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Advanced practice registered nurses (APRNs) have positioned themselves to serve an integral role in national health care reform. This article addresses both the policy and the process to develop this policy that has placed them in a strategic position. A successful transformation of the nation's health system will require utilization of all clinicians, particularly primary care providers, to the full extent of their education and scope of practice. APRNs are highly qualified clinicians who provide cost-effective, accessible, patient-centered care and have the education to provide the range of services at the heart of the reform movement, including care coordination, chronic care management, and wellness and preventive care. The APRN community faces many challenges amidst the opportunities of health reform. However, the APRN community's triumph in reaching consensus on APRN regulation signifies a cohesive approach to overcoming the obstacles. The consensus model for APRN regulation, endorsed by 44 national nursing organizations, will serve as a beacon for nursing, as well as a guidepost for consumers and policymakers, on titling, education, certification, accreditation, and licensing for all four APRN roles.Copyright © 2009 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Aim The clinical nurse leader (CNL(R)) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice. Background Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources. Method A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region. Results Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model. Conclusions With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs. Implications for nursing management Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings. [ABSTRACT FROM AUTHOR]

Background. Efficient peritoneal dialysis depends on an intact layer of mesothelial cells that line the peritoneal membrane. This layer is disrupted in patents on continuous ambulatory peritoneal dialysis during episodes of peritonitis (acute injury) and replaced by fibrous tissue during extended dialysis (chronic injury). Little is understood of human peritoneal mesothelial cell (HPMC) responses to wounding and episodes of peritonitis. [ABSTRACT FROM PUBLISHER]

Growing evidence suggests that conceptual knowledge influences emotion perception, yet the neural mechanisms underlying this effect are not fully understood. Recent studies have shown that brain representations of facial emotion categories in visual-perceptual areas are predicted by conceptual knowledge, but it remains to be seen if auditory regions are similarly affected. Moreover, it is not fully clear whether these conceptual influences operate at a modality-independent level. To address these questions, we conducted a functional magnetic resonance imaging study presenting participants with both facial and vocal emotional stimuli. This dual-modality approach allowed us to investigate effects on both modality-specific and modality-independent brain regions. Using univariate and representational similarity analyses, we found that brain representations in both visual (middle and lateral occipital cortices) and auditory (superior temporal gyrus) regions were predicted by conceptual understanding of emotions for faces and voices, respectively. Additionally, we discovered that conceptual knowledge also influenced supra-modal representations in the superior temporal sulcus. Dynamic causal modeling revealed a brain network showing both bottom-up and top-down flows, suggesting a complex interplay of modality-specific and modality-independent regions in emotional processing. These findings collectively indicate that the neural representations of emotions in both sensory-perceptual and modality-independent regions are likely shaped by each individual's conceptual knowledge., (© 2024 The Author(s). Human Brain Mapping published by Wiley Periodicals LLC.)

Nursing is the largest health profession, with nearly 4 million providers practicing across acute, primary, and public health care settings. In response to the pandemic, nursing schools halted on-site course delivery and redesigned programs to attenuate risks to students and faculty. Key challenges faced by schools included financial cutbacks, rapid increases in online learning technology, maintaining student academic progression, disruption to clinical learning opportunities, and meeting accreditation standards, while addressing the stress and loss experienced by faculty, staff, and students. Despite challenges, nursing organizations provided guidance for decision making, new learning resources, and faculty development opportunities. Schools of nursing leveraged their resources to redesign nursing curricula, strengthen partnerships for student clinical experiences, and address needs of the community. Nursing education will look different from its prepandemic profile in the future. Lessons learned during the pandemic point to gaps in nursing education, particularly related to disaster and public health preparedness, health equity, and technology. The American Association of Colleges of Nursing's new Essentials-standards for professional nursing education-were finalized during the pandemic and reflect these lessons. The need for nurse scientists to conduct emergency response research was made evident. The importance of strong academic-practice partnerships was highlighted for rapid communication, flexibility, and responses to dynamic environments. For the future, nursing education and practice must collaborate to ensure that students and practicing nurses are prepared to address emergencies and pandemics, as well as the needs of vulnerable populations., Competing Interests: Other disclosures: The authors of this paper have no personal, professional, or monetary conflicts of interest to disclose., (Copyright © 2021 by the Association of American Medical Colleges.)

Hamstring muscle injury is highly prevalent in sports involving repeated maximal sprinting. Although neuromuscular fatigue is thought to be a risk factor, the mechanisms underlying the fatigue response to repeated maximal sprints are unclear. Here, we show that repeated maximal sprints induce neuromuscular fatigue accompanied with a prolonged strength loss in hamstring muscles. The immediate hamstring strength loss was linked to both central and peripheral fatigue, while prolonged strength loss was associated with indicators of muscle damage. The kinematic changes immediately after sprinting likely protected fatigued hamstrings from excess elongation stress, while larger hamstring muscle physiological cross-sectional area and lower myoblast:fibroblast ratio appeared to protect against fatigue/damage and improve muscle recovery within the first 48 h after sprinting. We have therefore identified novel mechanisms that likely regulate the fatigue/damage response and initial recovery following repeated maximal sprinting in humans.

The nursing profession is tasked with identifying and evaluating models of care with potential to add value to health care delivery. In consideration of this goal, we describe the Clinical Nurse Leader (CNL) initiative and the activities of a national-level CNL research collaborative. The CNL initiative, launched by the American Association of Colleges of Nursing in collaboration with education and healthcare leaders, has delineated CNL education curriculum and practice competencies, and fostered the creation of academic-practice-policy partnerships to pilot CNL integration into frontline nursing care delivery. The partnership has evolved into an Agency for Healthcare Research and Quality affiliate practice-based research network, the CNL Research Collaborative, which links research, policy, education, and practice stakeholders to advance the CNL evidence base. We summarize foundational CNLRC research to explain CNL practice, quantify CNL effectiveness, and bring clarity to how CNLs can be implemented to consistently influence care, quality, and safety., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The crystal structures of 3,4,6a,7,10,10a-hexahydro-7,10-epoxypyrimido[2,1-a]isoindol-6(2H)-one, C11H12N2O2, and 2-(2-aminoethyl)-3a,4,7,7a-tetrahydro-1H-4,7-epoxyisoindole-1,3(2H)-dione, C10H12N2O3, two tricyclic imides, show one and two molecules in the asymmetric unit, respectively. Intermolecular hydrogen-bonding interactions are observed in both compounds.

Two hexanuclear 3d-4f Ni-Eu and Cu-Eu complexes [Eu(4)Ni(2)L(2)(OAc)(12)(EtOH)(2)] (1) and [Eu(4)Cu(2)L(2)(OAc)(12)]·2H(2)O (2) are reported which are formed from the salen type Schiff-base ligand H(2)L (H(2)L = N,N'-bis(3-methoxysalicylidene)butane-1,4-diamine). In both complexes, four Eu(3+) cations are bridged by eight OAc(-) groups and the chain is terminated at each end by two ML (M = Ni and Cu) units. The structures of 1 and 2 were determined by single crystal X-ray crystallographic studies and the luminescence properties of the free ligand and metal complexes in solution were measured.

Advanced practice registered nurses (APRNs) represent a crucial resource to meeting growing health care needs. Such resources must be used to the full extent and in the most effective way possible. Through the development of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education (LACE), nursing is assuming a leadership role within the health care system and participating as an equal partner in redesigning health care. When fully implemented, the Consensus Model will allow APRNs to practice to the full scope of their education and more easily move from one state to another, increasing access to quality health care for all populations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In this article, we review a newly developed evidence-based immersive simulation experience for use with health care personnel and students. The article provides information necessary for infection control professionals to understand the development process of the training. Evidence supporting the use of such training is provided, and opportunities to integrate this training into the health care setting and classroom are discussed., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.)

Three new lanthanide 1-D coordination polymers ({[Ln(2)(H(2)L)(OAc)(6)]·EtOH·2H(2)O}(n) (Ln = Eu (1), Er (2)) and {YbNiLCl(OAc)(2)(H(2)O)}(n) (3)) and a heterobinuclear complex [YbNiLCl(3)(H(2)O)(3)] (4) are reported which are formed from salen type Schiff-base ligands H(2)L (H(2)L = N,N'-bis(3-methoxysalicylidene)butane-1,4-diamine). The polymeric structures are formed by bridging H(2)L units in the case of 1 and 2, and by acetate groups in 3. The structures of 1-4 were determined by single crystal X-ray crystallographic studies and their luminescence properties in MeCN solution were determined.

In the title complex, [Pd(C(34)H(33)NP(2))(C(17)H(14)O)], the Pd(0) atom is coordinated in a trigonal planar geometry formed by two P atoms of a bis-[(diphenyl-phosphino)eth-yl]aniline ligand and a C=C (η(2)) bond involving the C atoms that are in the α,β positions relative to the central ketone of the dibenzyl-ideneacetone ligand.

Purpose: To answer the clinical question: In adults over 65 years of age with persistent atrial fibrillation (AF), do pharmacological rhythm-control agents offer a lower risk of stroke when compared to pharmacological rate-control agents? To address whether or not rhythm control improves quality of life compared to rate control was a secondary outcome question., Data Sources: Comprehensive review of pharmacological treatment of AF on stroke and quality of life outcomes; a meta-analysis of five randomized controlled trials., Conclusions: Research suggests that all AF patients should continue anticoagulant therapy long term, even if they convert to sinus rhythm. Adequate rate control or rhythm control does not appear to reduce the need for lifelong antithrombotic therapy., Implications for Practice: While an individualized treatment approach to AF is essential, a strong focus in the care of the older adult with AF should be on maintaining therapeutic International Normalized Ratio (INR) levels. Improved quality of life is more dependent on reducing thromboembolic events and subsequent sequelae of stroke., (©2011 The Author(s) Journal compilation ©2011 American Academy of Nurse Practitioners.)

Across the health disciplines, clinical prevention and population health activities increasingly are recognized as integral to the practice of their professions. Most of the major clinical health professions organizations have begun incorporating clinical prevention and population health activities and services into educational curricula, the accreditation process, and training to affect clinical practice. Students in each health profession need to understand the roles played by those in other health professions. This understanding is a prerequisite for better communication and collaboration among the professions and for accomplishing the educational objectives included in Healthy People 2020 and organized using the Education for Health framework. To help accomplish these goals, this article summarizes each health profession's contributions to the field of prevention and population health, explains how the profession contributes to interprofessional education or practice, reviews specific challenges faced in the provision of these types of services, and highlights future opportunities to expand the provision of these services. Several general themes emerge from a review of the different health professions' contributions to this area. First, having well-trained prevention and population health professionals outside of the traditional public health field is important because prevention and population health activities occur in almost all healthcare settings. Second, because health professionals work in interprofessional teams in the clinical setting, training and educating all health professionals within interprofessional models would be prudent. Third, in order to expand services, reimbursement for health promotion counseling, preventive medicine, and disease management assistance needs to be appropriate for each of the professions., (Published by Elsevier Inc.)

The Healthy People Curriculum Task Force was established in 2002 to encourage implementation of Healthy People 2010 Objective 1.7: "To increase the proportion of schools of medicine, schools of nursing and health professional training schools whose basic curriculum for healthcare providers includes the core competencies in health promotion and disease prevention." In 2004, the Task Force published a Clinical Prevention and Population Health Curriculum Framework ("Framework") to help each profession assess and develop more robust approaches to this content in their training. During the 6 years since the publication of the Framework, the Task Force members introduced and disseminated it to constituents, facilitated its implementation at member schools, integrated it into initiatives that would influence training across schools, and adapted and applied the Framework to meet the data needs of the Healthy People 2010 Objective 1.7. The Framework has been incorporated into initiatives that help promote curricular change, such as accreditation standards and national board examination content, and efforts to disseminate the experiences of peers, expert recommendations, and activities to monitor and update curricular content. The publication of the revised Framework and the release of Healthy People 2020 (and the associated Education for Health Framework) provide an opportunity to review the efforts of the health professions groups to advance the kind of curricular change recommended in Healthy People 2010 and Healthy People 2020 and to appreciate the many strategies required to influence health professions curricula., (Copyright © 2011 American Journal of Preventive Medicine. All rights reserved.)

A bromo tricarbonyl rhenium(I) complex with a thiophene-functionalized bis(pyrazolyl) pyridine ligand (L), ReBr(L)(CO)(3) (1), has been synthesized and characterized by variable temperature and COSY 2-D (1)H NMR spectroscopy, single-crystal X-ray diffraction, and photophysical methods. Complex 1 is highly luminescent in both solution and solid-state, consistent with phosphorescence from an emissive (3)MLCT excited state with an additional contribution from a LC (3)(pi-->pi*) transition. The single-crystal X-ray diffraction structure of the title ligand is also reported.

In the crystal structure of the title complex, K[Eu(C(5)HF(6)O(2))(2)(C(10)H(6)F(3)O(2))(2)], the Eu(III) ion is in a slightly distorted square-anti-prismatic coordination geometry which is defined by eight O atoms of the anionic β-diketone ligands. The two K(+) ions lie on crystallographic inversion centers. The Eu-O bond distances are in the range 2.294 (5)-2.413 (5) Å. The crystal used was a non-merohedral twin, the ratio of the twin domains being 0.5236 (5):0.4764 (5).

In the title dinuclear complex, [CuGd(C(20)H(22)N(2)O(4))(NO(3))(3)], the Cu(II) ion is located in the inner N(2)O(2) cavity of the Schiff base ligand and adopts a distorted square-planar geometry. The Gd(III) ion is ten-coordinate being bound to ten O atoms, four from the Schiff base ligand and six from three bidentate nitrate anions. The Cu(II) and Gd(III) ions are linked by two phenolate O atoms of the Schiff base ligand, with a separation of 3.5185 (9) Å.

A new class of highly luminescent nine-coordinated europium(III) tris(beta-diketonate) bis[(ethylenedioxythiophene)pyrazolyl]pyridine (L) complexes has been synthesized and the photophysical properties studied: 1 = Eu(hfac)(3)(L); 2 = Eu(tta)(3)(L); 3 = Eu(btfac)(3)(L). The solid-state structure of complex 1 has been determined by single-crystal X-ray crystallography and shows the geometry of the local coordination environment around the Eu(III) ion to be a slightly distorted tricapped trigonal prism. Luminescence lifetimes were found to be 581, 473, and 576 micros for complexes 1-3, respectively. Absolute quantum yields for complexes 1-3 were measured as 16.4 +/- 1.4%, 27.5 +/- 1.2%, and 22.2% +/- 0.3%, respectively.

Data from the 2005 Monitoring the Future survey were used to examine relationships between school-related factors and high school seniors' lifetime methamphetamine use. The study applied logistic regression techniques to evaluate effects of social bonding variables and social learning variables on likelihood of lifetime methamphetamine use. The results confirmed that likelihood of such use was higher when social bonding factors were weak and social learning factors were strong. Results also showed the social bonds' impact to be mediated by social learning factors. Policy implications are discussed briefly.

An Internet mapping application is being introduced in conjunction with the release of the second version of the Community Health Status Indicators (CHSI) Report. The CHSI Geographic Information Systems (GIS) Analyst is an easy-to-use Web-based mapping application that provides new opportunities for the visualization, exploration, and understanding of the indicators. Indicators can be mapped and compared visually to other areas, including peer counties and neighboring counties. The Web site is accessible from a link on the CHSI Report Web site or directly from an Internet Web browser. In this paper, we discuss the conceptualization and implementation of this public health mapping application.

Critical shortages in the nursing workforce pose life-and-death decisions for health care institutions. Similar shortages of nursing faculty, particularly nursing faculty with doctoral degrees, confront schools of nursing. Competition among health care institutions and schools of nursing for master's- and doctorally prepared nurses is fierce. Credentialed minority faculty are in even greater demand. Rising salaries and increasing opportunities outside of academia present significant barriers to schools of nursing seeking to recruit and retain minority nursing faculty. Challenges to increasing the number of minority nursing faculty surface very early in the pipeline and include competition among health professions and other disciplines for minority students. Successful long-term strategies to increase the number of minority nursing faculty must include strategies to attract higher numbers of minority students into baccalaureate, master's, and doctoral nursing programs. Several initiatives to increase minority student enrollment in the health professions are highlighted. Finally, strategies for recruiting, empowering, and retaining minority nursing faculty by schools of nursing are presented.

Calls to transform the healthcare system and evolve the preparation of healthcare professionals have increased in recent years. In response to the concerns and recommendations voiced in the series of national reports, the American Association of Colleges of Nursing (AACN) Board of Directors initiated a series of task forces from 1999-present. The pilot Clinical Nurse Leader (CNL(trade mark)) initiative which grew out of the work of the task forces represents an exemplary national partnership between nursing education and practice. The CNL is a new nursing role being developed and piloted by the AACN in collaboration with education and practice leaders. An AACN task force, comprised of equal representation from education and practice, is currently working with 86 partnerships, including 92 schools of nursing and 191 health care institutions, to implement the CNL initiative. All of the partnerships have committed to collaboratively develop a master's CNL degree program and to transform one or more units within the healthcare institution utilizing the new CNL role. Early patient care outcomes from the initiative are positive. However, one additional outcome realized from the initiative has been the coming together of nursing education and practice to achieve a common goal-improved patient care outcomes.

Nurses, because of their nursing education and perspective practicing in multiple roles and settings, are uniquely qualified for mass casualty preparedness and response. Educating the current 2.7 million registered nurses and all future nursing graduates is a daunting task. Nursing education must ensure that graduates are prepared with the necessary knowledge and skills for mass casualty incidents. Four key entities are essential for education's successful implementation of disaster preparedness: education and professional organizations, accreditation and regulatory bodies, schools of nursing, and continuing education providers. This article examines the role each of these key entities plays in the development of a nursing workforce prepared for mass casualty response. In addition, the International Nursing Coalition for Mass Casualty Education (INCMCE) registered nurse (RN) competencies for mass casualty incidents and guidelines for integrating these competencies into the nursing education curricula are presented.

Background: Connective tissue growth factor (CTGF) is a fibrogenic cytokine that is highly expressed in wound healing and fibrotic lesions. The role of transforming growth factor-beta (TGF-beta) in fibrosis is well documented, and the emerging understanding that its fibrogenic actions are mediated through CTGF has provided an attractive target molecule for the modulation of matrix overproduction in fibrotic disease. The involvement of CTGF in the pathogenesis of peritoneal membrane fibrosis in peritoneal dialysis (PD) patients has not been investigated, and so the aim of this study was to ascertain whether CTGF is produced in the peritoneal cavity of PD patients and to investigate its regulation by cytokines., Methods: Reverse transcription-polymerase chain reaction (RT-PCR), Northern blotting, and Western blotting were used to study CTGF expression by cultured human peritoneal mesothelial cells (HPMC) from peritoneal dialysis patients. Western blotting was used to detect CTGF expression in spent peritoneal dialysate from patients with and without peritonitis., Results: RT-PCR analysis demonstrated the expression of CTGF mRNA in cultured primay HPMCs isolated from spent peritoneal effluent. The production of the major 36 to 38 kD CTGF protein doublet by HPMC in addition to a 23 to 25 kD proteolytically processed form was confirmed by Western blotting. Several molecular weight forms of CTGF (18 to 38 kD) were also detected by Western blotting in peritoneal dialysate, with levels markedly elevated during episodes of peritonitis. Northern and Western blot analysis revealed that CTGF mRNA and protein production by HPMC was up-regulated by TGF-beta, with mRNA levels significantly increasing above the control (P < 0.01). In contrast, platelet-derived growth factor (PDGF), epidermal growth factor (EGF), and tumor necrosis factor-alpha (TNF-alpha) had no measurable effects on CTGF mRNA expression., Conclusion: These results are the first to demonstrate the production of CTGF by HPMC and its presence in the peritoneal cavity of PD patients. The marked increase in CTGF levels by factors implicated in the development of peritoneal membrane fibrosis suggests its involvement in the underlying pathophysiologic mechanism(s).

Objective: To investigate the expression and regulation of defensins in the peritoneal cavity of peritoneal dialysis (PD) patients., Design: The presence of defensins in the peritoneal cavity was assessed using reverse transcription polymerase chain reaction (RT-PCR). In vivo defensin expression was analyzed in human peritoneal membrane biopsies and in peritoneal cavity leukocytes isolated from spent dialysate. Defensin expression in vitro was assessed in cultured human peritoneal mesothelial cells (HPMC) and confirmed with PCR Southern blot and DNA sequencing. The effect of tumor necrosis factor alpha (TNFalpha) and epidermal growth factor (EGF) on beta2 defensin expression in HPMC was analyzed by Northern blot analysis and RT-PCR respectively., Results: Both alpha and beta classes of defensins are expressed in the peritoneal cavity of PD patients. Messenger RNA for the alpha-defensin human neutrophil peptide 3 and for beta-defensin-1 (hbetaD-1) were found in preparations containing predominantly peritoneal leukocytes, whereas beta-defensin-2 (hbetaD-2) is expressed by HPMC. HPMC isolated from different individuals displayed variability in both basal hbetaD-2 expression and in response to stimulation by TNFalpha. Conversely, EGF consistently downregulated the level of hbetaD-2 message in HPMC., Conclusion: Alpha- and beta-defensins are expressed in the peritoneal cavity, and hbetaD-2 is the main defensin present in the peritoneal membrane. Variable levels of expression of hbetaD-2 by mesothelial cells were seen, with evidence of regulation by cytokines and growth factors. This provides evidence for a previously unknown mechanism of innate immunity at that site.

Background: The mesothelial cell monolayer lining the peritoneal membrane needs constant repair in response to peritonitis and to the toxicity of peritoneal dialysate. In many continuous ambulatory peritoneal dialysis (CAPD) patients, the repair process progressively fails, and membrane dysfunction and fibrosis occur. Heparin-binding epidermal growth factor-like growth factor (HB-EGF) has an important role in wound repair and is also fibrogenic, and thus may be involved in these processes in the peritoneal cavity., Methods: The presence of HB-EGF, its receptors, and its associated proteins was determined in peritoneal membrane biopsies, cultured human peritoneal mesothelial cells (HPMCs), and peritoneal macrophages from CAPD patients by reverse transcription-polymerase chain reaction, flow cytometry, and immunofluorescence immunocytochemistry with confocal microscopy. HB-EGF effects on HPMC adhesion were measured by a static adhesion assay, on integrin expression by flow cytometry, and on migration by wound healing and chemotaxis assays., Results: HB-EGF, its receptors HER-1 and HER-4, and the associated proteins CD9, CD44, and integrin alpha(3)beta(1) were expressed by HPMCs and peritoneal macrophages. HB-EGF colocalized with HER-1 and HER-4 in HPMCs and induced their adhesion to collagen type I, expression of beta 1 integrins, and migration., Conclusions: HB-EGF is produced by cells in the peritoneal cavity of CAPD patients and has functional effects on HPMCs that would facilitate repair of the mesothelial layer.

In a rare study of effectiveness of an interviewing method, we previously reported a randomized controlled trial demonstrating that training in a step-by-step patient-centered interviewing method improved residents' knowledge, attitudes, and skills and had a consistently positive effect on trained residents' patients. For those who wish to use this evidence-based patient-centered method as a template for their own teaching, we describe here for the first time our training program--and propose that the training can be adapted for students, physicians, nurse practitioners, physician assistants, and other new learners as well. Training was skills-oriented and experiential, fostered positive attitudes towards patient-centered interviewing, and used a learner-centered approach which paid special attention to the teacher-resident relationship and to the resident's self-awareness. Skills training was guided by a newly identified patient-centered interviewing method that described the step-by-step use of specific behaviors.

Background: Interviewing and the physician-patient relationship are crucial elements of medical care, but residencies provide little formal instruction in these areas., Objective: To determine the effects of a training program in interviewing on 1) residents' attitudes toward and skills in interviewing and 2) patients' physical and psychosocial well-being and satisfaction with care., Design: Randomized, controlled study., Setting: Two university-based primary care residencies., Participants: 63 primary care residents in postgraduate year 1., Intervention: A 1-month, full-time rotation in interviewing and related psychosocial topics., Measurements: Residents and their patients were assessed before and after the 1-month rotation. Questionnaires were used to assess residents' commitment to interviewing and psychosocial medicine, estimate of the importance of such care, and confidence in their ability to provide such care. Knowledge of interviewing and psychosocial medicine was assessed with a multiple-choice test. Audiotaped interviews with real patients and videotaped interviews with simulated patients were rated for specific interviewing behaviors. Patients' anxiety, depression, and social dysfunction; role limitations; somatic symptom status; and levels of satisfaction with medical visits were assessed by questionnaires and telephone interviews., Results: Trained residents were superior to untrained residents in knowledge (difference in adjusted post-test mean scores, 15.7% [95% CI, 11% to 20%]); attitudes, such as confidence in psychological sensitivity (difference, 0.61 points on a 7-point scale [CI, 0.32 to 0.91 points]); somatization management (difference, 0.99 points [CI, 0.64 to 1.35 points]); interviewing of real patients (difference, 1.39 points on an 11-point scale [CI, 0.32 to 2.45 points]); and interviewing (data gathering) of simulated patients (difference, 2.67 points [CI, 1.77 to 3.56 points]). Mean differences between the study groups were consistently in the appropriate direction for patient satisfaction and patient well-being, but effect sizes were too small to be considered meaningful., Conclusion: An intensive 1-month training rotation in interviewing improved residents' knowledge about, attitudes toward, and skills in interviewing.

Several misunderstandings regarding the question of when to stop treatment are examined by considering two frameworks for sorting out the different dimensions of the question. One framework addresses what is meant, and what is not meant, by 'stopping treatment'. The other plots various strategies of stopping treatment on a continuum of increasing degrees of invasiveness. While significant disagreements remain at important points, there is evidence of an emerging consensus in Western medicine: (1) that palliative care and counselling through the dying process should be increased whenever curative or life-sustaining treatment is curtailed; (ii) that any treatment that is not curative, but merely life-sustaining, should be stopped whenever a patient makes an authentic request to have it stopped; (iii) that genuinely futile treatment should not be offered even if requested; (iv) that much more thought and discussion is required to achieve a workable agreement about the definitions of 'futile' and 'inappropriate' treatment; and (v) that assistance in dying, although profoundly problematic, is no longer unthinkable.

An adolescent with Graves' disease presented with acute painful swelling of the thyroid gland and overlying erythema simulating acute suppurative or subacute thyroiditis. She had an elevated radioactive iodine uptake, thyroid stimulating antibodies, thyrotrophin binding inhibiting immunoglobulins, and a normal sedimentation rate and leucocyte count. The course of the thyrotoxicosis and painful thyroid was protracted, and the pain and tenderness of the thyroid recurred on two subsequent relapses.

Thirty-three physicians, bioethicists, and medical economists from ten different countries met at Lawrence University, Appleton, Wisconsin, to create The Appleton Consensus: International Guidelines for Decisions to Forego Medical Treatment. The guidelines deal with four specific decision-making circumstances: 1. Five guidelines were created for decisions involving competent patients or patients who have executed an advance directive before becoming incompetent, and those guidelines fell into three categories. 2. Thirteen guidelines were created for decisions involving patients who were once competent, but are not now competent, who have not executed an advance directive. 3. Seven guidelines were created for decisions involving patients who are not now and never have been competent, for whom 'no substituted judgement' can be rendered. 4. Eleven guidelines were created for decisions involving the scarcity of medical resources, which exists in all communities. Five concepts were identified as being critical in the establishment of priorities, given the reality of scarce health resources (1). The term 'physician' is used in the American sense, synonymous with 'medical practitioner'.

The purpose of this study was to compare the effects of restricted environmental stimulation using a flotation tank (Flotation REST) to the effects of a normal sensory environment on relaxation. All of the subjects were first introduced to a simple relaxation program to be used during the experimental sessions. The program consisted of guided point-to-point relaxation, breathing techniques, and visual imagery techniques. Subjects were then pre-tested on measurements of electromyogram (EMG), galvanic skin response (GSR), peripheral skin temperature, and systolic and diastolic blood pressure. The experimental group experienced ten 45-minute sessions practicing the relaxation program in a Flotation REST environment. The control subjects practiced the same relaxation program in a similar body position for 45 minutes in a normal sensory environment. All subjects answered a five-question Subjective Relaxation Questionnaire on trials five through ten and were then post-tested on EMG, GSR, skin temperature, and blood pressure. The results indicated significant differences between groups from pre-test to post-test on systolic and diastolic blood pressure; the experimental group showed greater reductions. Significant differences also were observed on three of five questions on the Subjective Relaxation Questionnaire; the experimental group reported greater subjective relaxation and trends in a similar direction on the remaining two questions. The results of this study indicate that flotation REST enhances point-to-point relaxation, breathing techniques, and visual imagery techniques and, when combined with these techniques, can be an effective means of teaching normal subjects to lower systolic and diastolic pressure and heighten their subjective perception of relaxation.

A retrospective investigation of semen quality was undertaken at a fertility clinic in New Orleans. Semen specimens obtained during the summer had significantly lower sperm concentration, total sperm per ejaculate, percent motile sperm, and motile sperm concentration than samples provided at other times of year. Substantial summer deterioration in semen quality was likely to occur only among men whose work places were probably not air-conditioned. These findings suggest that the deleterious effects of summer heat on spermatogenic cells or on epididymal spermatozoa may reduce male fertility and account, at least partially, for the deficit of spring births in warm climates throughout the world.

To determine whether the carcinogenicity of dinitrotoluene (DNT) in rodent bioassays was predictive for humans, we examined the mortality experience of exposed workers at two ammunition plants. Cohorts of 156 and 301 men who had worked a month or more during the 1940s and 1950s at jobs with opportunity for substantial DNT exposure were followed through the end of 1980. Numbers of expected deaths and standardized mortality ratios (SMRs) were computed, using mortality rates of US white males as the standard. No evidence of a carcinogenic effect was found, but unsuspected excesses of mortality from ischemic heart disease were noted at both plants (SMRs) 131 and 143; 95% confidence limits 65 to 234 and 107 to 187, respectively). Deaths from ischemic heart disease remained high even when compared with expected numbers derived using mortality rates of the counties in which the plants were located. Additional analyses revealed evidence of a 15-year latent period and suggested a relationship with duration and intensity of exposure. Epidemiologic investigations of other heavily exposed populations are needed to confirm the etiologic significance of the association between DNT and heart disease described here.