Colmery-O'Neil VA Medical Center

OBJECTIVE: Carbohydrate counting is an effective approach to mealtime insulin adjustment in type 1 diabetes but has not been rigorously assessed in type 2 diabetes. We sought to compare an insulin-to-carbohydrate ratio with a simple algorithm for adjusting the dose of prandial insulin glusiline. RESEARCH AND DESIGN METHODS: This 24-week, multicenter, randomized, controlled study compared two algorithms for adjusting mealtime (glulisine) insulin along with a standard algorithm for adjusting background (glargine) insulin in 273 intent-to-treat patients with type 2 diabetes. Glulisine and glargine were adjusted weekly in both groups based on self-monitored blood glucose (SMBG) results from the previous week. The simple algorithm group was provided set doses of glulisine to take before each meal. The carbohydrate counting (carb count) group was provided an insulin-to-carbohydrate ratio to use for each meal and adjusted their glulisine dose based on the amount of carbohydrate consumed. RESULTS: A1C levels at week 24 were 6.70% (simple algorithm) and 6.54% (carb count). The respective mean A1C changes from baseline to 24 weeks were -1.46 and -1.59% (P = 0.24). A1C <7.0% was achieved by 73.2% (simple algorithm) and 69.2% (carb count) (P = 0.70) of subjects; respective values for A1C <6.5% were 44.3 and 49.5% (P = 0.28). The total daily dose of insulin was lower, and there was a trend toward less weight gain in carb count group patients. Severe hypoglycemia rates were low and equal in the two groups. CONCLUSIONS: Weekly basal-bolus insulin adjustments based on premeal and bedtime glucose patterns resulted in significant reductions in A1C. Having two effective approaches to delivering and adjusting rapid-acting mealtime insulin may increase physicians' and patients' willingness to advance therapy to a basal-bolus insulin regimen.

Sixty-four third-, fourth-, and fifth-grade teachers read vignettes describing boys and girls with (1) externalizing and internalizing disorders and (2) externalizing and internalizing problems of less severity. Teachers rated whether the child described in each vignette needed to be referred for mental health treatment and indicated whether they had referred a similar child for treatment. Teachers' ratings of need for referral did not differ for boys and girls, and there was no gender effect on the teachers' reported referral experience. However, teachers reported having referred more children with externalizing problems than with internalizing problems for treatment, even though they did not rate externalizing problems as needing referral more than internalizing problems. Such discrepancies are discussed in terms of the different effect of internalizing and externalizing problems on the classroom environment.

This double-blind, placebo-controlled, 6-month follow-up treatment study investigated the efficacy of bromocriptine and nortriptyline in attenuating drinking behavior and psychiatric symptoms in 216 male alcoholic patients subtyped by comorbid psychiatric disorder(s). Three well-defined subtypes were examined: alcoholism only, alcoholism + affective/anxiety disorder, and alcoholism + antisocial personality disorder. It was hypothesized that both medications would relieve negative affective symptoms associated with alcohol use and would be particularly effective for the affective/anxiety subgroup. Contrary to our predictions, the only significant effects found were with the antisocial personality disorder patients who were receiving nortriptyline. One interpretation of the results was that nortriptyline may have reduced impulsive drinking in the antisocial personality disorder subgroup by actions on serotonergic neurotransmission.

Journal Article The Effect of Singing on Alert Responses in Persons with Late Stage Dementia Get access Alicia Ann Clair, Ph.D., RMT-BC Alicia Ann Clair, Ph.D., RMT-BC The University of Kansas, The Colmery-O'Neil Veterans Affairs Medical Center Correspondence concerning this article should be addressed to Alicia Ann Clair, Division of Music Education and Music Therapy, 311 Bailey Hall, The University of Kansas, Lawrence, KS, 66045-2344. Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of Music Therapy, Volume 33, Issue 4, Winter 1996, Pages 234–247, https://doi.org/10.1093/jmt/33.4.234 Published: 01 December 1996

The purpose of this study was to examine the effects of music therapy programming, including singing, dancing, and rhythm playing, on participation engagement frequencies of family caregivers and their late stage dementia care receivers. During such engagement, data were taken for frequencies of initiated and responsive touch by caregivers and care receivers. Furthermore, this study assessed caregivers' perceptions of depression, burden, positive and negative affect, self-reported health, and satisfaction with visits through a pretest-posttest procedure. Fifteen couples, in which one member of the couple had late stage dementia, participated in groups for a series of 8 music therapy sessions, scheduled twice weekly for 4 weeks. All sessions were 50 minutes in duration which included 10 minutes of conversation both at the beginning and at the end. Randomly ordered between the two conversation periods were 10 minutes each of group singing, ballroom dancing, and participation in rhythm playing using paddle drums. All sessions were videotaped and later analyzed using a time interval method to determine frequencies for time intervals in each session that caregivers and their care receivers were (a) participating in music, (b) initiating touch, and (c) responding to touch. Caregivers' engagements in participations were higher in music applications when compared to conversation, and the greatest particpation occurred during rhythm playing, followed by singing and dancing, respectively. Care receivers had greatest participation during rhythm playing, followed by dancing and singing, respectively. Caregivers initiated touch more frequently than their care receivers, but care receivers were more responsive to touch than were their caregivers. Results also showed that caregivers' measures of depression, burden, positive and negative affect, and self-reported health did not change, but their increased satisfaction with visits in music therapy, as compared to visits before music therapy, was statistically significant as the .017 level of confidence.

Three male subjects with a primary diagnosis of Alzheimer's-type dementia participated in weekly, 30-minute music therapy sessions for 15 months. Subjects were selected randomly from among 29 residents of a nursing unit at Colmery-O'Neil Veterans Affairs Medical Center in Topeka, Kansas. All subjects were low functioning and required consistent supervision for behavioral management. Data were gathered in the last 11 weeks of the music therapy program for communicating, watching others, singing, interacting with an instrument, and sitting. Though the subjects deteriorated markedly in their cognitive, physical, and social capacities over the course of their disease in 15 months, data in the latter 11 weeks of the program indicated that they continued to participate in music activities in a structured group context. Data analyses showed that music participation was maintained over the course of the 11 weeks. Subjects consistently sat in chairs without physical restraints for the duration of each 30-minute session. Regardless of their deterioration, subjects were able to function with others in a group context. For most, this was the only time in their week when they could successfully interact with others in some acceptable form.

1. Provocation is an important risk predictor because these issues can be recognized, assessed, and appropriate interventions can be implemented to reduce the associated risks. It is only by the reduction of such "non-fixed" risk factors that any reduction of assaults can be accomplished. 2. Involuntary admission, patients with dementia or organic brain disorder, physical or verbal limits, staff attitude, denial of the possibility of assaults, and the educational level and clinical experience of the staff may help provoke an assaultive episode. 3. An important step is assessing the assault to identify provocation due to certain medical causes, and to document the extent of degeneration in patients with dementia or organic brain disorder. Medical intervention would be indicated and would appropriately address the causes of some violent episodes.

The preclinical development of anticancer drugs including immunotherapeutics and targeted agents relies on the ability to detect minimal residual tumor burden as a measure of therapeutic efficacy. Real-time quantitative (qPCR) represents an exquisitely sensitive method to perform such an assessment. However, qPCR-based applications are limited by the availability of a genetic defect associated with each tumor model under investigation. Here, we describe an off-the-shelf qPCR-based approach to detect a broad array of commonly used preclinical murine tumor models. In particular, we report that the mRNA coding for the envelope glycoprotein 70 (gp70) encoded by the endogenous murine leukemia virus (MuLV) is universally expressed in 22 murine cancer cell lines of disparate histological origin but is silent in 20 out of 22 normal mouse tissues. Further, we detected the presence of as few as 100 tumor cells in whole lung extracts using qPCR specific for gp70, supporting the notion that this detection approach has a higher sensitivity as compared with traditional tissue histology methods. Although gp70 is expressed in a wide variety of tumor cell lines, it was absent in inflamed tissues, non-transformed cell lines, or pre-cancerous lesions. Having a high-sensitivity biomarker for the detection of a wide range of murine tumor cells that does not require additional genetic manipulations or the knowledge of specific genetic alterations present in a given neoplasm represents a unique experimental tool for investigating metastasis, assessing antitumor therapeutic interventions, and further determining tumor recurrence or minimal residual disease.

Thirteen older persons (seven men and six women) in residential care participated as subjects in this study. All participants had histories of confusion due to dementia and were identified by staff as being consistently resistant to medication administration as indicated by vocal outbursts, moving away, or physical combativeness. Subjects were exposed to four aroma interventions during medication administration: 1) lavender vera (lavendula officinalis); 2) sweet orange (citrus aurantium); 3) tea tree (malaleuca alternifolia); and 4) no aroma (control). All medication administrations were videotaped for later data collection. Observers were trained to record frequency and duration of resistive behaviors during medication administration in allfour interventions for each subject. Reliability between two observers was extremely high. Results showed no statistically significant differences across all aroma conditions for either resistive behavior or duration of administration. Also, there were no statistically significant differences based on gender. This study indicates that aromatherapy does not reduce combative, resistive behaviors in individuals with dementia. Research with a larger sample in future studies may yield other results.

This study compared live, instrumental music, vocal music, and no music on the repetition frequencies for 14 prescribed physical therapy rehabilitation exercises. Male (N = 4) and female (N = 15) residents of care centers for older adults served as subjects. They ranged in age from 65 to 90 years (M= 84.3), and were either referred to physical therapy or were already involved in a physical therapy exercise pro-gram. All subjects (N = 19) participated in 6 treatment sessions under 3 conditions: Two sessions with live instrumental music, two with live vocal music, and two with no music. In all music sessions, familiar and recognizable songs were paired with specific exercises. Each exercise in all conditions had the same duration, and a metronome established consistent tempos. Each session was videotaped for later review and data collection. Analyses of variance were calculated for treatment effects and mean differences among the three conditions which yielded significant treatment effects and treatment differences among conditions for 6 of the 14 exercises. Unsolicited comments from subjects indicated preference for music over no music conditions while exercising. Further study is required to establish the relationship between music enhanced exercises and adherence to exercise regimens in populations of older adults.

The purpose of this study was to compare the durations of vibrotactile response, nonvibrotactile response, and singing in a SampIe of severely regressed persons with dementia of the Alzheimer's type. Six male subjects who ranged in age from 62 to 73 years participated individually in a four-session pilot test and 10 subsequent experimental testing sessions. Each session was videotaped and the 10 test sessions were later evaluated for the durations of (a) vibrotactile response, defined as drum playing with the drum held in the subject's lap; (b) nonvibrotactile response, defined as drum playing with the drum held in front of the subject; and (c) singing. A t test revealed a significant difference between durations of vibrotactile and nonvibrotactile responses (p < .05). Mean scores showed the vibrotactile responses were of longer duration that the nonvibrotactile responses. In addition, only one subject of the six sang, and his singing participation decreased as his dementia progressed. A t test computed to compare the difference between his durations of singing and composite drum playing was significant (p < .0005). Mean scores for this subject indicated longer durations for drum playing than for singing responses. Implications for music therapy practice are discussed.

I have this actual, physical reaction when I hear a helicopter, especially a Huey. If il gets close or loud, I feel this adrenaline rush. I shake and start breathing hard. I lose concentration and my mind tries to go off somewhere, oui I don't let it. Because it's embarrassing. If 1 hear helicopters from a distance, I have this compulsion to run outside and see where they are going. We used to have a great sex life. Then she stopped letting me touch her genital area - she said it was 'like somebody probing her.' She used to like it. I tried being very gentle, but she wouldn't allow it. Then she slarted gelling all panicky and upset when we had intercourse, when I was on top. It gol so the only way we could have sex was if she was on top. She got strange and wouldn't talk about it - she made me feel like I had done something wrong, or that I had hurt her or forced her in some way. It came from working in that clinic - she took all those stories to heart. She was really screwed up - it destroyed our relationship. The worst thing that happened was when I was driving to work. Out of the clear blue sky, a utility worker was off to the side of the road working around a manhole. He made a gesture, like he was raising a rifle to shoot me. I flinched and moved away, and nearly ran into the car in the other lane. Looking back I saw he didn't have a weapon, he was just working. That bothered me. especially because I overreacted like that and almost had an accident. The worst for me is that I can't enjoy watching the kids play sports. 1 just focus in on watching how the coaches and officials touch the children. This obsession ruins these activities for me, I can't seem to focus on the game itself. I know these people are probably really good people, and I admire their volunteering of their time. But they touch the children a lot during the game, and I can't seem to take my eyes away. I've got to keep watch for anything inappropriate.

To what extent do personal constructs affect the relationship between doctor and patient when the ill patient does not readily recover with treatment? Questionnaires were returned anonymously by 609 patients with a self-reported diagnosis of chronic fatigue syndrome, who were considered chronically ill. Findings were compared with those of an earlier study of a population of 397 general medical patients. The chronically ill patients lost an average of 65 days of work per year due to illness compared to general medical patients who missed six or fewer days per year because they were ill. The chronically ill patients also reported a 66% higher frequency of iatrogenic illness, spent more money on health care, took more medication, saw more specialists, and were more litigious than the general medical population. Research suggested several patterns of relationships between doctors and patients, and attitudes to health and illness, which may alert doctors to patients' perceptions, beliefs, encoded constructs, and patterns of relating that affect responses to treatment. More attention by doctors to patients who are experiencing the stress of chronic illness is indicated.

This paper summarizes the findings of a pilot study which found a relationship between the post-traumatic symptoms of a) psychic numbing, b) intrusive recollections of traumatic events, and c) hypervigilance and lateralization of electrodermal response (EDR) measurements in six victims of psychological trauma. Hypnotically induced imagery of past traumatic events was often associated with left-sided EDR increases, psychic numbing with left-sided EDR decreases or bilateral EDR unresponsiveness, and revivifications of hypervigilant states with right-sided EDR lateralization. In several cases control of the experience of fear was associated with left-sided or bilaterally decreased EDR These pilot study findings support previously stated hypotheses: a) EDR obtained from an extremity reflects contralateral cerebral hemisphere functioning; b) left hemisphere functioning is associated with hypervigilance; and c) right hemisphere functioning is associated with emotions and imagery. In addition, the pilot study findings suggest additional hypotheses: a) Post-traumatic symptoms are associated with poorly controlled or integrated cerebral hemisphere functioning; b) psychic numbing and intrusive images, flashbacks, and nightmares are associated with abnormal activation, suppression, or integration of right hemisphere functioning in relationship to the left; c) aggressive behavior, hypervigilance, and character pathology are associated with abnormal activation, suppression, or integration of functioning of the left hemisphere function in relationship to the right; and d) “splitting” as a psychological defense in Vietnam veterans with Borderline Personality Disorders is associated with physiologically impaired interhemispheric integration.

AIMS: Dulaglutide, a once weekly GLP-1 receptor agonist, is approved at two doses (1.5 and 0.75 mg) for treatment of type 2 diabetes (T2D). Two higher doses of dulaglutide (3.0 and 4.5 mg) were evaluated for safety and efficacy to determine whether these doses warrant further study for improved control of glucose and body weight. MATERIALS AND METHODS: This 18-week, double-blind, phase 2 trial randomized 318 patients with T2D using ≥1500 mg metformin, to receive subcutaneous injection of placebo (n = 82), dulaglutide 1.5 mg (n = 81), dulaglutide 3.0 mg (n = 79) or dulaglutide 4.5 mg (n = 76). The primary objective was superiority of dulaglutide doses over placebo in reduction of HbA1c at 18 weeks. Secondary objectives included superiority of dulaglutide over placebo in change from baseline in body weight and fasting serum glucose (FSG) at 18 weeks. Investigational doses of dulaglutide were compared to the 1.5 mg dose as an exploratory objective. RESULTS: HbA1c reduction at 18 weeks was significantly greater with dulaglutide vs placebo (placebo, -0.44% ± 0.10% [-4.8 ± 1.1 mmol/mol]; dulaglutide 1.5 mg, -1.23% ± 0.10% [-13.5 ± 1.1 mmol/mol]; dulaglutide 3.0 mg, -1.31% ± 0.10% [-14.3 ± 1.1 mmol/mol]; dulaglutide 4.5 mg, -1.40% ± 0.10% [-15.3 ± 1.1 mmol/mol]; P < 0.001, each dose), as were changes in body weight (placebo, -1.6 ± 0.39 kg; dulaglutide 1.5 mg, -2.8 ± 0.39 kg; dulaglutide 3.0 mg, -3.9 ± 0.39 kg; dulaglutide 4.5 mg, -4.1 ± 0.41 kg; P < 0.001, each dose). All three dulaglutide doses significantly reduced FSG from baseline (1.5 mg, -36.2 ± 4.7 mg/dL [-2.0 ± 0.3 mmol/L]; 3.0 mg, -34.5 ± 4.5 mg/dL [-1.9 ± 0.3 mmol/L]; 4.5 mg, -38.0 ± 4.7 mg/dL [-2.1 ± 0.3 mmol/L]) vs placebo (-12.4 ± 4.5 mg/dL [-0.7 ± 0.3 mmol/L]) (P < 0.001, all). Safety profiles of the higher doses were consistent with the established safety profile for dulaglutide. Gastrointestinal events were mostly mild to moderate, and was dose-related for nausea. CONCLUSION: All three dulaglutide doses were superior to placebo in improving glycaemic control and reducing body weight in participants with T2D using metformin. The potential for doses of dulaglutide of 3.0 and 4.5 mg to provide additional glycaemic benefit and weight reduction with an acceptable safety profile, compared with the 1.5 mg dose, warrants further study in a phase 3 trial.

Abstract Sixty male Vietnam combat veterans, 30 hospitalized for post-traumatic stress disorder (PTSD) and 30 with no PTSD or other psychiatric disorder, sorted and labeled their life events into numeric matrices (repertory grids). Through hierarchical-classes analysis of a subject's matrix, we could compare the hierarchical level (elaboration) of the subject's constructs of a negative combat event with the hierarchical levels of other subjects' constructs of negative combat events and with the subject's precombat life event construction. As predicted, the level of construct elaboration was virtually identical for the two groups for precombat non-trauma-related events but was reduced in the PTSD group for the negative combat event. In addition, the Pythagorean distance scores of the PTSD group indicated less conceptual distance between the negative combat event and negative life events after Vietnam compared with the non-PTSD group's scores. Patients with PTSD rated negative life events more extremely (fewer "shades of gray" ratings) than did the non-PTSD group, especially life events that occurred after Vietnam.

Twenty-eight severely regressed patients with dementias hospitalized at a Veterans Affairs Medical Center in the Midwest participated as subjects in this study. All patients, except for one, were male and all patients, except for one, had functional hearing. The purpose of this study was to determine the effects of no music, stimulative background music and sedative background music conditions on the agitated behaviors of patients with severe dementias. Data were taken with a placheck method for 30 days; 10 days for each of the three conditions, three times a day for 30 minutes. The conditions were assigned randomly. The results showed no significant differences in the percentages of agitated behaviors exhibited during the three testing conditions. The music and no music background conditions did not influence significantly the agitated behaviors. In addition, significant differences in the percentages exhibited across times of day and across days for the entire testing period were not found. The findings indicate background music, as it was selected and presented randomly in this study, had no apparent influence over agitated behaviors. It is possible that persons who experience music in structured contexts over time may respond differently. It is recommended that future research explore individual persons' responses to consistently presented music experiences and that music selected for them be specific to their preferences.

Persons in the late stages of dementia, including those with probable Alzheimer's type, are in need of meaningful activities which contribute to their life quality. These activities are mandated by accrediting agencies for facilities which provide services for these persons, but their abilities to participate exclude them from most therapeutic programs. Some preliminary work in music therapy has indicated that rhythm applications are very successful with persons who are severely regressed with dementia and who can no longer function well enough to maintain their activities of daily living and require institutional care (Clair & Bernstein, 1990a; Clair & Bernstein, 1990b). The purpose of this study was to describe the rhythm playing characteristics of persons who receive institutional care and who have a diagnosis of dementia, including those with probable Alzheimer's type. In this study subjects served as their own controls. Results indicated that they increased significantly in their success to imitate progressively more complex rhythm patterns. They also had significantly more successful participation, defined as striking a drum with either their hands or with mallets, from the first baseline to the first experimental session in which the music therapist provided the structure for the rhythm activity. From the first to the last experimental session subjects did not increase significantly in their participation, but there was a significant decrease in participation from the last experimental session to the return to baseline session which followed it. Results also showed the most participation occurred with the floor tom followed by bass, paddle, and frame drums respectively. This study demonstrated the success of rhythm applications using drums with persons in late stage dementia. Implications are that applications based on the protocol used in this study will be successful in other settings and can serve as the foundation upon which to build programming for individuals in special care settings.

Three groups of Vietnam-era veterans were compared on the frequency of symptoms typical of the diagnostic criteria for Post Traumatic Stress Disorder (PTSD), a diagnostic category introduced in DSM III (N = 90). The three groups consisted of veterans who had experienced (a) a war-related traumatic event; (b) a non-war-related traumatic event; or (c) no traumatic event. The results indicated that the two groups who experienced a traumatic event reported significantly more symptoms than the group who never experienced a traumatic event. Furthermore, the group who experienced a war-related traumatic event reported more symptoms than the group who experienced a non-war-related traumatic event. These results support the validity of PTSD.

In response to combat, some soldiers develop a feeling of satisfaction in killing. The authors label this reaction the "heart of darkness experience," after the story by Joseph Conrad (1903/1982). They describe their clinical experience of seeing this response as part of a spectrum of reactions ranging from no personality change to rather gross personality change. After exploring psychological factors involved in this change, they suggest relevant treatment considerations.