A Student-Run Outreach Clinic for Rural Communities in Appalachia

East Tennessee State University\u27s Department of Family Medicine (DFM) implements a student-run outreach clinic series that addresses health care needs of communities in the southern Appalachians. Offered during the third-year family medicine clerkship, the clinics link academic family physicians and students with community health care providers. Services vary with each community\u27s needs, but include history taking, physical examinations, patient education, and testing. The planning and implementation that begin with an annual meeting of faculty and community representatives include visits by DFM personnel to the rural communities and orientations of medical students conducted by faculty and community representatives. Students rate this experience highly because it provides them with useful hands-on experience, reasonable autonomy, collaboration with community providers, and understanding the needs of the underserved. Community hosts rate students highly in their respect for patients, sensitivity to confidentiality, and professionalism. Identified weaknesses are attributed to the fact that the outreach clinics were established in response to community needs and did not follow a careful curricular development. There was little attempt to standardize the procedures performed by each student or the amount of direct observation and feedback they received from their preceptors. Changes are underway that will strengthen the educational value of the outreach clinics. Participating students are provided a daylong orientation during which they practice full and focused physical examinations and review common medical problems such as diabetes, hypertension, and depression. Students also now document the patients encountered, their medical problems, and the clinical skills practiced

The Appalachian Preceptorship: Over Two Decades of an Integrated Clinical-Classroom Experience of Rural Medicine and Appalachian Culture

There is a need to encourage careers in rural medicine and to prepare potential rural physicians for life in rural communities. The authors describe a program that addresses this need, the Appalachian Preceptorship Program, and report the program\u27s experience from 1985 to 2004. The Appalachian Preceptorship is a four-week summer elective conducted by the Department of Family Medicine of East Tennessee State University (ETSU) that offers students clinical preceptorships in rural areas of southern Appalachia. By the conclusion of the 2004 preceptorships, the program had served 225 medical students from 95 medical schools across the country and abroad. The program combines an individual community-based preceptorship with an interactive group instructional block, emphasizes rural medicine, and provides students an understanding of the interface between culture and medicine in southern Appalachia. Follow-up of Appalachian Preceptorship students during the 18-year period studied demonstrates that 82% of the 157 participants who matched before 2004 had selected residencies in primary care, with 60% entering family medicine. Those completing the program were more than three times as likely to practice in a rural community compared with the national average. Fifty-six percent of their practice settings carry multiple rural or underserved designations. The program has helped transform a legislative mandate to train doctors for rural communities into an institutional culture leading to more extensive programs and a greater recognition of ETSU\u27s rural mission. The authors encourage other medical schools to develop combined clinical/classroom electives that reflect their institutional priorities and that can address a wide variety of clinical interests

Low plasma tryptophan in carcinoid patients is associated with increased urinary cortisol excretion

Background: Previously we observed inpatients suffering from a metastatic carcinoid tumor that irritability, aggression and lack of impulse control are associated with Low levels of plasma tryptophan and presumably with low brain serotonin function. In rats we showed that a diet of low tryptophan resulted in higher stress responses and higher corticosterone production. Here we tested in carcinoid patients whether tryptophan depletion due to tumor 5-HT overproduction is associated with high cortisol production. Methods: Urinary excretion of cortisol, serotonin, 5-hydroxyindole acetic acid (the main metabolite of serotonin a marker of tumor activity), plasma levels of tryptophan and platelet content of serotonin (index of peripheral serotonin synthesis) were determined in metastatic midgut carcinoid patients. Patients (N = 25) were divided into two groups based on their plasma tryptophan levels (= 49 mu mol/l, n = 13). Results: Carcinoid patients with low plasma tryptophan levels had significantly higher urinary excretion of free cortisol (p <0.01), independent of tumor activity. The inter-individual differences in the Low tryptophan group, however, were substantial. Conclusions: In a subgroup of the patients suffering from metastatic carcinoid disease the cerebral access of plasma tryptophan is impaired, thus rendering cerebral serotonin neurotransmission suboptimal and leading to hypercortisolism. The present study provides further support to the idea that low serotonergic function is a risk for developing stress-associated psychopathology. (C) 2008 Elsevier Ltd. All rights reserved

Weight changes associated with antiepileptic mood stabilizers in the treatment of bipolar disorder

Objective To present up-to-date information and recommendations on the management of body weight changes during the use of antiepileptic mood stabilizers in bipolar disorder to help clinicians and patients make well-informed, practical decisions. Data sources Umbrella review. Systematic reviews and meta-analyses on the prevention, treatment, and monitoring of body weight changes as a side effect of the mood stabilizers valproate, lamotrigine, topiramate, and carbamazepine were identified in Embase (2010-2015, no language restrictions). Study selection The search yielded 18 relevant publications on antiepileptic mood stabilizers and weight changes in bipolar disorder. Data extraction Relevant scientific evidence was abstracted and put into a clinical perspective by a multidisciplinary expert panel of clinicians with expertise in the treatment of bipolar disorders across all age groups and a patient representative. Results Valproate has been proven to be associated with weight gain in up to 50% of its users, and can be detected 2-3 months after initiation. Carbamazepine has been proven to have a low risk of weight gain. Lamotrigine and topiramate are associated with weight loss. Other option for this sentence = Weigth gain has been proven to be associated with valproate use in up to 50% of its users, and can be detected within 2-3 months after initiation. Conclusion Each antiepileptic mood stabilizer has specific effects on body weight and accordingly requires a discrete education, prevention, monitoring, and treatment strategy. Clinicians are recommended to adopt an active, anticipatory approach, educating patients about weight change as an important side effect in order to come to informed shared decisions about the most suitable mood stabilizer

Practice Locations of Graduates of Family Physician Residency and Nurse Practitioner Programs: Considerations Within the Context of Institutional Culture and Curricular Innovation Through Titles VII and VIII

Background: Studies have described the aggregate results of federal funding for health professions education at the national level, but analysis of the long‐term impact of institutional participation in these programs has been limited. Purpose: To describe and assess federally supported curricular innovations at East Tennessee State University designed to promote family medicine and nurse practitioner graduate interest in rural and underserved populations. Methods: Descriptive analysis of a survey to determine practice locations of nurse practitioner graduates (1992‐2002) and graduates of 3 family medicine residencies (1978‐2002). Graduates’ (N = 656) practice locations were documented using specific federal designations relating to health professions shortages and rurality. Results: Overall, 83% of family medicine residency and 80% of nurse practitioner graduates selected practice locations in areas with medically underserved or health professions shortage designations; 48% of family physicians and 38% of nurse practitioners were in rural areas. Conclusions: Graduates who study in an educational setting with a mission‐driven commitment to rural and community health and who participate in curricular activities designed to increase their experience with rural and underserved populations choose, in high numbers, to care for these populations in their professional practice

The development of peripartum depressive symptoms is associated with gene polymorphisms of MAOA, 5-HTT and COMT

Background: Polymorphisms of monoamine-related genes have been associated with depression following life events. The peripartum is a physiologically and psychologically challenging period, characterized by fluctuations in depressive symptoms, therefore facilitating prospective investigations in this gene x environment (G x E) interaction. Methods: Eighty nine pregnant women filled in two Edinburgh Postpartum Depression Scale (EPDS) questionnaires during pregnancy and two in the postpartum period. MAOA, COMT and 5-HTT polymorphisms were analyzed. Results: We found a significant interaction between the development of depressive symptoms in the course of pregnancy and polymorphisms in 5-HTT(p = 0.019): MAOA (p = 0.044) and COMT(p = 0.026), and MAOAxCOMT (p Conclusion: We found that MAOA in combination with COMT appears to regulate not only the stress response in laboratory experiments, but also seems to influence the stress-evoked onset of mood during normal, mild, stressful events, such as experienced in the peripartum period. These findings support the G x E concept for depression, but they underline the complexity of this concept as the cumulating effects of these polymorphic genes (i.e. MAOA + COMT) might be needed and the effects of these polymorphic genes becomes apparent in special environmental or physiological conditions (i.e. the peripartum period). We therefore suggest that G x E interactions become especially noticeable from longitudinal study designs in specific physiological or social challenging periods. (C)2009 Elsevier Inc. All rights reserved