgamma1 has a broader expression pattern. Transcriptional regulation by PPARs requires heterodimerization with the retinoid X receptor (RXR). When activated by a ligand, the dimer modulates transcription via binding to a specific DNA sequence element called a peroxisome proliferator response element (PPRE) in the promoter region of target genes. A wide variety of natural or synthetic compounds was identified as PPAR ligands. Among the synthetic ligands, the lipid-lowering drugs, fibrates, and the insulin sensitizers, thiazolidinediones, are PPARalpha and PPARgamma agonists, respectively, which underscores the important role of PPARs as therapeutic targets. Transcriptional control by PPAR/RXR heterodimers also requires interaction with coregulator complexes. Thus, selective action of PPARs in vivo results from the interplay at a given time point between expression levels of each of the three PPAR and RXR isotypes, affinity for a specific promoter PPRE, and ligand and cofactor availabilities.

Heavy Agricultural Loads on Pavements and Bridges, HR-1073, 1999

During the harvest season in Iowa, it is common to have single axle loads on secondary roads and bridges that are excessive (typical examples are grain carts) and well beyond normal load limits. Even though these excessive loads occur only during a short time of the year, they may do significant damage to pavements and bridges. In addition, the safety of some bridges may be compromised because of the excessive loads, and sometimes there may be little indication to the users that damage may be imminent. At this time there are no Iowa laws regulating axle loads allowed for agricultural equipment. This study looks at the potential problems this may cause on secondary roads and timber stringer bridges. Both highway pavement and timber bridges are evaluated in this report. A section (panel) of Iowa PCC paved county road was chosen to study the effects of heavy agricultural loads on pavements. Instrumentation was applied to the panel and a heavily loaded grain cart was rolled across. The collected data were analyzed for any indication of excessive stresses of the concrete. The second study, concerning excessive loads on timber stringer bridges, was conducted in the laboratory. Four bridge sections were constructed and tested. Two of the sections contained five stringers and two sections had three stringers. Timber for the bridges came from a dismantled bridge, and deck panels were cut from new stock. All timber was treated with creosote. A hydraulic load was applied at the deck mid-span using a foot print representing a tire from a typical grain cart. Force was applied until failure of the system resulted. The collected data were evaluated to provide indications of load distribution and for comparison with expected wheel loads for a typical heavily loaded single axle grain cart. Results of the pavement tests showed that the potential of over-stressing the pavement is a possibility. Even though most of the tension stress levels recorded were below the rupture strength of the concrete, there were a few instances where the indicated tension stress level exceeded the concrete rupture strength. Results of the bridge tests showed that when the static ultimate load capacity of the timber stringer bridge sections was reached, there was sudden loss of capacity. Prior to reaching this ultimate capacity, the load sharing between the stringers was very uniform. The failure was characterized by loss of flexural capacity of the stringers. In all tests, the ultimate test load exceeded the wheel load that would be applied by an 875 bushel single axle grain cart.

Quantitative comparison between simulations of seismic wave propagation in heterogeneous poro-elastic media and equivalent visco-elastic solids for marine-type environments

There is increasing evidence to suggest that the presence of mesoscopic heterogeneities constitutes an important seismic attenuation mechanism in porous rocks. As a consequence, centimetre-scale perturbations of the rock physical properties should be taken into account for seismic modelling whenever detailed and accurate responses of specific target structures are desired, which is, however, computationally prohibitive. A convenient way to circumvent this problem is to use an upscaling procedure to replace each of the heterogeneous porous media composing the geological model by corresponding equivalent visco-elastic solids and to solve the visco-elastic equations of motion for the inferred equivalent model. While the overall qualitative validity of this procedure is well established, there are as of yet no quantitative analyses regarding the equivalence of the seismograms resulting from the original poro-elastic and the corresponding upscaled visco-elastic models. To address this issue, we compare poro-elastic and visco-elastic solutions for a range of marine-type models of increasing complexity. We found that despite the identical dispersion and attenuation behaviour of the heterogeneous poro-elastic and the equivalent visco-elastic media, the seismograms may differ substantially due to diverging boundary conditions, where there exist additional options for the poro-elastic case. In particular, we observe that at the fluid/porous-solid interface, the poro- and visco-elastic seismograms agree for closed-pore boundary conditions, but differ significantly for open-pore boundary conditions. This is an important result which has potentially far-reaching implications for wave-equation-based algorithms in exploration geophysics involving fluid/porous-solid interfaces, such as, for example, wavefield decomposition.

Constitution, Diversification and Normalisation of a Health Problem: Organising the Fight against AIDS in Switzerland (1984-2005)

The article traces the formation, diversification and normalization of the AIDS cause in Switzerland. Particular emphasis is placed on interactions between the medical field, public authorities and associative space, the latter being understood as the place where individual and collective actors compete to define the cause. The authors argue that the major phases in the structuring of the struggle, the pace of state intervention and the creation of a multi-organizational field, can only be understood if one adopts a 'configurational perspective' attentive to the manner in which, in a given context and under the effect of particular constraints, key actors strategically interact and contribute to transforming their environment and their chances of reaching their goals. This approach takes into account the changing socio-biological characteristics of those who have committed themselves to the cause. In turn, internal movement divisions about how to respond to the epidemic as well as the changing perceptions of the disease have modified the opportunities for commitment, encouraging certain individual kinds of people and excluding others.

In situ fluorescence imaging of glutamate-evoked mitochondrial Na+ responses in astrocytes.

Astrocytes can experience large intracellular Na+ changes following the activation of the Na+-coupled glutamate transport. The present study investigated whether cytosolic Na+ changes are transmitted to mitochondria, which could therefore influence their function and contribute to the overall intracellular Na+ regulation. Mitochondrial Na+ (Na+(mit)) changes were monitored using the Na+-sensitive fluorescent probe CoroNa Red (CR) in intact primary cortical astrocytes, as opposed to the classical isolated mitochondria preparation. The mitochondrial localization and Na+ sensitivity of the dye were first verified and indicated that it can be safely used as a selective Na+(mit) indicator. We found by simultaneously monitoring cytosolic and mitochondrial Na+ using sodium-binding benzofuran isophthalate and CR, respectively, that glutamate-evoked cytosolic Na+ elevations are transmitted to mitochondria. The resting Na+(mit) concentration was estimated at 19.0 +/- 0.8 mM, reaching 30.1 +/- 1.2 mM during 200 microM glutamate application. Blockers of conductances potentially mediating Na+ entry (calcium uniporter, monovalent cation conductances, K+(ATP) channels) were not able to prevent the Na+(mit) response to glutamate. However, Ca2+ and its exchange with Na+ appear to play an important role in mediating mitochondrial Na+ entry as chelating intracellular Ca2+ with BAPTA or inhibiting Na+/Ca2+ exchanger with CGP-37157 diminished the Na+(mit) response. Moreover, intracellular Ca2+ increase achieved by photoactivation of caged Ca2+ also induced a Na+(mit) elevation. Inhibition of mitochondrial Na/H antiporter using ethylisopropyl-amiloride caused a steady increase in Na+(mit) without increasing cytosolic Na+, indicating that Na+ extrusion from mitochondria is mediated by these exchangers. Thus, mitochondria in intact astrocytes are equipped to efficiently sense cellular Na+ signals and to dynamically regulate their Na+ content.

Increased vulnerability to kainic acid-induced epileptic seizures in mice underexpressing the scaffold protein Islet-Brain 1/JIP-1.

Islet-Brain 1, also known as JNK-interacting protein-1 (IB1/JIP-1) is a scaffold protein mainly involved in the regulation of the pro-apoptotic signalling cascade mediated by c-Jun-N-terminal kinase (JNK). IB1/JIP-1 organizes JNK and upstream kinases in a complex that facilitates JNK activation. However, overexpression of IB1/JIP-1 in neurons in vitro has been reported to result in inhibition of JNK activation and protection against cellular stress and apoptosis. The occurrence and the functional significance of stress-induced modulations of IB1/JIP-1 levels in vivo are not known. We investigated the regulation of IB1/JIP-1 in mouse hippocampus after systemic administration of kainic acid (KA), in wild-type mice as well as in mice hemizygous for the gene MAPK8IP1, encoding for IB1/JIP-1. We show here that IB1/JIP-1 is upregulated transiently in the hippocampus of normal mice, reaching a peak 8 h after seizure induction. Heterozygous mutant mice underexpressing IB1/JIP-1 showed a higher vulnerability to the epileptogenic properties of KA, whereas hippocampal IB1/JIP-1 levels remained unchanged after seizure induction. Subsequently, an increasing activation of JNK in the 8 h following seizure induction was observed in IB1/JIP-1 haploinsufficient mice, which also underwent more severe excitotoxic lesions in hippocampal CA3, as assessed histologically 3 days after KA administration. Taken together, these data indicate that IB1/JIP-1 in hippocampus participates in the regulation of the neuronal response to excitotoxic stress in a level-dependent fashion.

In vivo and in vitro development of alpha-MSH and ACTH in the embryonic and postnatal rat brain.

The appearance of immunoreactive alpha-melanotropin (alpha-MSH) and adrenocorticotropin (ACTH) during development was studied in 3 areas of the rat brain--cerebral hemispheres, midbrain and hindbrain--from embryonic day (ED) 13-14 until day 21 postnatally. The alpha-MSH content in vivo was always highest in the midbrain; a peak content at birth was followed by a transient decline and a later, higher plateau from postnatal day 7 onwards. The alpha-MSH content in the cerebral hemispheres rose progressively after birth reaching a peak at day 21. Values in the hindbrain rose at day 3 and changed relatively sue taken at ED 15-16 showed a gradual increase in alpha-MSH content over the 20 days. The alpha-MSH content of hindbrain cultures remained at constant low levels, while no alpha-MSH was detectable in cerebral hemisphere cultures. ACTH appeared in vivo earlier than alpha-MSH and was detectable in embryonic brains at ED 13-14. A transient rise was seen at ED 17-18 and major peaks at birth, day 2 and day 3, in the midbrain, hemispheres and hindbrain, respectively. In vitro, the ACTH content increased in all brain regions during the first 5 days in culture and showed no further change thereafter. Comparisons of the in vivo and in vitro development of alpha-MSH and ACTH demonstrate that (i) these two peptide systems are independent in respect to their localization and time of appearance; (ii) they undergo maturation both in vivo and in vitro; (iii) epigenetic factors, such as interactions with other neurotransmitter systems may modulate the developmental pattern of these two peptides.

Cobertura y desamparo: garantías jurídicas de los españoles en el Perú (1870-1945) = Coverage and helplessness: legal guarantees of the spanish in Peru (1870-1945)

The archives of the Prefecture of the Peruvian Ministry of Foreign Affairs provide a perspective from which to reconstruct the broad range of legal circumstances in which Spanish residents in various regions of the country find themselves immersed (assets of relatives who have died without wills or family in Peru, political conflicts, legal problems -whether criminal or civil as a result of business activities- or the requested intervention ofconsular authorities when decisions considered detrimental to their compatriots are made by prefects and sub-prefects). The legal framework protecting Spanish nationals in Peru is analysed to understand the mechanisms of immigration in the country and the mechanisms that led them to keep their Spanish nationality, even after establishing wide-reaching family and business interests

Effects of coastal submarine canyons on tsunami propagation and impact

We analyse the variations produced on tsunami propagation and impact over a straight coastline because of the presence of a submarine canyon incised in the continental margin. For ease of calculation we assume that the shoreline and the shelf edge are parallel and that the incident wave approaches them normally. A total of 512 synthetic scenarios have been computed by combining the bathymetry of a continental margin incised by a parameterised single canyon and the incident tsunami waves. The margin bathymetry, the canyon and the tsunami waves have been generated using mathematical functions (e.g. Gaussian). Canyon parameters analysed are: (i) incision length into the continental shelf, which for a constant shelf width relates directly to the distance from the canyon head to the coast, (ii) canyon width, and (iii) canyon orientation with respect to the shoreline. Tsunami wave parameters considered are period and sign. The COMCOT tsunami model from Cornell University was applied to propagate the waves across the synthetic bathymetric surfaces. Five simulations of tsunami propagation over a non-canyoned margin were also performed for reference. The analysis of the results reveals a strong variation of tsunami arrival times and amplitudes reaching the coastline when a tsunami wave travels over a submarine canyon, with changing maximum height location and alongshore extension. In general, the presence of a submarine canyon lowers the arrival time to the shoreline but prevents wave build-up just over the canyon axis. This leads to a decrease in tsunami amplitude at the coastal stretch located just shoreward of the canyon head, which results in a lower run-up in comparison with a non-canyoned margin. Contrarily, an increased wave build-up occurs on both sides of the canyon head, generating two coastal stretches with an enhanced run-up. These aggravated or reduced tsunami effects are modified with (i) proximity of the canyon tip to the coast, amplifying the wave height, (ii) canyon width, enlarging the areas with lower and higher maximum height wave along the coastline, and (iii) canyon obliquity with respect to the shoreline and shelf edge, increasing wave height shoreward of the leeward flank of the canyon. Moreover, the presence of a submarine canyon near the coast produces a variation of wave energy along the shore, eventually resulting in edge waves shoreward of the canyon head. Edge waves subsequently spread out alongshore reaching significant amplitudes especially when coupling with tsunami secondary waves occurs. Model results have been groundtruthed using the actual bathymetry of Blanes Canyon area in the North Catalan margin. This paper underlines the effects of the presence, morphology and orientation of submarine canyons as a determining factor on tsunami propagation and impact, which could prevail over other effects deriving from coastal configuration.

06015-008 Bear Creek Watershed Final Report

Big Bear Creek is the upper portion of Bear Creek which drains 26,734 acres and ends at the Highway 136 crossing of Bear Creek. Bear Creek flows into the section of the Maquoketa River, which is on the EPA’s 303(d) List of Impaired Waters. Monitoring by the Iowa DNR indicates that Bear Creek is contributing significant amounts of sediment and nutrients to the Maquoketa River. The primary use of land in the Big Bear Creek Watershed is row crop production. A roadside survey completed by Anamosa Field Office Staff indicated that 123,747 tons/yr. of sediment was being lost due to sheet and rill erosion only. The sediment delivered to Big Bear Creek is 24,447 tons/yr. Based on this data, 34,226 lbs. of Phosphorus is reaching the stream per year. With the added amount of sediment and phosphorus delivery through gully and streambank erosion, one can clearly see that the water quality in Bear Creek is severely impaired. The Big Bear Watershed Project will work to reduce the sediment and phosphorus delivered to the stream by 30% through the installation of practices that trap sediment and reduce erosion.

07021-008 Sand Creek Watershed Final Report

Sand Creek is the most significant recreational fishery in Delaware County because of its location to Manchester and Lake Delhi. It is a feeder stream for game fish to the main stem of the Maquoketa River which is limited by the dams at Manchester and Lake Delhi. Sand Creek encompasses 16,045 acres and is dominated by row crop agriculture. It is being impacted by sediment, nutrients and E coli bacteria. Sand Creek will be a good example for habitat impaired watershed. The purpose of this project is to decrease the amount of sediment and nutrients reaching Sand Creek and to increase the habitat in Sand Creek to make it a better spawning and growing area for the fish and the food chain for the fish. The objectives of this project are to reduce sediment delivery by 40%, to improve in-stream habitat on 40% of identified critical areas and implement an information/education program. The project will install 3,800 acres of new no-till planting, 6 water and sediment control basins, 4,000 feet of terraces, 20,000 feet of improved or new waterways, 3,200 feet of streambank/ habitat enhancement, 4,500 feet of livestock exclusion fencing and 6 acres of wetlands.