Battle Creek VA Medical Center

BACKGROUND: The National Cardiogenic Shock Initiative is a single-arm, prospective, multicenter study to assess outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI). METHODS: Between July 2016 and February 2019, 35 sites participated and enrolled into the study. All centers agreed to treat patients with AMICS using a standard protocol emphasizing invasive hemodynamic monitoring and rapid initiation of MCS. Inclusion and exclusion criteria mimicked those of the "SHOCK" trial with an additional exclusion criteria of intra-aortic balloon pump counter-pulsation prior to MCS. RESULTS: A total of 171 consecutive patients were enrolled. Patients had an average age of 63 years, 77% were male, and 68% were admitted with AMICS. About 83% of patients were on vasopressors or inotropes, 20% had a witnessed out of hospital cardiac arrest, 29% had in-hospital cardiac arrest, and 10% were under active cardiopulmonary resuscitation during MCS implantation. In accordance with the protocol, 74% of patients had MCS implanted prior to PCI. Right heart catheterization was performed in 92%. About 78% of patients presented with ST-elevation myocardial infarction with average door to support times of 85 ± 63 min and door to balloon times of 87 ± 58 min. Survival to discharge was 72%. Creatinine ≥2, lactate >4, cardiac power output (CPO) <0.6 W, and age ≥ 70 years were predictors of mortality. Lactate and CPO measurements at 12-24 hr reliably predicted overall mortality postindex procedure. CONCLUSION: In contemporary practice, use of a shock protocol emphasizing best practices is associated with improved outcomes.

Management of the behavioral complications of dementia, including agitation and aggression, presents a tremendous challenge to families and caregivers of afflicted patients. Most previous pharmacotherapies have shown minimal efficacy and significant side effects. We report our initial, open-label experience using the anticonvulsant sodium valproate in four dementia patients with severe behavioral disturbance. The drug was well tolerated by all patients, with no side effects or laboratory abnormalities, during 1- to 3-month trials. Two patients showed significant improvement in behavior, and a third had a transient response. Valproate may be a useful agent in the treatment of behavioral disturbance in dementia; controlled trials are needed to document its efficacy.

We studied genetic diversity in Streptococcus pneumoniae and Haemophilus influenzae in throat culture isolates from 38 children attending two day-care centers in Michigan. Culture specimens were collected weekly; 184 S. pneumoniae and 418 H. influenzae were isolated from the cultures. Pulsed-field gel electrophoresis identified 29 patterns among the S. pneumoniae isolates and 87 among the H. influenzae isolates. Of the cultures, 5% contained multiple genetic types of S. pneumoniae, and 43% contained multiple types of H. influenzae. Carriage of multiple H. influenzae isolates, which was associated with exposure to smoking, history of allergies, and age 36 to 47 months, may increase risk for otitis media in children.

Federal mandates to increase biofuel production in North America will require large new tracts of land with potential to negatively impact biodiversity, yet empirical information to guide implementation is limited. Because the temperate grassland biome will be a production hotspot for many candidate feedstocks, production is likely to impact grassland birds, a group of major conservation concern. We employed a multiscaled approach to investigate the relative importance of arthropod food availability, microhabitat structure, patch size and landscape-scale habitat structure and composition as factors shaping avian richness and abundance in fields of one contemporary (corn) and two candidate cellulosic biomass feedstocks (switchgrass and mixed-grass prairie) not currently managed as crops. Bird species richness and species density increased with patch size in prairie and switchgrass, but not in corn, and was lower in landscapes with higher forest cover. Perennial plantings supported greater diversity and biomass of arthropods, an important food for land birds, but neither metric was important in explaining variation in the avian community. Avian richness was higher in perennial plantings with greater forb content and a more diverse vegetation structure. Maximum bird species richness was commonly found in fields of intermediate vegetation density and grassland specialists were more likely to occur in prairies. Our results suggest that, in contrast to corn, perennial biomass feedstocks have potential to provide benefits to grassland bird populations if they are cultivated in large patches within relatively unforested landscapes. Ultimately, genetic improvement of feedstock genets and crop management techniques that attempt to maximize biomass production and simplify crop vegetation structure will be likely to reduce the value of perennial biomass plantings to grassland bird populations.

BACKGROUND: The goal of this retrospective cohort study (REVATA) was to determine the site, source, and contributory factors of varicose vein recurrence after radiofrequency (RF) and laser ablation. METHODS: Seven centers enrolled patients into the study over a 1-year period. All patients underwent previous thermal ablation of the great saphenous vein (GSV), small saphenous vein (SSV), or anterior accessory great saphenous vein (AAGSV). From a specific designed study tool, the etiology of recurrence was identified. RESULTS: 2,380 patients were evaluated during this time frame. A total of 164 patients had varicose vein recurrence at a median of 3 years. GSV ablation was the initial treatment in 159 patients (RF: 33, laser: 126, 52 of these patients had either SSV or AAGSV ablation concurrently). Total or partial GSV recanalization occurred in 47 patients. New AAGSV reflux occurred in 40 patients, and new SSV reflux occurred in 24 patients. Perforator pathology was present in 64% of patients. CONCLUSION: Recurrence of varicose veins occurred at a median of 3 years after procedure. The four most important factors associated with recurrent veins included perforating veins, recanalized GSV, new AAGSV reflux, and new SSV reflux in decreasing frequency. Patients who underwent RF treatment had a statistically higher rate of recanalization than those treated with laser.

Neutral buffered formalin (NBF) has been the standard fixative in histopathology for many decades; however, new technologies and increasing time constraints have made this common fixative less widely applicable. The attributes of universal and ideal fixatives are reviewed and compared with those of NBF. On the strength of a growing body of literature and experience in the histopathology field, zinc formalin solutions are recommended as a functional replacement for NBF. Zinc formalin permits better morphological preservation and preserves immunoreactivity even after prolonged fixation times. Coordinated zinc ions are postulated to maintain macromolecules in their original three-dimensional conformation as formaldehyde forms addition products with them. Significant crosslinking and gross distortion of tertiary structure are thereby avoided.

One of the primary areas of investigation in the pathophysiology of Parkinson's disease (PD) is the loss of the dopamine-producing cells in the melanized neurons of the substantia nigra, believed to be caused by oxidative stress resulting from excessive free radical activity. The cuprozinc enzyme, superoxide dismutase (SODCu2Zn2), catalyzes the dismutation of superoxide anions to hydrogen peroxide plus oxygen, and is normally found in high concentrations in the substantia nigra where it protects neurons by scavenging free radicals. Zinc supplementation has been shown to significantly increase SODCu2Zn2 in vitro. A novel oral zinc tally test (ZTT) used in the assessment of zinc status was administered to 100 PD patients and 25 controls. Patients with PD showed a significantly decreased zinc status as compared to controls (p < 0.001). Significance was also established for 3 self-reported health-related variables thought to be related to zinc status: vision problems, olfactory loss, and taste loss (p < 0.05). Relative risks for patients with PD for these variables were 1.51, 1.56, and 1.33, respectively. Zinc status as measured by the ZTT is negatively correlated with PD status. PD status is positively correlated with self-reported vision problems, and olfactory and taste loss. Further study of the role of zinc in the development and treatment of PD is warranted.

Abstract Post‐traumatic stress disorder is a legacy of the Vietnam War. Perhaps as many as a half‐million U.S. veterans suffer from the problem to some degree. Hospitalized U.S. veterans, diagnosed as suffering from PTSD were given the Internalized Shame Scale, the Beck Depression Inventory, and the Rosenberg Self‐Esteem Scale. Hospitalized veterans suffering from (1) depression and (2) substance abuse were also given these instruments and the resulting data were compared. Veterans suffering from PTSD scored higher on Internalized Shame and on Depression than did the Substance Abuse group and scored higher numerically on Depression than did the Depression group itself. All groups were compared on factors related to Shame, Inferiority and Alienation. Data indicated that the PTSD group scored numerically highest on both factors. Results are discussed in accordance with current Shame induction theory.

BACKGROUND: There are several endovenous methods to ablate the saphenous vein, all of which require tumescent anesthesia. This report was designed to evaluate the efficacy of a tumescent-free technique using mechanochemical ablation (MOCA). METHODS: This was a prospective observational multicenter report on the efficacy of MOCA in selected patients with lower extremity chronic venous disease. Demographic information, clinical and procedural data were collected on a customized database. The distribution and extent of venous reflux and the closure rate of the treated veins were assessed with duplex ultrasound. Pain was evaluated during the procedure and postoperatively using an analog scale. The presence and severity of complications were recorded. Patient improvement was assessed by clinical-etiology-anatomy-pathophysiology (CEAP) class and venous clinical severity score (VCSS). RESULTS: There were 126 patients that were included at baseline, 81% females, with a mean age of 65.5 ± 14 years. The average BMI was 30.5 ± 6. The mean diameter of the great saphenous vein in the upper thigh was 7.3 mm and the mean treatment length was 38 cm. Adjunctive treatment of the varicosities was performed in 11% of patients during the procedure. Closure rates were 100% at one week, 98% at three months, and 94% at six months. Post-procedure complications included hematoma 1%, ecchymosis 9%, and thrombophlebitis 10%. There were no cases of venous thromboembolism. There was significant improvement in VCSS (p < 0.001) for all time intervals. CONCLUSION: MOCA of the saphenous veins has the advantage of endovenous ablation without tumescent anesthesia, making it an almost pain-free procedure. High occlusion rates with significant clinical improvement can be achieved with this method at short term.

Importance: The full effect of the COVID-19 pandemic on cancer care disparities, particularly by race and ethnicity, remains unknown. Objectives: To assess whether the race and ethnicity of patients with cancer was associated with disparities in cancer treatment delays, adverse social and economic effects, and concerns during the COVID-19 pandemic and to evaluate trusted sources of COVID-19 information by race and ethnicity. Design, Setting, and Participants: This national survey study of US adults with cancer compared treatment delays, adverse social and economic effects, concerns, and trusted sources of COVID-19 information by race and ethnicity from September 1, 2020, to January 12, 2021. Exposures: The COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was delay in cancer treatment by race and ethnicity. Secondary outcomes were duration of delay, adverse social and economic effects, concerns, and trusted sources of COVID-19 information. Results: Of 1639 invited respondents, 1240 participated (75.7% response rate) from 50 US states, the District of Columbia, and 5 US territories (744 female respondents [60.0%]; median age, 60 years [range, 24-92 years]; 266 African American or Black [hereafter referred to as Black] respondents [21.5%]; 186 Asian respondents [15.0%]; 232 Hispanic or Latinx [hereafter referred to as Latinx] respondents [18.7%]; 29 American Indian or Alaska Native, Native Hawaiian, or multiple races [hereafter referred to as other] respondents [2.3%]; and 527 White respondents [42.5%]). Compared with White respondents, Black respondents (odds ratio [OR], 6.13 [95% CI, 3.50-10.74]) and Latinx respondents (OR, 2.77 [95% CI, 1.49-5.14]) had greater odds of involuntary treatment delays, and Black respondents had greater odds of treatment delays greater than 4 weeks (OR, 3.13 [95% CI, 1.11-8.81]). Compared with White respondents, Black respondents (OR, 4.32 [95% CI, 2.65-7.04]) and Latinx respondents (OR, 6.13 [95% CI, 3.57-10.53]) had greater odds of food insecurity and concerns regarding food security (Black respondents: OR, 2.02 [95% CI, 1.34-3.04]; Latinx respondents: OR, 2.94 [95% CI, [1.86-4.66]), financial stability (Black respondents: OR, 3.56 [95% CI, 1.79-7.08]; Latinx respondents: OR, 4.29 [95% CI, 1.98-9.29]), and affordability of cancer treatment (Black respondents: OR, 4.27 [95% CI, 2.20-8.28]; Latinx respondents: OR, 2.81 [95% CI, 1.48-5.36]). Trusted sources of COVID-19 information varied significantly by race and ethnicity. Conclusions and Relevance: In this survey of US adults with cancer, the COVID-19 pandemic was associated with treatment delay disparities and adverse social and economic effects among Black and Latinx adults. Partnering with trusted sources may be an opportunity to overcome such disparities.

Combat veterans seeking treatment for posttraumatic stress disorder (PTSD) tend to report high levels of psychopathology on self-report instruments. The purpose of the current archival study was to replicate research on the relationships among symptom exaggeration, attempts to obtain compensation, and treatment outcome on the Beck Depression Inventory, the Mississippi Scale for Combat-Related PTSD, and selected MMPI-2 and MCMI-II subscales. Results indicated that symptom exaggeration as defined by an MMPI-2 F-K index over 13 was related to higher scores on all scales examined. Compensation seeking was not related to assessment scores or exaggeration. Neither compensation seeking nor exaggeration was related to treatment outcome. Limitations of the study and implications for future research are discussed.

OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.

This study compared the MMPI-2 profiles of 27 veterans diagnosed with post-traumatic stress disorder with a non-PTSD comparison group of 27 veteran patients receiving inpatient treatment for other mental disorders. Three multivariate analyses of variance were conducted comparing the two groups on the 10 traditional clinical scales, the 12 supplemental scales and the 15 new content scales on the MMPI-2. The PTSD group obtained a mean profile with peak elevations on the F validity scale and on clinical Scales 2 (D) and 8 (Sc). The multivariate analysis of variance comparing the PTSD and non-PTSD groups across the 10 traditional clinical scales was not significant. The multivariate analyses of variance comparing the two groups on the 12 supplemental scales and the 15 content scales were significant. Significant univariate supplemental scale differences were found on the Keane PTSD scale (PK) and the Post-Traumatic Stress Disorder (PS) scale with the PTSD group scoring higher on PK and PS. Significant univariate content scale differences were found for the Anger (ANG) scale with the PTSD group scoring higher. A cut-off score of 28 on the PK scale correctly classified 76% of the overall sample, 67% of the PTSD group and 85% of the non-PTSD-comparison group.

Abstract This study compared the MMPI‐2 profiles of 27 veterans diagnosed with post‐traumatic stress disorder with a non‐PTSD comparison group of 27 veteran patients receiving inpatient treatment for other mental disorders. Three multivariate analyses of variance were conducted comparing the two groups on the 10 traditional clinical scales, the 12 supplemental scales and the 15 new content scales on the MMPI‐2. The PTSD group obtained a mean profile with peak elevations on the F validity scale and on clinical Scales 2 (D) and 8 (Sc). The multivariate analysis of variance comparing the PTSD and non‐PTSD groups across the 10 traditional clinical scales was not significant. The multivariate analyses of variance comparing the two groups on the 12 supplemental scales and the 15 content scales were significant. Significant univariate supplemental scale differences were found on the Keane PTSD scale (PK) and the Post‐Traumatic Stress Disorder (PS) scale with the PTSD group scoring higher on PK and PS. Significant univariate content scale differences were found for the Anger (ANG) scale with the PTSD group scoring higher. A cut‐off score of 28 on the PK scale correctly classified 76% of the overall sample, 67% of the PTSD group and 85% of the non‐PTSD‐comparison group.

A calculation method is described, which presumes that linac output has two components. One component is direct x rays from the target and the remaining component is an extra-focal, distributed source of radiation that is scattered from the flattening filter, primary collimator, and the jaws of the moveable collimator. This calculation method gives values for output factors that differ from measured values by no more than 0.5% for field widths from 4 to 40 cm, rectangular fields with long to short axis ratios as great as 10, symmetric and asymmetric fields, and source-to-axis distances from 65 to 360 cm. While this calculation method has great accuracy and flexibility, a minimal amount of input data is required: (1) measured output factors at a source-to-axis distance of 100 cm for square fields; (2) positions of the collimator with respect to the x-ray source target; and (3) output factors measured at various source-to-axis distances for a 10 cm x 10 cm field.

Head-scatter factors, Sh, also referred to as output factors, are measured in-air with an ion chamber and a semiconductor diode fitted with cylindrical build-up caps and columnar miniphantoms fabricated from materials of different atomic number. Sh increases with field size less rapidly when cylindrical build-up caps are constructed from high atomic number materials. This is a consequence of a net scatter of contamination electrons away from the detector. Ion chambers and diodes give identical results when the same type of build-up caps are used. Contamination electrons can be avoided by the use of columnar miniphantoms that have sufficient wall thickness in the radial direction. This radial wall thickness is characterized in this work for 6, 10, and 18 MV x-ray beams. Sh increases with field size less rapidly when columnar miniphantoms are constructed from high atomic number materials. This is due to the decrease in the average energy of photons at large field sizes. It is concluded that to obtain Sh for dosimetry in water, cylindrical build-up caps and columnar miniphantoms should be constructed from material with an atomic number close to that of water.

PURPOSE: Over 95% of patients who screen positive on the Patient Health Questionnaire-9 (PHQ-9) suicide risk item do not attempt or die by suicide, which could lead to unnecessary treatment and/or misallocation of limited resources. The present study seeks to determine if suicide risk screening can be meaningfully improved to identify the highest-risk patients. METHODS: Patients eligible to receive medical treatment from the US Department of Defense medical system were recruited from 6 military primary care clinics located at 5 military installations around the United States. Patients completed self-report measures including the PHQ-9 and 16 items from the Suicide Cognitions Scale (SCS) during routine primary care clinic visits. Postbaseline suicidal behaviors (suicide attempts, interrupted attempts, and aborted attempts) were assessed by evaluators who were blind to screening results using the Self-Injurious Thoughts and Behaviors Interview. RESULTS: Among 2,744 patients, 13 (0.5%) engaged in suicidal behavior in the 30 days after screening and 28 (1.0%) displayed suicidal behavior in the 90 days after screening. Multiple SCS items differentiated patients with suicidal behavior less than 30 days after screening positive for suicide risk. Augmenting the PHQ-9 suicide risk item with SCS items improved the identification of patients who were most likely to have suicidal behavior within a month of screening positive without sacrificing sensitivity. CONCLUSION: Among primary care patients who screen positive for suicide risk on the PHQ-9, SCS items improved screening efficiency by identifying those patients who are most likely to engage in suicidal behavior within the next 30 days.

This article reviews current treatment algorithms for the conservative treatment of hip and knee osteoarthritis. The available treatment options for osteoarthritis (physical therapy, medical therapeutics, steroid injections, nutraceuticals, hyaluronic acid injections, acupuncture, pulsed electrical stimulation, and topical ointments) are compared to determine efficacy in the treatment of pain and return of function in the osteoarthritic joint. A literature review was conducted to determine combinations of appropriate concomitant therapy. Based on the available literature, we conclude that an early transition to multimodal and concomitant therapy is the most efficacious approach to decrease pain and improve joint function in the osteoarthritic hip and knee.

An empirical model is presented that uses a sector-integration method for calculating the output factors of irregularly shaped electron fields. The sector-integration method accounts for changes in electron fluence, lateral scatter equilibrium, and scatter from the edge of a cutout shield. This method is tested for elliptical and rectangular fields with a ratio of the long-to-short axis as great as 4 to 1. Differences between measured and calculated values for output factors were less than +/- 1%. Comparisons were also carried out for a large number of cutout shields that were used in the clinic and similar levels of accuracy were obtained.