Susanna L. Cunningham

Elevated Blood Pressure

Behavioral interventions to modify diet, activity, and emotional stress constitute the recommended initial treatment for mild essential hypertension in children and should accompany pharmacological therapy in more severe cases (Task Force on Blood Pressure Control in Children, 1987; referred to hereafter as the Second Task Force). The first concern is to ensure that the blood pressure evaluation process itself does not generate excessive anxiety and negative self-labeling on the part of child and family (Bloom & Monterossa, 1981; Bergman & Stamm, 1967). If, upon repeated assessment, the child’s blood pressure is found to be significantly elevated, this can usually be presented as a timely cue to start changing life-style patterns that could lead to health problems later on. Behavioral assessment and intervention efforts then focus on modifying diet habits, increasing physical activity, and reducing excessive emotional stress.

Application of appropriate use criteria for stress myocardial perfusion imaging at two academic medical centers: compliance and association with image findings.

Purpose: Explore the extent to which stress myocardial perfusion imaging (MPI) studies for coronary heart disease detection met published appropriate use criteria (AUC), and the association between AUC classification and image findings. Data sources: Retrospective, descriptive review of stress studies performed at the University of Washington Medical Center (UWMC n= 1377) and the Veterans Health Administration of Puget Sound (VA n= 1445) in the 31 months following AUC publication. Conclusions: At UWMC and VA, 69% and 89% of MPI studies, respectively, were classified as appropriate, 16% and 3% as inappropriate, and 15% and 8% as uncertain. All differences were significant, p < .001. At UWMC, 11% of appropriate studies and 10% of inappropriate or uncertain studies were abnormal (demonstrating myocardial ischemia or myocardial infarction), p= .93; these analyses were not performed on VA studies. Implications for practice: Most studies at both sites were classified as appropriate. At UWMC, the likelihood of a study classified as appropriate demonstrating an abnormality was not significantly different from a study classified as uncertain or inappropriate. AUC are imperfect tools but are increasingly created and referenced; as such, it is vital that practicing nurse practitioners are knowledgeable about their creation, application, and evaluation.

What Is the Link between Eating, Reproducing, & Addiction?

VOLUME 74, NO. 8, OCTOBER 2012 The Brain Reward System We are wired with the drive to stay alive – with a system that makes it pleasurable for us to eat, to seek shelter, and to reproduce. The problem is that addictive substances can subvert these same processes that were intended to keep us alive and to ensure species survival. This column is the first in a series that will explore the neuroscientific bases of addiction. As a basis for understanding addiction, this article focuses on the brain’s reward system, also known as the pleasure center or motivation system, which is the foundation for life-maintaining but also addictive behaviors. Subsequent articles will explore the influence of genetics, learning, risk and protective factors, stress, and specific neurotransmitters, such as glutamate. As we know, the “reward system” includes key areas or centers, connecting tracts, and several key neurotransmitters. The main areas are the ventral tegmental area (VTA) located in the mid-brain just above the hippocampus and in front of the substantia nigra; the nucleus accumbens (NAc) in the striatum just below the front end of the corpus callosum; and the prefrontal cortex, located just behind the forehead and just in front of the motor areas of the cortex. Some of the other areas involved include the locus coeruleus, the amygdala, the hippocampus, and the insula. The main nerve bundles or tracts that connect these areas are the mesolimbic, mesocortical, and mesostriatal pathways. The main neurotransmitters include dopamine, endogenous opioids, endocannabinoids, serotonin, and glutamate, although it is likely that other neurotransmitters as well as neuropeptides are also involved (Figure 1). The power of the reward system has been revealed in experiments in which experimental animals were found to vigorously continue self-stimulation when electrodes were placed in various locations within the reward-system structures (Olds & Milner, 1954). Esch and Stefano (2004) reviewed the important role of this system both in maintaining health and in addiction. More recently, brain-imaging techniques such as positron emission tomography (PET) scanning have helped us appreciate how addiction itself modifies the function of the brain’s reward system. In research by Volkow and colleagues (2009, 2011), cocaine use in nonaddicted persons resulted in a significant increase in dopamine release in the vicinity of the nucleus accumbens. Both the speed of drug administration, which is a function of the route of administration, and the amount of dopamine subsequently released, were directly related to the “high” experienced by the drug recipient. In cocaine-addicted individuals, however, this response was altered so that the dopamine released in response to cocaine intake was markedly diminished. Instead, there was a marked increase in dopamine in response to conditioning cues – such as seeing a video of another person buying or smoking cocaine. When the stimulus for dopamine release occurred in response to these conditioned cues, the addicted person experienced “craving” for the drug. There was a direct relationship between addiction severity and dopamine release during the viewing of these videos (Volkow et al., 2011). Another recent finding related to addiction is the modulating influence of a variety of stress-related neuropeptides, particularly a corticotropin-releasing factor that has been shown to increase dopamine release in the nucleus accumbens during the development of addictive behaviors (Sinha, 2008). Neuropeptides are brain signaling molecules of fewer than 40 amino acids that can modulate neuronal function in ways that are similar, but not identical, to the actions of neurotransmitters (Burbach, 2011; Logrip et al., 2011). The use of addictive drugs and the associated stress are known to activate the hypothalamic–pituitary–adrenal (HPA) axis, an action that probably has a role in addiction but may have an even greater effect during drug abstinence in addicted persons. Research has shown that the increases in corticotropin-releasing factor that occur during withdrawal are related to the signs and symptoms associated with withdrawal, particularly the anxiety that may contribute to relapse (Shalev et al., 2009; Logrip et al., 2011). Given that we all have brain reward systems, why is it that some of us when

Addiction & the Brain

In our previous column (in the February ABT ), we reviewed the impact of two key factors that precipitate relapse: (1) priming (introduction of small amounts of the drug), which acts on the mesolimbic dopamine pathway in the brain; and (2) stress, which acts on a variety of neural pathways. As our exploration of addiction and the brain continues, the endocannabinoid system contributes additional pieces of information to enhance our understanding of addiction. Who ever would have thought that the active ingredient in marijuana, tetrahydrocannabinol (THC), had receptor sites ready and waiting in our brains? The plant that gives us marijuana, Cannabis sativa , has been known for thousands of years. Its psychoactive properties have been used over the centuries and across the world. Once the chemical structure of THC was identified, the research began (Gaoni & Mechoulam, 1964). There have …In our previous column (in the February ABT ), we reviewed the impact of two key factors that precipitate relapse: (1) priming (introduction of small amounts of the drug), which acts on the mesolimbic dopamine pathway in the brain; and (2) stress, which acts on a variety of neural pathways. As our exploration of addiction and the brain continues, the endocannabinoid system contributes additional pieces of information to enhance our understanding of addiction. Who ever would have thought that the active ingredient in marijuana, tetrahydrocannabinol (THC), had receptor sites ready and waiting in our brains? The plant that gives us marijuana, Cannabis sativa , has been known for thousands of years. Its psychoactive properties have been used over the centuries and across the world. Once the chemical structure of THC was identified, the research began (Gaoni & Mechoulam, 1964). There have …

Application of appropriate use criteria for stress myocardial perfusion imaging at two academic medical centers

Purpose: Explore the extent to which stress myocardial perfusion imaging (MPI) studies for coronary heart disease detection met published appropriate use criteria (AUC), and the association between AUC classification and image findings. Data sources: Retrospective, descriptive review of stress studies performed at the University of Washington Medical Center (UWMC n= 1377) and the Veterans Health Administration of Puget Sound (VA n= 1445) in the 31 months following AUC publication. Conclusions: At UWMC and VA, 69% and 89% of MPI studies, respectively, were classified as appropriate, 16% and 3% as inappropriate, and 15% and 8% as uncertain. All differences were significant, p < .001. At UWMC, 11% of appropriate studies and 10% of inappropriate or uncertain studies were abnormal (demonstrating myocardial ischemia or myocardial infarction), p= .93; these analyses were not performed on VA studies. Implications for practice: Most studies at both sites were classified as appropriate. At UWMC, the likelihood of a study classified as appropriate demonstrating an abnormality was not significantly different from a study classified as uncertain or inappropriate. AUC are imperfect tools but are increasingly created and referenced; as such, it is vital that practicing nurse practitioners are knowledgeable about their creation, application, and evaluation.

Application of appropriate use criteria for stress myocardial perfusion imaging at two academic medical centers: Compliance and association with image findings: Application of AUC for stress MPI

Purpose: Explore the extent to which stress myocardial perfusion imaging (MPI) studies for coronary heart disease detection met published appropriate use criteria (AUC), and the association between AUC classification and image findings. Data sources: Retrospective, descriptive review of stress studies performed at the University of Washington Medical Center (UWMC n= 1377) and the Veterans Health Administration of Puget Sound (VA n= 1445) in the 31 months following AUC publication. Conclusions: At UWMC and VA, 69% and 89% of MPI studies, respectively, were classified as appropriate, 16% and 3% as inappropriate, and 15% and 8% as uncertain. All differences were significant, p < .001. At UWMC, 11% of appropriate studies and 10% of inappropriate or uncertain studies were abnormal (demonstrating myocardial ischemia or myocardial infarction), p= .93; these analyses were not performed on VA studies. Implications for practice: Most studies at both sites were classified as appropriate. At UWMC, the likelihood of a study classified as appropriate demonstrating an abnormality was not significantly different from a study classified as uncertain or inappropriate. AUC are imperfect tools but are increasingly created and referenced; as such, it is vital that practicing nurse practitioners are knowledgeable about their creation, application, and evaluation.

Can Your Genes “Make You Do It”?

A friend used to say “I don’t gamble because I have an addictive personality.” She felt that she was somehow predisposed to lose volitional control over her gambling. Indeed, curiosity about a putative genetic predisposition to addiction has not been restricted to a few would-be gambling addicts. It is estimated that 40–60% of the “addiction” trait is controlled by gene products (Uhl, 2004). For example, the risk of becoming an alcoholic is elevated five- to eightfold if a primary relative is an alcoholic (Merikangas et al., 1998). For twins, genetically identical pairs show more sharing of alcoholism than fraternal twin pairs (Prescott & Kendler, 1999). But what are the genes implicated in addiction? The thirst for understanding of, and potentially treatment for, addiction has pressured many to jump hastily to the conclusion that “THE” addiction gene has been identified. But it is clear that addiction, like any complex behavioral trait, is influenced by MANY genes …