Beckley VA Medical Center

Personality is known to be relatively stable throughout adulthood. Nevertheless, it has been shown that major life events with high personal significance, including experiences engendered by psychedelic drugs, can have an enduring impact on some core facets of personality. In the present, balanced-order, placebo-controlled study, we investigated biological predictors of post-lysergic acid diethylamide (LSD) changes in personality. Nineteen healthy adults underwent resting state functional MRI scans under LSD (75µg, I.V.) and placebo (saline I.V.). The Revised NEO Personality Inventory (NEO-PI-R) was completed at screening and 2 weeks after LSD/placebo. Scanning sessions consisted of three 7.5-min eyes-closed resting-state scans, one of which involved music listening. A standardized preprocessing pipeline was used to extract measures of sample entropy, which characterizes the predictability of an fMRI time-series. Mixed-effects models were used to evaluate drug-induced shifts in brain entropy and their relationship with the observed increases in the personality trait openness at the 2-week follow-up. Overall, LSD had a pronounced global effect on brain entropy, increasing it in both sensory and hierarchically higher networks across multiple time scales. These shifts predicted enduring increases in trait openness. Moreover, the predictive power of the entropy increases was greatest for the music-listening scans and when "ego-dissolution" was reported during the acute experience. These results shed new light on how LSD-induced shifts in brain dynamics and concomitant subjective experience can be predictive of lasting changes in personality. Hum Brain Mapp 37:3203-3213, 2016. © 2016 Wiley Periodicals, Inc.

BACKGROUND: Insomnia is frequently co-morbid with depression, with a bidirectional relationship between these disorders. There is evidence that insomnia-specific interventions, such as cognitive behavioral therapy for insomnia, may lead to improvements in depression. The purpose of this systematic review and meta-analysis is to determine whether treatment of insomnia leads to improved depression outcomes in individuals with both insomnia and depression. METHODS: We conduct a systematic review and meta-analysis to explore the effect of treatment for insomnia disorder on depression in patients with both disorders. RESULTS: Three thousand eight hundred and fifteen studies were reviewed, and 23 studies met inclusion criteria. Although all of the studies suggested a positive clinical effect of insomnia treatment on depression outcomes, most of the results were not statistically significant. Although the interventions and populations were highly variable, the meta-analysis indicates moderate to large effect size (ES) improvement in depression as measured with the Hamilton Depression Rating Scale (ES = -1.29, 95%CI [-2.11, -0.47]) and Beck Depression Inventory (ES = -0.68, 95%CI [-1.29, -0.06]). CONCLUSIONS: These results support that treating insomnia in patients with depression has a positive effect on mood. Future trials are needed to identify the subtypes of patients whose depression improves during treatment with insomnia-specific interventions, and to identify the mechanisms by which treating insomnia improves mood.

Simultaneous extrathoracic and intrathoracic flow resistance was measured in 19 unanesthetized subjects during mouth breathing. Lateral intratracheal pressure was recorded from a needle introduced 2 cm below the larynx. The intratracheal-oral pressure gradient was recorded during various respiratory maneuvers. The pressure drop from esophagus to trachea was also recorded. The extrathoracic pressure-flow relationships were alinear. Large inter- and intrasubject variability in upper airway resistance was encountered. Some factors contributing to this variability were defined. The upper airway accounted for approximately 45% of the total airway resistance in nine normal and 20% in 10 emphysematous human subjects. Upper airway resistance decreased with increasing lung inflation in four normal subjects. The magnitude and potential variability of the upper airway resistance must be considered in evaluating maneuvers designed to alter intrathoracic flow resistance, especially in normal human beings. It appears that during mouth breathing the major component of the upper airway resistance is located in the larynx. Submitted on September 14, 1960

In this paper the effects of quantization in an important class of networked control systems called model-based networked control systems (MB-NCS) are considered. The MB-NCS architecture uses an explicit model of the plant in the controller in order to reduce the network traffic, while attempting to prevent excessive performance degradation. Sufficient stability conditions for two types of static and a dynamic quantization schemes for MB-NCS are derived. An important feature is that the stability conditions are explicitly expressed in terms of the plant and controller dynamics, the error between the model and the plant parameters, the transmission or update times, the quantization parameters, and a robustness measure of the system to parameter uncertainty. This is important because it allows the design of the controller and network parameters to achieve the desired goals. Examples are used throughout to illustrate the main results.

Abstract Cadmium (Cd) has no known essential biological function, but it is toxic to plants, animals, and humans. A promising approach to prevent Cd from entering the food chain would be to select and/or create Cd‐accumulating plants to remediate contaminated soils or to develop Cd‐excluding plants to reduce Cd flow from soils into foods. The present study was undertaken to examine the differences in Cd influx, transport, and accumulation among five plant species in relation to plant tolerance to Cd toxicity. Ryegrass (Lolium perenne L.) had the least reduction in dry matter which may be due to its lowest Cd transport rate (TR) to shoots at all Cd levels among the plant species tested. White‐clover (Trifolium repens L.) was the most sensitive species to Cd toxicity, likely because of its highest Cd influx rate (IR) and high TR when plants were grown at low Cd2+ activity (≤8 μM). The high tolerance of cabbage (Brassica oleracea var. capitata L.) to moderate Cd toxicity (≤14 μM) appeared to be mainly due to the detoxification of Cd inside plant tissue since it recorded the highest TR and relatively high IR for Cd among the tested species. At Cd2+ activities up to 28 uM, the Cd uptake ratios of shoot/root for ryegrass were, on average, about 50‐fold and 27‐fold lower than that for cabbage and maize (Zea mays L.), respectively. These results showed that Cd could be easily transported into shoots of cabbage and maize, but was mainly confined to roots of ryegrass. We suggest that influx and transport rates, especially transport rate, could be used as plant physiological parameters for screening Cd‐excluding genotypes among monocotyledonous plants.

Cholinesterase inhibitors are known to enhance cognitive function among patients with dementia of the Alzheimer's type. It is quite possible that this clinical benefit may extend to other patient groups, yet this issue awaits further exploration. This study examines the use of the cholinesterase inhibitor donepezil in the treatment of patients with a history of brain injury and subsequent cognitive impairment. The sample was comprised of 53 ambulatory psychiatric patients who were receiving care for psychiatric sequelae of brain injury. In this sample, residual cognitive impairment was treated with adjunctive donepezil. This study reports the clinical assessments of this patient sample in outpatient follow-up for up to two years duration. Assessments of cognition with the Wechsler Adult Intelligence Scale-Revised and the Hooper Visual Organization Test were obtained on a subset of this sample (N = 22). Clinician assessment ratings were analyzed for the entire sample. Results indicated an improvement in full-scale IQ (t = 2.5, p = 0.02) score as well as clinician-based ratings (t = 12.2, p < 0.0001). Further research will likely delineate whether specific types of brain injuries are most responsive to cholinesterase inhibitors. These findings suggest that donepezil may enhance clinical response by complementing the medication management of other concomitant psychiatric disturbances related to brain injury.

We investigated the release of P from 10 surface and subsurface soil horizons, using four kinetic equations (Elovich, modified Freundlich, parabolic diffusion, and first-order) to describe the desorption rate data. The results demonstrate the successful use of the first-order rate equation to describe P-desorption rates. The choice of the first-order rate equation over others investigated was based on the goodness of fit (lower standard error of estimate obtained) and on the more scientific theoretical assumptions of the equation. We also investigated the relationship between first-order equation constants and the selected physical and chemical properties of the studied soils. Multiple regression models relating first-order equation constants to soil variables yielded high R2 values. The ratios of exchangeable A1/clay and Fe2O3/organic C were strong contributors in the first-order constants models. The regression models were successful in predicting the first-order equation constants, as well as the P desorbed from soils.

The O(2) permeability of legume root nodules is under physiological control; decreases in permeability are triggered by various forms of stress. Two linked mathematical models were used to explore several hypotheses concerning the physical nature of the variable diffusion barrier in nodules. Respiration and diffusion of dissolved O(2) and oxygenated leghemoglobin were simulated for the nodule cortex and the nodule interior. Measured nodule permeabilities were shown to be inconsistent with the hypothesis that large numbers of air-filled pores penetrate the diffusion barrier. Changes in the affinity of leghemoglobin for O(2) or in the rate of cytoplasmic streaming in diffusion barrier cells did not result in the large changes in O(2) permeability reported for real nodules. The presence or absence, but not the thickness, of aqueous plugs in radial pores through the cortex was found to have a large effect on permeability. Flooding of intercellular spaces, either between layers of cells in the cortex or in the nodule interior, also caused large changes in simulated permeability. The unsteady-state O(2) method for determining nodule permeability was tested using data generated by the model. The accuracy of the method was confirmed, provided that certain assumptions (full oxygenation of leghemoglobin under pure O(2) and uniform conditions in the nodule interior) are met.

INTRODUCTION: The CUSTOMIZE hybrid III implementation-effectiveness study evaluated implementation of once-monthly long-acting (LA) cabotegravir + rilpivirine in diverse US healthcare settings. Here, we report patient participant perspectives after 12 months in CUSTOMIZE. METHODS: CUSTOMIZE was a phase IIIb, 12-month study conducted from July 2019 to October 2020 at eight diverse US HIV clinics that enrolled virologically suppressed people living with HIV-1 (PLHIV) on a stable oral regimen to receive monthly cabotegravir + rilpivirine LA injections after a 1-month oral lead-in. Participants were administered quantitative surveys before injections at months 1 (baseline), 4 and 12. A randomly selected subset of participants was interviewed at baseline and month 12. Data collection at month 12 was completed by October 2020 (during the COVID-19 pandemic). RESULTS: At baseline, 109 and 34 participants completed surveys and interviews, respectively; 87% were male; 35% were Black or African American. All participants who remained in the study at month 12 (n = 102) maintained HIV-1 RNA <50 copies/ml; two participants withdrew due to injection-related reasons. Mean total scores measuring acceptability and appropriateness of cabotegravir + rilpivirine LA were high at baseline (4.5-4.6 out of 5) and month 12 (4.7-4.9). At month 12, 74% of participants reported nothing interfered with receiving LA injections; injection pain or soreness was the most common concern (15%). Time spent in the clinic and coming to the clinic for monthly injections was very or extremely acceptable after 12 months for most participants (93% and 87%, respectively), with 64% reporting having spent ≤30 minutes in the clinic for injection visits. At month 12, 92% of participants preferred LA injections to daily oral tablets (3%); 97% plan to continue LA treatment going forward. In month 12 interviews, 24 (77%) of 31 participants reported the COVID-19 pandemic did not impact their ability to receive treatment. CONCLUSIONS: Once-monthly cabotegravir + rilpivirine LA was highly acceptable among PLHIV who were virologically suppressed on a stable antiretroviral regimen and interested in trying LA therapy, with few participants reporting challenges receiving LA injections. Implementation data from CUSTOMIZE suggest that monthly LA injections provide a convenient and appealing treatment option for PLHIV.

The objective of this study was to examine the complications encountered in a series of 150 consecutive thyroid and parathyroid procedures performed by a single surgeon in a rural community hospital setting. The goal was to demonstrate that these procedures may be performed safely and with outcomes equivalent to those of academic hospitals in major metropolitan areas despite the lack of availability of specific technologies that are being increasingly used for these procedures in tertiary care settings. Specifically, these include intraoperative parathyroid hormone measurements, intraoperative recurrent laryngeal nerve monitoring, and the use of the gamma probe for detection of parathyroid adenoma. A retrospective chart review was conducted on a series of 150 patients undergoing any thyroid or parathyroid operation by a single surgeon in a rural setting over a 4-year period. Data was reported regarding success at achieving the goal of the operation and any perioperative complications such as recurrent laryngeal nerve injury, permanent hypoparathyroidism, wound hematoma, infection, or pneumonia. One hundred thirty-one thyroid procedures were performed (71 lobectomies, 60 total or near total procedures) for a diverse range of patholological conditions: multinodular goiter, 76 (50.7%) patients, follicular adenoma, 9 (6.0%) patients, Hashimoto's thyroiditis, 13 (8.7%) patients, papillary carcinoma, 14 (9.3%) patients, follicular carcinoma, 5 (3.3%) patients, follicular variant of papillary carcinoma, 13 (8.7%) patients, and medullary carcinoma, 1 (0.7%) patient. Nineteen successful parathyroid explorations were performed for primary hyperparathyroidism. The overall incidence of recurrent nerve injury was 1.33 per cent overall (0.99% for each nerve encountered). The incidence of transient postoperative hypocalcemia was 13 per cent, with one patient suffering permanent hypoparathyroidism (0.8%). Two patients developed wound hematomas requiring evacuation. The overall complication rate with respect to recurrent laryngeal nerve injury and permanent hypoparathyroidism was consistent with or below that that in recent large series, despite the absence of specialized equipment for nerve monitoring. The success of identifying parathyroid adenoma was 100 per cent, despite the absence of intraoperative parathormone assays, and the decision not to perform radio-guided parathyroidectomy. We conclude that outcomes and complications in thyroid and parathyroid surgical procedures are largely dependent on surgeon skill and experience, and can be performed safely in the community setting by an experienced general surgeon despite the absence of advanced technology in this setting. We encourage all surgeons to continually examine their operative results with all technically demanding procedures when deciding the composition of their individual practices.

IN THE PAST reciprocal rhythm in man has been associated mostly with AV nodal rhythm; there are several reviews of the lit- erature.1-4 In the described cases the AV nodal impulse activates first the ventricles, then after some delay the atria; somewhere in its course to or toward the atria the impulse presum- ably turns back to activate the ventricles again. This phenomenon was first recognized in electrocardiograms of man by White.5 Mines6 had previously observed a similar phenomenon in experimental animals, the im- pulse originating in an atrium or ventricle, traveling to the other chamber, then back to the chamber of origin, then back again to the other chamber, etc., etc. for a number of cycles. Pan7 applied this explanation to hu- man polygraphic tracings in which he believed the impulse originated in a ventricular pre- mature systole, traveled to the atria and then back to the ventricles. The phenomenon was possibly represented but not recognized in polygraphic tracings of Wenckebach.89 Re- cent studies indicate that reciprocal rhythm in man may be initiated by ventricular prema- ture systoles far more frequently than has heretofore been suspected and may often ac- count for the ventricular systole which follows the commonplace interpolated ventricular pre- mature systole.10

OBJECTIVE: To evaluate the impact of neoadjuvant multi-agent systemic chemotherapy and radiation (TNT) vs neoadjuvant single-agent chemoradiation (nCRT) and multi-agent adjuvant chemotherapy on overall survival (OS), tumor downstaging, and circumferential resection margin (CRM) status in patients with locally advanced rectal cancer. SUMMARY OF BACKGROUND DATA: Outside of clinical trials and small institutional reports, there is a paucity of data regarding the short and long-term oncologic impact of TNT as compared to nCRT. METHODS: Adult patients with stage II-III rectal adenocarcinoma were identified in the National Cancer Database [2006-2015]. RESULTS: Out of 8,548 patients, 36% received TNT and 64% nCRT. In the cohort, 13% had a pCR and 20% a neoadjuvant rectal (NAR) score <8. In multivariable analysis, as compared to nCRT, TNT demonstrated numerically higher pCR rates ( P = 0.05) but had similar incidence of positive CRM ( P = 0.11). Similar results were observed with NAR scores <8 as the primary endpoint. After adjusting for confounders, OS was comparable between the 2 groups. Additional factors independently associated with lower OS included male gender, uninsured status, low income status, high comorbidity score, poorly differentiated tumors, abdominoperineal resection, and positive surgical margins (all P <0.01). In separate models, both pCR and a NAR score <8 were associated with improved OS. CONCLUSION: In this national cohort, TNT was not associated with better survival and/or CRM negative status in comparison with nCRT, despite numerically higher downstaging rates. Further refinement of patient selection and treatment regimens are needed to establish effective neoadjuvant platforms to improve outcomes of patients with rectal cancer.

INTRODUCTION: CUSTOMIZE evaluated the implementation of long-acting (LA) cabotegravir + rilpivirine, a novel healthcare provider-administered injectable antiretroviral therapy regimen, in diverse US healthcare settings. Findings from staff-study participants (SSPs) through 12 months of implementation are reported. METHODS: CUSTOMIZE was a phase IIIb, 12-month, single-arm, hybrid III implementation-effectiveness study conducted from July 2019 to October 2020 at eight US clinics of five clinic types: private practice (n = 2), federally qualified health centre (n = 2), university (n = 2), AIDS Healthcare Foundation (n = 2) and health maintenance organization (n = 1). Eligible patient participants received monthly cabotegravir + rilpivirine LA injections after a 1-month oral lead-in. At baseline, month 4 and month 12, SSPs (n = 3 each per clinic), including physicians, nurses or injectors, and administrators, completed quantitative surveys and semi-structured interviews to assess implementation outcomes (acceptability, appropriateness and feasibility of intervention measures), programme sustainability and SSP perceptions of, attitudes towards, and expectations for cabotegravir + rilpivirine LA. Month 12 data collection occurred during the COVID-19 pandemic. RESULTS: In surveys, SSPs reported high mean total scores for acceptability, appropriateness and feasibility of cabotegravir + rilpivirine LA implementation at baseline (4.43, 4.52 and 4.38 of 5, respectively) and month 12 (4.45, 4.61 and 4.46 of 5, respectively), regardless of clinic type. At month 12, SSPs were positive about the implementation sustainability (mean Program Sustainability Assessment Tool score, 5.83 out of 7). At baseline, SSPs' top concern was patients' ability to maintain monthly appointments (81%); at month 12, 39% had this concern. The proportion of SSPs reporting patient injection pain or soreness as a barrier was consistent at month 12 versus baseline (48% vs. 46%). Most (78%) SSPs reported optimal implementation of cabotegravir + rilpivirine LA in their clinics was achieved in 1-3 months. In interviews, SSP-reported strategies for successful implementation included teamwork, using a web-based treatment planner and having a designated person to track appointment scheduling. In month 12 interviews, SSP-reported structural changes needed for implementation included changing clinic hours and purchasing refrigerators. CONCLUSIONS: In CUSTOMIZE, cabotegravir + rilpivirine LA was successfully implemented across a range of US healthcare settings. Barriers were mitigated with minor process adjustments.

INTRODUCTION: Stercoral perforation of the colon is a rare pathology, which is believed to be caused by an increased intraluminal pressure created by a fecaloma. Opioid induced constipation is a rare and often unsuspected cause of colonic perforation. PRESENTATION OF CASE: We report the case of a 58-year-old woman, who presented to the emergency department (ED) with severe hypotension, abdominal pain and gastrointestinal bleeding. She was found to have a diffusely tender and distended abdomen. Her history was positive for long-term suboxone use and chronic constipation. Abdominopelvic computed tomography (CT) scan revealed a bowel perforation, ascites and fecal impaction. Emergency laparotomy revealed extensive stool in the peritoneal cavity as well as hemoperitoneum. There was a fecal bolus with perforation located in the sigmoid colon. On postoperative day (POD) six, a second abdominopelvic CT scan was performed and results revealed the necessity of a second exploratory laparotomy. She had multiple loculated abscesses within the small bowel and other areas, which were opened and washed out. DISCUSSION: Due to the inflating use of drugs in the opioid class, the recognition of this pathology has become increasingly important. The action of the drug on the mu-opioid receptors, any patients taking opioid medications are at risk for constipation progressing to stercoral perforation and should be monitored closely. CONCLUSION: Patients presenting with chronic constipation, fecal impaction on imaging and clinical signs of peritonitis or sepsis, should consider stercoral perforation in their differential diagnosis since early detection is key to reduce mortality rates in these cases.

Abstract Soil biochemical properties are influenced by management practices and the type of plant cover, and such changes affect the levels of enzyme activities in soil. In turn, enzymes influence the nutrient supply in soil and growth and mineral composition of the plants. Acidic infertile upland soils are relatively colder in crop‐growing season than low land soils and require application of sulfur (S) and phosphorus (P) to improve crop production. Field experiments were carried out on Gilpin silt loam (Typic Hapludult at elevation of 908 m) soil with initial application of four levels of S (0, 16.8, 33.6, and 67.2 kg S ha−1) and three levels of P (22.4, 89.6, and 358.4 kg P ha−1). Acid phosphatase (AP), arylsulfatase (AS) and urease (UR) activities were determined 3 years after the initial fertilizer application. Increasing levels of soil‐applied S decreased enzyme activities, but the highest level of applied S (67.2 kg S ha−1) in fact stimulated higher enzyme activities. Increasing levels of soil‐applied P reduced AP activities significantly and resulted in reducing trends in AS and UR activities. Overall, the enzyme activities were reduced significantly with increasing soil depth. Activities of all three enzymes were significantly correlated with soil moisture content, total carbon (C) and nitrogen (N), S, and organic sulfur. Findings of this research are helpful in designing management systems that could improve the production potentials of acid soils.

Beer potomania, a unique syndrome of hyponatremia, was first reported in 1972. It is described as the excessive intake of alcohol, particularly beer, together with poor dietary solute intake that leads to fatigue, dizziness, and muscular weakness. The low solute content of beer, and suppressive effect of alcohol on proteolysis result in reduced solute delivery to the kidney. The presence of inadequate solute in the kidney eventually causes dilutional hyponatremia secondary to reduced clearance of excess fluid from the body. Early detection of hyponatremia due to beer potomania in the hospital is necessary to carefully manage the patient in order to avoid neurological consequences as this syndrome has unique pathophysiology. We are reporting two cases, presenting to the emergency department with severe hyponatremia. After a detailed initial evaluation of the patients and labs for hyponatremia, a diagnosis of beer potomania was established in both cases. Considering the unique pathophysiology of beer potomania syndrome, the patients were closely monitored and treated appropriately to prevent any neurological sequelae.

Various forms of stress result in decreased O(2) permeability or decreased capacity to consume O(2) in legume root nodules. These changes alter the nodule interior O(2) concentration (O(i)). To determine the relationship between O(i) and nitrogenase activity in attached soybean (Glycine max) nodules, we controlled O(i) by varying external pO(2) while monitoring internal H(2) concentration (H(i)) with microelectrodes. O(i) was monitored by noninvasive leghemoglobin spectrophotometry (nodule oximetry). After each step-change in O(i), H(i) approached a new steady state, with a time constant averaging 23 s. The rate of H(2) production by nitrogenase was calculated as the product of H(i), nodule surface area, and nodule H(2) permeability. H(2) permeability was estimated from O(2) permeability (measured by nodule oximetry) by assuming diffusion through air-filled pores; support for this assumption is presented. O(i) was nearly optimal for nitrogenase activity (H(2) production) between 15 and 150 nm. A 1- to 2-min exposure to elevated external pO(2) (40-100 kPa) reduced H(i) to zero, but nitrogenase activity recovered quickly under air, often in <20 min. This rapid recovery contrasts with previous reports of much slower recovery with longer exposures to elevated pO(2). The mechanism of nitrogenase inhibition may differ between brief and prolonged O(2) exposures.

The anti-pancreatic lipase and antioxidant activity of Momordica charantia, Morinda citrifolia fruit, and Centella asiatica extract were evaluated for potential use as an anti-obesity agent. Antioxidant activity of the extracts was determined using 2,2-diphenyl-1-picrylhdrazyl and ferric-reducing antioxidant power assays. Inhibition of pancreatic lipase was measured in vitro. Results from this study showed that Momordica charantia, Morinda citrifolia fruit, and Centella asiatica extract exhibited different levels of antioxidant activity, with IC50 ranging from 0.90 ± 0.1 to 3.7 ± 0.8 mg/mL of extracts. All extracts were found to inhibit pancreatic lipase activity, with Momordica charantia, Morinda citrifolia fruit, and Centella asiatica extract demonstrating 21.0 ± 1.3, 25.8 ± 0.1, and 25.3 ± 0.4% inhibition, respectively.

Motivational interviewing (MI) is an empirically supported clinical method to help individuals make behavioral changes to achieve a personal goal. Through a set of specific techniques, MI helps individuals mobilize their own intrinsic values and goals to explore and resolve ambivalence about change. This article examines how MI-informed approaches can be applied to help staff adopt new evidence-based practices in organizational settings. Although the implementation science literature offers strategies for implementing new practices within organizations, leaders of quality improvement initiatives often encounter ambivalence about change among staff. Implementation approaches that require staff to make substantial changes may be facilitated by drawing from MI strategies. These include building a sense of collaboration from the beginning, eliciting "change talk," and addressing any ambivalence encountered. Motivational interviewing techniques may be particularly helpful in working with those in a stage of precontemplation (who have yet to see a reason for change) and those who are contemplating change (who see that a problem exists but are ambivalent about change). This article provides examples of how an MI-informed approach can be applied to help facilitate change in staff within organizations that are implementing quality improvement initiatives. These techniques are illustrated using a representative scenario.

The interval between an ectopic QRS and a retrograde P wave measured in simultaneous esophageal and other leads may help to identify beats which originate in the atrio-ventricular (A-V) junction. In six cases beats which seem to originate in the A-V junction are associated with a QRS which differs in configuration from the QRS of sinus origin, and in each case atrial premature systoles which give rise to normal QRS complexes occur in tracings which contain the A-V junctional beats also. Comparison of the QRS of the atrial premature systoles with the QRS of the A-V junctional beats with respect to the time of occurrence in the cardiac cycle and the duration of the preceding cycle makes it seem unlikely that the altered QRS of the A-V junctional beats can be explained by aberrant conduction during incomplete recovery. In five of the cases, fusion QRS complexes occur, suggesting activation of the ventricles partly by an impulse of sinus origin and partly by the impulse of A-V junctional origin. These observations support the interpretation previously made by others that impulses of A-V junctional origin may reach the ventricles by pathways other than the usual A-V pathway. If such beats as are described here occur at all frequently, then the diagnostic value of fusion, heretofore considered an almost conclusive criterion of a ventricular focus, may be impaired.