Berkshire Medical Center

OBJECTIVE: To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION: This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.

OBJECTIVE: To develop updated guidelines for the pharmacologic management of rheumatoid arthritis. METHODS: We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations. RESULTS: The guideline addresses treatment with disease-modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high-risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional). CONCLUSION: This clinical practice guideline is intended to serve as a tool to support clinician and patient decision-making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients' values, goals, preferences, and comorbidities.

BACKGROUND: Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence. METHODS AND RESULTS: This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends. CONCLUSIONS: Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.

The stages of the process of migration are described, with the implications of each for family conflict and appropriate therapeutic intervention.

Resilience is the ability of people to 'spring back' in the face of adversity. It is an important concept for nurses as we endeavour to assist individuals to meet the challenges of living with illness and ageing. Researchers from many disciplines in both the social and health sciences have investigated resilience of individuals throughout the life cycle in a variety of situations related to health as well as other life events. Some researchers have investigated resilience as a trait of individuals while other view resilience as a process. This article reviews the current literature on resilience from many disciplines and discusses implications for nursing practice and research.

Heparin, the most widely used anticoagulant drug in the world today, remains an animal-derived product with the attendant risks of adulteration and contamination. A contamination crisis in 2007-2008 increased the impetus to provide non-animal-derived sources of heparin, produced under cGMP conditions. In addition, recent studies suggest that heparin may have significant antineoplastic activity, separate and distinct from its anticoagulant activity, while other studies indicate a role for heparin in treating inflammation, infertility, and infectious disease. A variety of strategies have been proposed to produce a bioengineered heparin. In this review, we discuss several of these strategies including microbial production, mammalian cell production, and chemoenzymatic modification. We also propose strategies for creating "designer" heparins and heparan-sulfates with various biochemical and physiological properties.

When problematic-symptomatic behaviors are conceived as embedded, retained, and maintained in collective stories, therapy can be described as the transformative process by which patients, families, and therapists co-generate qualitative changes in those stories. An emphasis on narratives allows one to specify further how those transformations unfold at the more "micro" level of the exchanges that take place throughout the consultation. To that specification is devoted the core of this essay, which closes with a discussion of the clinical, training, and, especially, research potentials of this systematization.

From Berkshire Medical Center, Pittsfield, Mass (Ms Rosier); Nanticoke Health Services, Seaford, Del (Ms Wright); and Thomason Hospital, El Paso, Tex (Ms Chasco).

An historic meeting of 44 major medical and injury prevention organizations and the American Bar Association was hosted by the American College of Surgeons (ACS) February 10-11, 2019. Leaders of these professional organizations met with the goal of building consensus around opportunities to work together to address the growing problem of firearm injury and death in the US. A multidisciplinary planning committee invited speakers who are leading experts and researchers in this field to review the epidemiology of firearm injury, discuss structural violence and the social determinants of health, review the public health approach to the problem, and discuss opportunities for injury prevention interventions. The goal was to be maximally inclusive and include organizations that represent physicians, nurses, public health professionals, and emergency medical services providers who are both on the front lines in caring for injured patients and also manage the long-term consequences of violence in the community. All invited organizations were encouraged to submit digital materials related to their organization’s firearm injury prevention initiatives and these were shared before the Medical Summit. A list of the organizations that have agreed to support the consensus statements from this conference can be found in Appendix 1. For the past 30 years, many medical organizations have led efforts to address firearm injury and firearm violence, but most (if not all) of these efforts have become mired in a debate about personal liberty and the Second Amendment to the US Constitution. Some of this controversy has been internal to professional organizations, and some has been external. In general, this debate has not been productive—while death rates from other medical conditions such as traffic injury, heart disease, cancer, and HIV have decreased, firearm death rates in the US are increasing. The ACS Committee on Trauma has worked steadily to move beyond this debate, and to move from published statements to constructive action. The keys to this approach center on addressing firearm injury as a medical and public health problem, not a political problem; developing research agendas to understand and address root causes of violence; and committing to a professional and civil dialogue centered on how best to reduce and prevent firearm injury, death, and disability. This mirrors the public health model that has been so effective in improving outcomes in traffic-related injury. The following were the objectives of this Summit: Identify opportunities for the medical community to reach a consensus-based, non-partisan approach to firearm injury prevention Discuss the key components of a public health approach and define interventions this group will support Develop consensus on actionable items for firearm injury prevention using the public health framework We also sought to learn about the current independent efforts of all participating organizations to identify gaps and collaborative opportunities (Appendix 2). These objectives focus on injury prevention, which is integrated into a healthcare and trauma system framework that also functions to turn bystanders into immediate responders, and ensures the delivery of optimal prehospital, hospital/trauma center, and rehabilitative care. This system also serves as a framework for disaster and mass casualty response. This systematic approach requires engagement, stakeholder partnerships, data collection, research, education, advocacy, communication, and cooperation. The public health approach to firearm injury prevention is identical to other highly successful injury prevention initiatives. The underlying philosophy is grounded in an ethical framework centered on the principles of beneficence, autonomy, and honesty. Although not speaking specifically about injury prevention, Dr Richard Moulton sums up the philosophic approach well about the rationale for professionals leading in this sphere. He states, “We dedicate ourselves to the service of humanity, and most importantly we place the needs of the patient above those of the doctor…” And, “We will base our knowledge and actions on objective scientific truth as best we can determine it.” This ethical framework is the foundation of why professional societies are engaged in injury prevention programs. Firearm injury is a significant health problem for our patients and the communities we serve; therefore, it is important that we develop effective injury prevention strategies. Coming together as a professional community and approaching this epidemic as a disease and a public health problem promises to make our neighborhoods and our country safer, stronger, and more resilient. We believe that this can be done in a manner that preserves (or even enhances) freedom. This professional approach requires freedom with responsibility. The group reviewed survey data from the ACS that, on the surface, are consistent with a philosophic divide concerning the general benefit of firearms and views of firearms and freedom. In previous surveys of surgeons, a majority in the US adheres to 1 of 2 contrasting and conflicting narratives about firearm ownership.1 The visual abstract in Figure 1 graphically depicts this polarized debate and an inclusive alternative.2 This philosophic divide is most evident on the extremes, but these competing philosophies lead to polarized personal narratives and create the perception of a large chasm between 2 groups. One of 2 dominant narratives asserts that firearms are beneficial, necessary, and a protected right. The strongest adherents of this philosophic view very tightly link freedom and firearms; so for them, the term gun control is synonymous with freedom control. The second narrative asserts that firearms are harmful, generally unnecessary in civil life, and decrease personal liberty because of increased risk of harm (in homes and in communities). Strong adherents of this philosophic view very tightly link guns with violence, so for them gun control is synonymous with violence control.Figure 1.: Visual abstract describing the American College of Surgeons Committee on Trauma Consensus–based approach to the dialog related to firearm injury prevention.When faced with a perceived stress or crisis, those who view firearms as critical for personal freedom and protection push for greater availability and tend to purchase more firearms. Those who view firearms as emblematic of violence and harm push for increased restriction on access to firearms, and protest the violence. Both sides appear convinced they are absolutely correct, and both often react to each other by reinforcing their own position, while simultaneously villainizing the other. When searching for constructive solutions that realistically could positively impact hundreds of thousands of American lives annually, this gap can initially appear uncrossable. However, the chasm is not as wide as it might seem. In surveys of both medical professionals and the lay public there are many areas of agreement about firearm injury prevention. In a recent survey of ACS members, most respondents believe that firearms are both beneficial and harmful. When questioned about the role of firearms in protecting or restricting freedom, the most common response was that firearms neither protect nor limit personal freedom (unpublished data, ACS membership survey). The view of 2 conflicting narratives creates a false dichotomy. As Figure 1 depicts, there is a common narrative, inclusive of both philosophic views: firearm ownership is a constitutionally protected right and we also have a major firearm violence problem. The way to address the epidemic of firearm violence is to work together to fully understand and address the underlying causes of violence, while simultaneously working to make firearm ownership as safe as possible (for those who own firearms and for those who do not). The emergency healthcare community has led the implementation of a systematic approach to developing emergency medical services, trauma, and emergency healthcare the of these important have been that are to addressing health The general approach to implementation of these is on the following key be maximally inclusive with of create a dialogue and develop a consensus centered on is the right to do for the patient or the that and and communication, develop data with support for research and and a for with a focus on and system This approach requires professional freedom with to the patient and the community. This approach and to and These professional principles are to or other as firearm injury prevention. 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Item response theory (IRT) methods were used to develop a neuropsychological test battery with matched English and Spanish language forms. Candidate items for 12 scales measuring core neuropsychological abilities were generated and administered to 200 community-dwelling elderly participants tested in Spanish and 208 tested in English. IRT methods were used to eliminate linguistically biased items and refine scales to assess broad ability ranges. Reasonably good psychometric matching of scales was achieved within and across English and Spanish language forms. All scales were sensitive to cognitive impairment as measured by the Mini-Mental State Examination (MMSE), with highly similar relationships between scale scores and MMSE across English and Spanish groups. The outcome supports the use of IRT methods in cross-cultural and multilingual test development and indicates that this strategy has potential for future neuropsychological test development.

Word-list verbal learning and memory tests with appropriate normative data can be highly sensitive to cognitive decline, but there are significant limitations of such tests available for use with older Hispanic and non-Hispanic people living in the US. The purpose of this study was to (1) create a new word-list learning and memory test in both English and Spanish and, (2) validate it with respect to sensitivity to cognitive impairment, and (3) develop statistical corrections for the effects of significant demographic variables, including ethnicity, language of administration, age, education, and gender. A community dwelling sample of 801 English- and Spanish-speaking older people was employed. Recall on learning trials and the delayed recall trial of the word-list learning test were strongly related to the Mini-Mental State Examination (MMSE). moderately related to age, and weakly related to gender and education. The relationship of word-list variables and the MMSE did not significantly differ across ethnicity/language groups. Regression coefficients for demographic variables were used in a statistical correction formula to adjust raw word-list scores, and then to develop specific percentile cut-off values.

BACKGROUND: Hyperglycemia has been associated with adverse outcomes in patients with acute ischemic stroke (AIS) and may influence outcomes after tissue plasminogen activator (tPA). We sought to analyze the association of acute and chronic hyperglycemia on clinical outcomes in tPA-treated patients. METHODS AND RESULTS: We identified 58 265 AIS patients from 1408 sites who received tPA from 2009 to 2013 in Get With The Guidelines-Stroke. Acute hyperglycemia at admission was defined as a plasma glucose level >140 mg/dL. Chronic hyperglycemia was defined by plasma glycosylated hemoglobin (HbA1c) >6.5%. Post-tPA outcomes were analyzed using logistic regression. Blood glucose >140 mg/dL and HbA1c >6.5 were associated with worse clinical outcomes (symptomatic intracranial hemorrhage [sICH], life-threatening hemorrhage, and in-hospital mortality and length of stay) in diabetic and nondiabetic patients. Among patients with documented history of diabetes, increasing admission glucose up to 200 mg/dL was associated with increased adjusted odds ratio (aOR) of in-hospital mortality (aOR, 1.07) and sICH (aOR, 1.05) per 10 mg/dL increase in blood glucose. Increasing HbA1C to 8% was associated with increased odds of in-hospital mortality (aOR, 1.19) and sICH (aOR, 1.16) per 1% increase in HbA1c. Similar findings were observed in patients without a documented history of diabetes. There was no further increase in poor outcomes above the blood glucose level of 200 mg/dL or HbA1c >8. CONCLUSION: Acute and chronic hyperglycemia are both associated with increased mortality and worse clinical outcomes in AIS patients treated with tPA. Controlled trials are needed to determine whether acute correction of hyperglycemia can improve outcomes after thrombolysis.

Suicide is the tenth leading cause of death in the United States (US). An early-warning system (EWS) for suicide attempt could prove valuable for identifying those at risk of suicide attempts, and analyzing the contribution of repeated attempts to the risk of eventual death by suicide. In this study we sought to develop an EWS for high-risk suicide attempt patients through the development of a population-based risk stratification surveillance system. Advanced machine-learning algorithms and deep neural networks were utilized to build models with the data from electronic health records (EHRs). A final risk score was calculated for each individual and calibrated to indicate the probability of a suicide attempt in the following 1-year time period. Risk scores were subjected to individual-level analysis in order to aid in the interpretation of the results for health-care providers managing the at-risk cohorts. The 1-year suicide attempt risk model attained an area under the curve (AUC ROC) of 0.792 and 0.769 in the retrospective and prospective cohorts, respectively. The suicide attempt rate in the "very high risk" category was 60 times greater than the population baseline when tested in the prospective cohorts. Mental health disorders including depression, bipolar disorders and anxiety, along with substance abuse, impulse control disorders, clinical utilization indicators, and socioeconomic determinants were recognized as significant features associated with incident suicide attempt.

Background We aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program. Methods and Results We assessed pre- and in-hospital care and outcomes from 2008 to 2012 for patients with ST -segment-elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines Registry. In-hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact-to-device for emergency medical systems transport to percutaneous coronary intervention-capable hospitals (93 to 84 minutes), first door-to-device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door-in-door-out at non-percutaneous coronary intervention-capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in-hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years ( P<0.001). Conclusions Quality of care for patients with ST -segment-elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times-to-treatment. In-hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high-risk patients increased.

Numerous studies over the past decade have pointed to the frequent occurrence of trauma and neglect in the childhood experience of patients with Borderline Personality Disorder (BPD). Advancing research on Posttraumatic Stress Disorder (PTSD) and Dissociative Disorders offers further insight into understanding shared clinical phenomena with BPD. Drawing upon attachment theory, models of learned helplessness, and early primate deprivation, empirical, theoretical and clinical data are integrated to conceptualize the role of trauma and neglect in the etiology of BPD.

BACKGROUND: Preliminary semi-quantitative cardiovascular magnetic resonance (CMR) perfusion studies have demonstrated reduced myocardial perfusion reserve (MPR) in patients with angina and risk factors for microvascular disease (MVD), however fully quantitative CMR has not been studied. The purpose of this study is to evaluate whether fully quantitative CMR identifies reduced MPR in this population, and to investigate the relationship between epicardial atherosclerosis, left ventricular hypertrophy (LVH), extracellular volume (ECV), and perfusion. METHODS: Forty-six patients with typical angina and risk factors for MVD (females, or males with diabetes or metabolic syndrome) who had no obstructive coronary artery disease by coronary angiography and 20 healthy control subjects underwent regadenoson stress CMR perfusion imaging using a dual-sequence quantitative spiral pulse sequence to quantify MPR. Subjects also underwent T1 mapping to quantify ECV, and computed tomographic (CT) coronary calcium scoring to assess atherosclerosis burden. RESULTS: In patients with risk factors for MVD, both MPR (2.21 [1.95,2.69] vs. 2.93 [2.763.19], p < 0.001) and stress myocardial perfusion (2.65 ± 0.62 ml/min/g, vs. 3.17 ± 0.49 ml/min/g p < 0.002) were reduced as compared to controls. These differences remained after adjusting for age, left ventricular (LV) mass, body mass index (BMI), and gender. There were no differences in native T1 or ECV between subjects and controls. CONCLUSIONS: Stress myocardial perfusion and MPR as measured by fully quantitative CMR perfusion imaging are reduced in subjects with risk factors for MVD with no obstructive CAD as compared to healthy controls. Neither myocardial hypertrophy nor fibrosis accounts for these differences.

Care for US military personnel with combat-related concussive traumatic brain injury (TBI) has substantially changed in recent years, yet trends in clinical outcomes remain largely unknown. Our prospective longitudinal studies of US military personnel with concussive TBI from 2008-2013 at Landstuhl Regional Medical Center in Germany and twp sites in Afghanistan provided an opportunity to assess for changes in outcomes over time and analyze correlates of overall disability. We enrolled 321 active-duty US military personnel who sustained concussive TBI in theater and 254 military controls. We prospectively assessed clinical outcomes 6-12 months later in 199 with concussive TBI and 148 controls. Global disability, neurobehavioral impairment, depression severity, and post-traumatic stress disorder (PTSD) severity were worse in concussive TBI groups in comparison with controls in all cohorts. Global disability primarily reflected a combination of work-related and nonwork-related disability. There was a modest but statistically significant trend toward less PTSD in later cohorts. Specifically, there was a decrease of 5.9 points of 136 possible on the Clinician Administered PTSD Scale (-4.3%) per year (95% confidence interval, 2.8-9.0 points, p = 0.0037 linear regression, p = 0.03 including covariates in generalized linear model). No other significant trends in outcomes were found. Global disability was more common in those with TBI, those evacuated from theater, and those with more severe depression and PTSD. Disability was not significantly related to neuropsychological performance, age, education, self-reported sleep deprivation, injury mechanism, or date of enrollment. Thus, across multiple cohorts of US military personnel with combat-related concussion, 6-12 month outcomes have improved only modestly and are often poor. Future focus on early depression and PTSD after concussive TBI appears warranted. Adverse outcomes are incompletely explained, however, and additional studies with prospective collection of data on acute injury severity and polytrauma, as well as reduced attrition before follow-up will be required to fully address the root causes of persistent disability after wartime injury.

Wexner, Steven D. M.D.1,8,a; Beck, David E. M.D. (ASCRS)2; Baron, Todd H. M.D. (ASGE)3; Fanelli, Robert D. M.D. (SAGES)4; Hyman, Neil M.D. (ASCRS)5; Shen, Bo M.D. (ASGE)6; Wasco, Kevin E. M.D. (SAGES)7 Author Information

OBJECTIVE: To provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). RESEARCH METHODS AND PROCEDURES: Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. RESULTS: We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well-defined postsurgical diet progression. DISCUSSION: Obesity-related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling.

Background— Significant disparities have been reported in the application of evidence-based guidelines in the treatment of coronary artery disease (CAD) in women and the elderly. We hypothesized that participation in a quality-improvement program could improve care for all patients and thus narrow treatment gaps over time. Methods and Results— Treatment of 237 225 patients hospitalized with CAD was evaluated in the Get With the Guidelines–CAD program from 2002 to 2007. Six quality measures were evaluated in eligible patients without contraindications: aspirin on admission and discharge, β-blockers use at discharge, angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist use, lipid-lowering medication use, and tobacco cessation counseling along with other care metrics. Over time, composite adherence on these 6 measures increased from 86.5% to 97.4% (+10.9%) in men and 84.8% to 96.2% (+11.4%) in women. There was a slight difference in composite adherence by sex that remained significant over time ( P &lt;0.0001), but this was confined to patients &lt;75 years. Composite adherence in younger patients (&lt;75 years) increased from 87.1% to 97.7% (+10.6%) and from 83.0% to 95.1% (+12.1%) in the elderly (≥75 years) over time. Conclusions— Among hospitals participating in Get With the Guidelines–CAD, guideline adherence has improved substantially over time for both women and men and younger and older CAD patients, with only slight age and sex differences in some measures persisting.