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Tyrka A.R.,Butler Hospital | Price L.H.,Butler Hospital | Walters O.C.,Butler Hospital | Carpenter L.L.,Butler Hospital
PLoS ONE | Year: 2012

Background: A history of early adverse experiences is an important risk factor for adult psychopathology. Changes in stress sensitivity and functioning of the hypothalamic-pituitary-adrenal (HPA) axis may underlie the association between stress and risk for psychiatric disorders. Preclinical work in rodents has linked low levels of maternal care to increased methylation of the promoter region of the glucocorticoid receptor (GR) gene, as well as to exaggerated hormonal and behavioral responses to stress. Recent studies have begun to examine whether early-life stress leads to epigenetic modifications of the GR gene in humans. Methods: We examined the degree of methylation of a region of the promoter of the human GR gene (NR3C1) in leukocyte DNA from 99 healthy adults. Participants reported on their childhood experiences of parental behavior, parental death or desertion, and childhood maltreatment. On a separate day, participants completed the dexamethasone/corticotropin-releasing hormone (Dex/CRH) test, a standardized neuroendocrine challenge test. Results: Disruption or lack of adequate nurturing, as measured by parental loss, childhood maltreatment, and parental care, was associated with increased NR3C1 promoter methylation (p<.05). In addition, NR3C1 promoter methylation was linked to attenuated cortisol responses to the Dex/CRH test (p<.05). Conclusions: These findings suggest that childhood maltreatment or adversity may lead to epigenetic modifications of the human GR gene. Alterations in methylation of this gene could underlie the associations between childhood adversity, alterations in stress reactivity, and risk for psychopathology. © 2012 Tyrka et al.

News Article | December 10, 2016

Healthcare Real Estate Insights™ magazine has announced the Winners of the 2016 HREI Insights Awards™, the only national awards totally dedicated to recognizing excellence in the areas of healthcare real estate (HRE) development and executive leadership. The 2016 awards were presented today in nine different categories during the RealShare Healthcare Real Estate Conference in Scottsdale, Ariz. The awards were presented by Healthcare Real Estate Insights™, the first and only national magazine entirely devoted to covering healthcare real estate (HRE) development, financing and investment. HREI™ Publisher Murray Wolf noted, “The HREI Insights Awards™ have honored the best of the best in healthcare real estate since 2013.Yet we never fail to be astounded by the quality of the people and projects that are nominated. The projects that are submitted demonstrate the remarkable persistence and creativity of the development teams behind them. The development process is complicated and fraught with challenges. Yet, year after year, we receive dozens of entries demonstrating the amazing vision, creativity and hard work of the people in the healthcare real estate sector. The same goes for the individual awards. We are proud that this has become a very prestigious program with sought-after awards.” Sponsors of the 2016 HREI Insights Awards are: The 2016 Winners and Finalists will be featured in upcoming editions of Healthcare Real Estate Insights™ magazine, the 2017 HREI Resource Guide™ and on Best New Medical Office Building and Other Outpatient Facilities (Less than 25,000 square feet): Five Star ER, Pflugerville, Texas Developer: Lockard Lockard Emergency Service Partners had identified an optimal site in Pflugerville, an Austin, Texas, suburb, for its next freestanding emergency room under its Five Star ER brand. However, because the overall development plan had not been finalized, the lot needed for the project could not be sold individually. Lockard stepped in and worked directly with the land developer to finalize the development plan and expedite approval of other aspects of the agreement and process. In doing so, the company avoided costly delays. Construction on the 9,960 square foot facility got underway in March 2015 and was completed in October 2015. Best New Medical Office Building and Other Outpatient Facilities (25,000 to 49,999 square feet): Buck Creek Medical Plaza, Avon, Colo. Developer: NexCore Group LLC Colorado Mountain Medical needed to expand its service offerings in a new, centralized location with more parking. In a market with few buildable lots, NexCore found a 2.15-acre site in Avon that fit the bill. But there were challenges to overcome, and NexCore eventually acquired an adjacent lot and swapped parcels with the local fire district. Fast-tracking the project, NexCore opened the 48,300 square foot Buck Creek Medical Plaza in summer 2016. The company recruited Centennial, Colo.-based Centura Health as the emergency care anchor as well as a vibrant mix of providers to bring occupancy to 94 percent at the opening. Best New Medical Office Building and Other Outpatient Facilities (50,000 to 99,999 square feet): Penn Medicine Southern Chester County, West Grove, Penn. Developer: Anchor Health Properties Chester County Hospital wanted to grow its market share in the southernmost portion of its service area in Chester County and to position itself to deliver needed services well into the future. So the hospital sought to consolidate and expand services in a comprehensive new facility. Anchor Health Properties identified and then controlled a strategic, highly visible site and developed a 72,000 square foot “one-stop” healthcare destination. The MOB was fully occupied when it opened in summer 2015. Penn Medicine exceeded patient volume projections by 20 percent in Year 1 and increased outpatient registrations by 40 percent. Best New Medical Office Building and Other Outpatient Facilities (100,000 square feet or more): Hoag Health Center-Irvine-Sand Canyon, Irvine, Calif. Developer: PMB The Hoag Memorial system wanted to develop an outpatient facility adjacent to its Hoag Hospital Irvine to meet the healthcare needs of the rapidly growing area. The development team faced numerous challenges, including high voltage overhead power lines and underground issues, plus they wanted to link the MOB to the hospital with fiber-optic cable installed under a busy six-lane road. The team was able to deliver the 157,200 square foot facility below budget and on schedule. The facility was fully leased upon opening and is expected to achieve LEED Silver designation. Best Renovated or Repurposed Healthcare Facility: Clara Maass Medical Center MOBs, Belleville, N.J. Developer: Rendina Healthcare Real Estate Clara Maass Medical Center (CMMC) needed to significantly improve the condition of three MOBs on its campus and enhance the satisfaction of the tenant physicians. Rendina acquired the three buildings totaling 128,006 square feet and completely modernized and renovated all common areas. They also added new building systems, signage, wayfinding, artwork, furniture and handicap parking improvements. Since Rendina took ownership, occupancy has increased nearly 10 percent, many physician groups have shifted from short-term commitments to long-term leases, and overall satisfaction has increased 7 percent. Hospitals and Other Inpatient Facilities – Best New Ground-Up Development: TriHealth Bethesda Butler Hospital, Hamilton, Ohio Developer: Duke Realty TriHealth wanted to enter a Cincinnati sub-market and employ a physician practice that owned a six-building hospital campus. TriHealth needed to immediately add an ED and lab and in the future additional beds to accommodate its growing patient base. The development team orchestrated a four-phase expansion to minimize disruptions to the hospital’s daily operations. The expanded 90,788 square foot facility has enabled TriHealth to add more services, physicians and staff; treat more patients; and have room for future growth. It’s also helping it be more competitive in the Cincinnati market and serve as a convenient, full-service campus. Finalists Advocate Christ Medical Center, East Patient Tower, Oak Lawn, IL    Advocate Health Care Scripps Networks Tower at E. Tenn. Children’s Hospital, Knoxville, TN    Realty Trust Group Sibley Memorial Hospital New Patient Tower, Washington D.C.    Sibley Memorial Hospital Zuckerberg San Francisco General Hospital and Trauma Center, S.F.    San Francisco Health Network Post-Acute & Senior Living Facilities – Best New Ground-Up Development: Beach House Assisted Living and Memory Care, Naples, Fla. Developer: Prevarian Companies LP It has taken more than a decade for the site at 1000 Airport Pulling Road S. in Naples to finally be developed after years of delays caused by a long entitlement process and the recession. Making the project a reality was Prevarian, which started pursuing a development on the site just two years prior to opening the 113-unit Beach House Assisted Living and Memory Care community. The company had to make sure the design conformed to a previously approved footprint and site plan, and it received permits within four months of securing the land. Beach House is close to a shopping district and a community hospital. Healthcare Real Estate Executive of the Year: Jason Signor, Caddis Under Jason Signor’s leadership, Caddis has grown from seven employees to 47 and become an industry-leading, full-service developer, owner and property manager of MOBs, ASCs, hospitals and, under its Heartis brand, senior living communities. With offices in Dallas, Atlanta, Houston and Phoenix, the firm has developed and/or acquired more than 40 assets with a total value of more than $700 million spanning 2.7 million square feet of space and 1,500 beds. Caddis has deployed $150 million of equity and manages about 3 million square feet in seven states. During his time with Caddis, Mr. Signor also has spurred the creation of a proprietary, GIS mapping interface used for identifying market opportunities and allowing clients to make informed, evidence-based site selection decisions. Tim Oliver’s legacy includes being involved in the development and consulting engagements for more than 90 facilities totaling 5 million square feet in the past 40-plus years. Mr. Oliver has focused exclusively on medical real estate since 1974 and has cofounded several firms. Tim Oliver and John McWilliams were involved in the formation of Western Skies (WSI) in 1970, and led the company’s development of its first on-campus MOB in 1975. At the time, the concept of on-campus medical office buildings was in its infancy. WSI developed the second on-campus MOB in the Rocky Mountain region for Mercy Hospital. Over the next 16 years, WSI developed 1.5 million square feet of ambulatory facilities and managed over 1 million square feet of healthcare properties. In 1986, Tim was one of the original founders of Integrated Medical Campus, providing strategic planning/development services for over 50 medical projects. In 1987, IMC developed one of the nation’s first “medical mall” or “hospital without beds” projects that featured a freestanding emergency department, ambulatory surgery center, imaging, physical therapy and medical offices. In 2004, Mr. Oliver joined five other founders from The Neenan Company to form the Denver-based NexCore Group. To date, NexCore Group has developed and acquired 6.5 million square feet of real estate, executed leases totaling 3.5 million square feet, and now has 65 employees in seven offices across the United States. Today, Mr. Oliver is actively training the next generation of strategic-thinking development executives at NexCore Group. He has been a thought leader at NexCore, responsible for understanding the legislative and economic environment, best practices in the delivery of care, and population health management/wellness initiatives that affect the development of healthcare real estate. His strategic thinking continues to provide top-of-class service to NexCore’s national healthcare clients. Launched in 2003, HREI was the first and remains the only national magazine entirely dedicated to covering healthcare real estate development, financing and investment. This monthly, national, business-to-business magazine offers sophisticated players the most comprehensive coverage in the industry available anywhere. Introduced in 2008, the HREI Resource Guide was the first and is still the only annual directory of healthcare real estate services. And HREI’s companion website,, has been totally redesigned and vastly expanded with more than 10 years of content, more than 2,000 articles and nearly 2 million words of copy, becoming the new hub for healthcare real estate news and information. For more information on HREI products and services, or to subscribe or advertise, please visit us at

Inouye S.K.,Institute for Aging Research | Kosar C.M.,Institute for Aging Research | Tommet D.,Butler Hospital | Schmitt E.M.,Institute for Aging Research | And 4 more authors.
Annals of Internal Medicine | Year: 2014

Background: Quantifying the severity of delirium is essential to advancing clinical care by improved understanding of delirium effect, prognosis, pathophysiology, and response to treatment. Objective: To develop and validate a new delirium severity measure (CAM-S) based on the Confusion Assessment Method. Design: Validation analysis in 2 independent cohorts. Setting: Three academic medical centers. Patients: The first cohort included 300 patients aged 70 years or older scheduled for major surgery. The second included 919 medical patients aged 70 years or older. Measurements: A 4-item short form and a 10-item long form were developed. Association of the maximum CAM-S score during hospitalization with hospital and posthospital outcomes related to delirium was evaluated. Results: Representative results included adjusted mean length of stay, which increased across levels of short-form severity from 6.5 days (95% CI, 6.2 to 6.9 days) to 12.7 days (CI, 11.2 to 14.3 days) (P for trend < 0.001) and across levels of long-form severity from 5.6 days (CI, 5.1 to 6.1 days) to 11.9 days (CI, 10.8 to 12.9 days) (P for trend < 0.001). Representative results for the composite outcome of adjusted relative risk of death or nursing home residence at 90 days increased progressively across levels of short-form severity from 1.0 (referent) to 2.5 (CI, 1.9 to 3.3) (P for trend < 0.001) and across levels of long-form severity from 1.0 (referent) to 2.5 (CI, 1.6 to 3.7) (P for trend < 0.001). Limitation: Data on clinical outcomes were measured in an older data set limited to patients aged 70 years or older. Conclusion: The CAM-S provides a new delirium severity measure with strong psychometric properties and strong associations with important clinical outcomes. © 2014 American College of Physicians.

Anderson B.J.,Brown University | Stein M.D.,Brown University | Stein M.D.,Butler Hospital
AIDS and Behavior | Year: 2011

We created a model conceptualizing sexual risk as a series of discrete event-specific behavioral decisions and tested the hypothesis that marijuana use was associated with increased sexual risk-taking. Three hundred eight marijuana-using women aged 18-24 completed a 90-day time-line-follow-back to assess sexual behaviors and marijuana use. A sequential logit model estimated the effect of marijuana use on the likelihood of being sexually active, partner type when sexually active, and condom nonuse conditional on partner type. Participants had a mean age of 20.4 years, with 67% Caucasian. Marijuana use was associated with an increased likelihood of being sexually active (OR 1.6; 95% CI 1.33, 1.93) and with condom nonuse when sexually active with casual partners (OR 2.58; 95% CI 1.1, 6.09). This behavioral decision model identified where marijuana use affected sexual risk, and suggests where interventions designed to reduce risk may have an impact. © 2010 Springer Science+Business Media, LLC.

Friedman J.H.,Butler Hospital | Friedman J.H.,Brown University
Expert Opinion on Pharmacotherapy | Year: 2013

Introduction: Parkinson's disease (PD) is a neurobehavioral disorder defined by its motor features. Its treatment is frequently complicated by the presence of psychotic symptoms, most prominently hallucinations and delusions. These cause major distress and are the primary cause for nursing home placement. Current treatment requires either a reduction in medications for mobility or the addition of atypical antipsychotics, none of which are approved in the United States, and which are associated with major potential drawbacks. Areas covered: Information from extensive personal experience, a Pubmed literature search plus a direct request to Acadia Pharmaceuticals was used for this review. A brief review of the clinical problem and its current state of treatment will be followed by a discussion of pimavanserin and its potential role in treating PD psychosis (PDP). Several observations have implicated serotonin in the physiology of psychotic symptoms. Lysergic acid diethylamide, phencyclidine, and similar drugs that activate 5HT2A serotonin receptors produce psychotic syndromes, and almost all antipsychotic neuroleptics share the property of blocking the 5HT2A receptor as well as the dopamine D2 receptor. The reduced motor side effects of the second-generation antipsychotics have been ascribed to these drugs having greater 5HT2A antagonism than the first generation. Studies in animal models of psychosis have suggested benefits from drugs blocking the 5HT2A receptor alone without the motor side effects seen with D2 receptor antagonism. Expert opinion: Pimavanserin, a 5HT2A inverse agonist, has no motor side effects, and a remarkable safety profile that is comparable to placebo. Its antipsychotic effects coupled with its lack of motor side effects could make it an ideal drug for treating psychotic symptoms in PD, a major unmet need. One Phase III trial in PDP has demonstrated excellent tolerability and significant benefit. The FDA agreed to the filing of a planned new drug approval (NDA) for an indication in the treatment of PDP. © 2013 Informa UK, Ltd.

Whisman M.A.,University of Colorado at Boulder | Uebelacker L.A.,Brown University | Uebelacker L.A.,Butler Hospital
Health Psychology | Year: 2012

Objective: Metabolic syndrome (MetS) is a constellation of features- central obesity, dyslipidemia, elevated blood pressure, and dysglycemia-that are associated with increased risk for cardiovascular disease, diabetes, stroke, and mortality. This longitudinal study was conducted to evaluate whether marital adjustment, which has been shown to predict a variety of health outcomes, increases risk for incidence of MetS. Methods: A population-based English sample of couples (N = 216 couples) completed a self-report measure of marital adjustment at baseline and nurse visits that included collection of blood pressure, blood samples, and anthropometric measures at baseline and 4-year follow-up. Multilevel modeling was used to evaluate the association between both partners' report of baseline marital adjustment and incidence of MetS, controlling for other baseline risk factors (demographics, current and previous smoking status, alcohol use, activity level, depressive symptoms, number of MetS criteria). Results: Gender moderated the association between marital adjustment and incidence of MetS. Follow-up analyses indicated that husbands' report of marital adjustment at baseline was significantly associated with incident MetS for wives at follow-up, controlling for baseline risk factors. Marital adjustment was not significantly associated with incident MetS for men. Conclusions: Findings suggest that MetS may be one mechanism by which poor marital adjustment increases risk for poor health outcomes in women. Improving marital adjustment may help prevent the incidence of MetS and improve health, particularly for women. © 2011 American Psychological Association.

Johnson J.E.,Brown University | Zlotnick C.,Brown University | Zlotnick C.,Butler Hospital
Journal of Psychiatric Research | Year: 2012

This study, the largest randomized controlled trial of treatment for major depressive disorder (MDD) in an incarcerated population to date, wave-randomized 38 incarcerated women (6 waves) with MDD who were attending prison substance use treatment to adjunctive group interpersonal psychotherapy (IPT) for MDD or to an attention-matched control condition. Intent-to-treat analyses found that IPT participants had significantly lower depressive symptoms at the end of 8 weeks of in-prison treatment than did control participants. Control participants improved later, after prison release. IPT's rapid effect on MDD within prison may reduce serious in-prison consequences of MDD. © 2012 Elsevier Ltd.

Friedman J.H.,Butler Hospital | Friedman J.H.,Brown University
Parkinsonism and Related Disorders | Year: 2011

There is very little data on the treatment of idiopathic Parkinson's disease (IPD) in patients with schizophrenia. Since schizophrenia is treated primarily with dopamine receptor blocking medications, it is unknown if the beneficial effects of anti-PD medications might be blocked or if the drugs may trigger worsened psychosis. A chart review was performed which identified nine patients with schizophrenia and presumed Idiopathic Parkinson's Disease (IPD). None of the patients suffered worsened psychosis from l-Dopa or a dopamine agonist if taking antipsychotics, and motor response did not appear blunted. © 2010.

Ting S.A.,Massachusetts General Hospital | Sullivan A.F.,Massachusetts General Hospital | Boudreaux E.D.,University of Massachusetts Medical School | Miller I.,Butler Hospital | Camargo C.A.,Massachusetts General Hospital
General Hospital Psychiatry | Year: 2012

Objective: The objective was to describe the epidemiology of emergency department (ED) visits for attempted suicide and self-inflicted injury over a 16-year period. Method: Data were obtained from the National Hospital Ambulatory Medical Care Survey including all visits for attempted suicide and self-inflicted injury (E950-E959) during 1993-2008. Results: Over the 16-year period, there was an average of 420,000 annual ED visits for attempted suicide and self-inflicted injury [1.50 (95% confidence interval, 1.33-1.67) visits per 1000 US population], and the average annual number for these ED visits more than doubled from 244,000 in 1993-1996 to 538,000 in 2005-2008. During the same time frame, ED visits for these injuries per 1000 US population almost doubled for males (0.84 to 1.62), females (1.04 to 1.96), whites (0.94 to 1.82) and blacks (1.14 to 2.10). Visits were most common among ages 15-19, and the number of visits coded as urgent/emergent decreased from 0.95 in 1993-1996 to 0.70 in 2005-2008. Conclusions: ED visit volume for attempted suicide and self-inflicted injury has increased over the past two decades in all major demographic groups. Awareness of these longitudinal trends may assist efforts to increase research on suicide prevention. In addition, this information may be used to inform current suicide and self-injury related ED interventions and treatment programs. © 2012 Elsevier Inc.

Cameron A.,Clark University | Reed K.P.,Clark University | Ninnemann A.,Butler Hospital
Addictive Behaviors | Year: 2013

Avoidance of negative affect is one motivational factor that explains smoking cessation relapse during cessation attempts. This negative reinforcement model of smoking cessation and relapse has demonstrated the importance of one's ability to tolerate nicotine withdrawal symptoms, particularly negative affect states, in remaining abstinent from smoking. Distress tolerance and implicit associations are two individual constructs that may influence the strength of this relationship. In this pilot study the authors examined implicit associations related to avoidance and negative affect using a modified Implicit Association Test (IAT), a measure designed to examine implicit associations related to negative affect and avoidance, and the relationship of these associations to distress tolerance and smoking relapse. In total, 40 participants were recruited through community flyers as part of a larger smoking cessation study. Participants completed a brief smoking history, behavioral distress tolerance assessments, and the modified IAT. Smoking status was assessed via phone 3. days and 6. days post-quit date. Results from a Cox proportional hazard model revealed that implicit associations between avoidance and negative affect were significantly negatively correlated with time to relapse after a smoking cessation attempt, whereas the behavioral distress tolerance assessments did not predict time to relapse. This study provides novel information about the cognitive associations that may underlie avoidant behavior in smokers, and may be important for understanding smoking relapse when negative affect states are particularly difficult to tolerate. Authors discuss the importance of implicit associations in understanding smoking relapse and how they can be targeted in treatment.© 2013 Elsevier Ltd.

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