Dwight D. Eisenhower VA Medical Center

BACKGROUND: Vancomycin-resistant Enterococcus bloodstream infections (VRE-BSIs) are becoming increasingly common. Linezolid and daptomycin are the primary treatment options for VRE-BSI, but optimal treatment is unclear. METHODS: This was a national retrospective cohort study comparing linezolid and daptomycin for the treatment of VRE-BSI among Veterans Affairs Medical Center patients admitted during 2004-2013. The primary outcome was treatment failure, defined as a composite of (1) 30-day all-cause mortality; (2) microbiologic failure; and (3) 60-day VRE-BSI recurrence. Poisson regression was conducted to determine if antimicrobial treatment was independently associated with clinical outcomes. RESULTS: A total of 644 patients were included (linezolid, n = 319; daptomycin, n = 325). Overall, treatment failure was 60.9% (n = 392/644), and 30-day all-cause mortality was 38.2% (n = 246/644). Linezolid was associated with a significantly higher risk of treatment failure compared with daptomycin (risk ratio [RR], 1.37; 95% confidence interval [CI], 1.13-1.67; P = .001). After adjusting for confounding factors in Poisson regression, the relationship between linezolid use and treatment failure persisted (adjusted RR, 1.15; 95% CI, 1.02-1.30; P = .026). Linezolid was also associated with higher 30-day mortality (42.9% vs 33.5%; RR, 1.17; 95% CI, 1.04-1.32; P = .014) and microbiologic failure rates (RR, 1.10; 95% CI, 1.02-1.18; P = .011). No difference in 60-day VRE-BSI recurrence was observed between treatment groups. CONCLUSIONS: Treatment with linezolid for VRE-BSI resulted in significantly higher treatment failure in comparison to daptomycin. Linezolid treatment was also associated with greater 30-day all-cause mortality and microbiologic failure in this cohort.

This investigation extended work on the Wechsler Adult Intelligence Scaled-Revised (WAIS-R) to the WAIS-III by determining how allotments of scaled-score points change with age, and to evaluate WAIS-III performance in terms of the Horn-Cattell constructs of crystallized and fluid intelligence. The age norms for the 14 individual WAIS-III subtests indicate that additional scaled-score points are awarded primarily to the Letter-Number Sequencing subtest of the Verbal Scale and to the seven Performance Scale subtests at ages 45 to 89 years for the same performance as individuals in the 20- to 34-year-old reference group. Subtests that measure speed of information processing showed more of a decline than subtests that measure verbal processing. Results are consistent with the view that measures of fluid intelligence show more of a decline with advancing age than do measures of crystallized intelligence. Published by Elsevier Science Ltd

Abstract WAIS-R IQs were estimated using the National Adult Reading Test (NART) in a sample of 126 normal elderly. Linear regression equations to predict WAIS-R IQs from NART error scores were generated for a development sample of 85 subjects. Correlations between reading errors and Verbal, Performance, and Full Scale IQs were -.78, -.56, and -.74, respectively. Cross-validation on 41 elderly subjects yielded significant correlations between earned IQ and the NART that ranged from -.40 to - .83. Mean earned and estimated IQs for the normal elderly cross-validation sample were the same. Additional cross-validation on a sample of 20 neurologically impaired subjects revealed significant overestimation of the actual WAIS-R IQs by the NART estimated IQs. Thus, the NART estimated IQs adequately demonstrated intellectual deterioration in a brain-damaged sample.

Background: Vancomycin-resistant Enterococcus bloodstream infections (VRE-BSIs) are associated with significant mortality. Daptomycin exhibits concentration-dependent activity vs VRE in vitro, yet the clinical impact of higher-dose strategies remains unclear. Methods: We performed a national retrospective cohort study of hospitalized Veterans Affairs patients treated with standard-dose (6 mg/kg total body weight), medium-dose (8 mg/kg total body weight), or high-dose (≥10 mg/kg total body weight) daptomycin for VRE-BSI. Patient-related, microbiological, and outcomes data were abstracted from clinical databases. The primary outcome was overall survival, evaluated by Cox regression. Secondary outcomes included 30-day mortality, time to microbiological clearance, and creatine phosphokinase (CPK) elevation. Results: A total of 911 patients were included (standard dose, n = 709; medium dose, n = 142; high dose, n = 60). Compared to high-dose daptomycin, both standard-dose (hazard ratio [HR], 2.68; 95% confidence interval; [CI], 1.33-3.06; P = .002) and medium-dose (HR, 2.66; 95% CI, 1.33-3.92; P = .003) daptomycin were associated with poorer survival. After adjusting for confounders, the relationship between poorer survival and standard-dose (adjusted HR [aHR], 2.58; 95% CI, 1.27-4.88; P = .004) and medium-dose (aHR, 2.52; 95% CI, 1.27-5.00; P = .008) daptomycin persisted. Thirty-day mortality was significantly lower among high-dose daptomycin-treated patients compared with other dosing strategies (risk ratio, 0.83; 95% CI, .74-.94; P = .015). Compared with standard-dose daptomycin, both medium-dose (HR, 0.78; 95% CI, .55-.90; P = .012) and high-dose daptomycin (HR, 0.70; 95% CI, .41-.84; P = .006) were associated with significantly improved microbiological clearance. No difference in the risk of CPK elevation was observed between the treatment groups (P = .504). Conclusions: High-dose daptomycin was associated with improved survival and microbiological clearance in VRE-BSI.

OBJECTIVE: This study was intended to examine the extent of dissociative experiences that exist within a substance abuse population and to determine how demographic and clinical variables affect these experiences. METHOD: A total of 265 male veterans being treated on an inpatient substance abuse unit completed a standard test battery that included the MMPI-2, the Shipley-Hartford Institute of Living Scale, and the Dissociative Experiences Scale. Additional demographic and clinical information was obtained from the patients' medical records. RESULTS: Over 41% of the cohort had scores on the Dissociative Experiences Scale that suggested the need for further evaluation of a dissociative disorder. A stepwise multiple regression analysis revealed that level of psychological discomfort, IQ, and race accounted for more than 24% of the variance in Dissociative Experiences Scale scores. CONCLUSIONS: Substance abuse populations may need to be routinely screened for dissociative symptoms just as they are for depression and anxiety.

Blood pressure (BP) control rates and number of antihypertensive medications were compared (average follow-up, 4.9 years) by randomized groups: chlorthalidone, 12.5-25 mg/d (n=15,255), amlodipine 2.5-10 mg/d (n=9048), or lisinopril 10-40 mg/d (n=9054) in a randomized double-blind hypertension trial. Participants were hypertensives aged 55 or older with additional cardiovascular risk factor(s), recruited from 623 centers. Additional agents from other classes were added as needed to achieve BP control. BP was reduced from 145/83 mm Hg (27% control) to 134/76 mm Hg (chlorthalidone, 68% control), 135/75 mm Hg (amlodipine, 66% control), and 136/76 mm Hg (lisinopril, 61% control) by 5 years; the mean number of drugs prescribed was 1.9, 2.0, and 2.1, respectively. Only 28% (chlorthalidone), 24% (amlodipine), and 24% (lisinopril) were controlled on monotherapy. BP control was achieved in the majority of each randomized group-a greater proportion with chlorthalidone. Over time, providers and patients should expect multidrug therapy to achieve BP <140/90 mm Hg in a majority of patients.

Validity and reliability coefficients and standard errors of measurement for 2 7-subtest short forms (SF) of the Wechsler Adult Intelligence Scale-III (WAIS-III; D. Wechsler, 1997) are provided. Data for the study were obtained from the WAIS-III-WMS-III Technical Manual and were based on the 2,450 adolescents and adults in the WAIS-III standardization sample. SF1 consists of Information, Digit Span, Arithmetic, Similarities, Picture Completion, Block Design, and Digit Symbol-Coding. SF2 uses the same subtest combination, except Matrix Reasoning is substituted for Block Design. For the 13 age groups in the standardization sample, the 2 short forms have impressively high validity and reliability, and small standard errors of measurement. Whenever a short form IQ is used, it is recommended that the examiner append the abbreviation Est next to the value.

Two methods for estimating premorbid WAIS-R IQ (Barona Reynolds & Chastain, 1984; Barona & Chastain, 1986) were compared in a sample of normal elderly and a sample of neurologically impaired persons. The normals consisted of 75 males with a mean age of 80.48 (SD = 4.57) years and the neurological group consisted of 20 males averaging 78.65 (SD = 5.62) years of age. For the normals, the percent of obtained IQs that fell within one standard error of estimate of the formula-estimated IQs demonstrated adequate agreement of both methods for the Full Scale IQ, but relatively poor prediction for the Performance Scale. The Verbal IQ was adequately predicted by the 1984 method, but not the 1986 procedure. As expected, both estimation procedures overestimated the obtained IQs of the brain-damaged subjects.

The Controlled Oral Word Association Test (COWAT) is a measure of a person's ability to make verbal associations to specified letters (i.e., C, F, and L). This measure is a useful component of a neuropsychological battery as it is able to detect changes in word association fluency often found with various disorders. In order to generate current norms for the elderly and aid in interpreting their performance, the COWAT was administered to a group of community-dwelling elderly persons. Information regarding total numbers of words produced as well as frequency of perseverations, breaking set, using the same word stem, and using a proper noun is provided.

We factor analyzed the Chinese revision of the Wechsler Adult Intelligence Scale (WAIS-RC) in a sample of 59 individuals with medically diagnosed brain damage. The Chinese subjects consisted of 42 males and 17 females with means for Verbal. Performance, and Full Scale IQ of 83.88 (SD = 22.11), 75.49 (SD = 20.63), and 78.42 (SD = 21.97), respectively. Clear support was found for a general intelligence factor (g) and the Full Scale IQ. Similarly, the two-factor solution provided support for Wechsler's (1981) Verbal and Performance IQ designations. The three-factor solution revealed the familiar Verbal-Comprehension and Perceptual-Organization factors. However, the Freedom From Distractibility factor was less clearly defined. Comparisons of Chinese and American factor structures for neurologically impaired persons demonstrated high coefficients of congruence, ranging from .93 to .98. Overall, the findings demonstrated substantial congruence cross culturally for Chinese and American brain-damaged samples and suggest that the WAIS-RC measures essentially the same constructs as the WAIS-R.

In this article, we analyze aspects of the complex literacy lives of three Spanish dominant, mainland Puerto Rican kindergartners who were beginning readers at the time of the study. We investigate literacy as a social and cultural practice in the children’s bilingual classroom, homes, and churches, describing the people who supported their developing literacy, their beliefs about literacy, and the characteristics of literacy events that the children coconstructed with them. Our analysis is based on data collected with ethnographic methods, including participant observation, interviews, and audio recording. At home and in church, the children’s developing literacy was supported by a network of people, many of whom believed that reading was about combining sounds into words and that meaning was inherent in text. Literacy events were often social, collaborative interactions as the families created a syncretic literacy by drawing on the multiple resources in their lives, including their religion, their culture, and their knowledge of two languages as well as their experiences in school. Overall, we found both similarities anddifferences between literacy in school and literacy in the children’s homes and community rather than the matches ormismatches described in the literature.

Administration times were recorded for the WAIS-III subtests, IQs, and Indexes for 62 VA patients. Also calculated were the administration times for a select group of short forms. The 11 subtests that yield the Verbal, Performance, and Full Scale IQs averaged approximately 91 minutes. The 11 subtests that yield the Organization, Working Memory, and Processing Speed Indexes averaged approximately 77 minutes. The administration time estimates in the standardization sample of 75 minutes for the Full Scale IQ and 60 minutes for the Indexes do not generalize to a clinical population. Ten of 11 short forms reduced testing time by at least 50%. The least time-consuming consisted Verbal Comprehension, suming was the Ward (1990) seven-subtest short form.

BACKGROUND: Currently, there is debate over whether the daptomycin susceptibility breakpoint for enterococci (ie, minimum inhibitory concentration [MIC] ≤4 mg/L) is appropriate. In bacteremia, observational data support prescription of high doses (>8 mg/kg). However, pharmacodynamic targets associated with positive patient outcomes are undefined. METHODS: Data were pooled from observational studies that assessed outcomes in daptomycin-treated enterococcal bacteremia. Patients who received an additional antienterococcal antibiotic and/or a β-lactam antibiotic at any time during treatment were excluded. Daptomycin exposures were calculated using a published population pharmacokinetic model. The free drug area under the concentration-time curve to MIC ratio (fAUC/MIC) threshold predictive of survival at 30 days was identified by classification and regression tree analysis and confirmed with multivariable logistic regression. Monte Carlo simulations determined the probability of target attainment (PTA) at clinically relevant MICs. RESULTS: Of 114 patients who received daptomycin monotherapy, 67 (58.8%) were alive at 30 days. A fAUC/MIC >27.43 was associated with survival in low-acuity (n = 77) patients (68.9 vs 37.5%, P = .006), which remained significant after adjusting for infection source and immunosuppression (P = .026). The PTA for a 6-mg/kg/day (every 24 hours) dose was 1.5%-5.5% when the MIC was 4 mg/L (ie, daptomycin-susceptible) and 91.0%-97.9% when the MIC was 1 mg/L. CONCLUSIONS: For enterococcal bacteremia, a daptomycin fAUC/MIC >27.43 was associated with 30-day survival among low-acuity patients. As pharmacodynamics for the approved dose are optimized only when MIC ≤1 mg/L, these data continue to stress the importance of reevaluation of the susceptibility breakpoint.

We developed a Satz-Mogel short form of the WAIS-III and evaluated its accuracy for predicting IQs of 50 men with substance abuse disorders. Means for age, education, and Full Scale IQ were 44.20 years (SD = 7.23), 12.82years (SD = 1.53), and 98.06 (SD = 11.93). Correlations between the forms were significant for the 11 subtests (all rs> or =.79) and three IQs (all rs> or =.93). Short form estimated Verbal, Performance, and Full scale IQs were within +/-6 points of the WAIS-III 92% 80% and 90% of the time. The abbreviation may be used to estimate general intelligence, but interpretation of short-form-based IQ discrepancies should be avoided. The short form detected reliable WAIS-III Verbal-Performance IQ discrepancies only 67% of the time.

Narcolepsy is a chronic neurological sleep disorder with potentially disabling symptoms ranging from occupational concerns to mental health difficulties. Recent advances related to the neurobiological basis of narcolepsy have led to newer pharmacological treatment options and adjunctive behavioral techniques that support symptom management. This article outlines evidence-based pharmacologic therapies, behavioral techniques, and psychosocial costs related to narcolepsy. Psychosocial factors, although frequently acknowledged, deserve further attention and awareness from researchers and providers. The American Academy of Sleep Medicine's (AASM) Quality Measure Drivers and potential future treatment options are also discussed.

Objective This study evaluated the effectiveness of cognitive processing therapy and prolonged exposure in conditions reflective of current clinical practice within the Veterans Health Administration. Method This study involved a retrospective review of 2030 charts. A total of 750 veterans from 10 U.S. states who received cognitive processing therapy or prolonged exposure in individual psychotherapy were included in the study (participants in cognitive processing therapy, N = 376; participants in prolonged exposure, N = 374). The main dependent variable was self-reported posttraumatic stress disorder symptoms as measured by total scores on the Posttraumatic Stress Disorder Checklist. The study used multilevel modeling to evaluate the absolute and relative effectiveness of both treatments and determine the relationship between patient-level variables and total Posttraumatic Stress Disorder Checklist scores during treatment. Results Cognitive processing therapy and prolonged exposure were equally effective at reducing total Posttraumatic Stress Disorder Checklist scores. Veterans who completed therapy reported significantly larger reductions in the Posttraumatic Stress Disorder Checklist than patients who did not complete therapy. There were no significant differences in the improvement of posttraumatic stress disorder symptoms with respect to age and three racial/ethnic groups (Caucasian, African American, and Hispanic). Conclusions Cognitive processing therapy and prolonged exposure were shown to be effective in conditions highly reflective of clinical practice and with a highly diverse sample of veterans. Challenges related to dropout from trauma focused therapy should continue to be researched.

The Parkinson's disease (PD) patient has been characterized as having a distinctive personality with introverted features. These personality traits are said to predate motor symptoms and are theorized to serve as a subtle clue to latent PD. To examine this hypothesis, we compared remote and current personality features in 35 PD subjects and 35 controls. Subjects' spouses completed a personality inventory (PI) characterizing patients' premorbid and current status. The premorbid PI of PD subjects differed from that of controls in being more "quiet," "generous," "cautious," and "even-tempered," and less "flexible." The characterization of the PD subjects' current personality differed greatly from reported premorbid personality features, i.e., significant change in 13 of 24 PI items. Personality inventory responses regarding both the PD subjects' premorbid and current personality correlated to symptoms of depression and disease severity. Cognition, tobacco use, alcohol consumption, and rural versus urban residency did not correlate with PI responses. We conclude that PD patients are apt to be viewed as introverts premorbidly, and, with disease onset, more striking personality changes are recognized. These perceptions appear to be closely linked to depressed affect and correlate with motor impairment to a lesser extent.

BACKGROUND: Continuity is a tenant central to family practice. Continuity is associated with improved satisfaction in populations that can easily change providers. However, little is known about the importance of continuity where patients are assigned providers. METHODS: A pretested survey was distributed to patients of a family practice residency clinic in a military medical center for a week's period. Results were analyzed using chi2, unpaired t test, correlation matrices, and linear regression for patient satisfaction. RESULTS: The response rate was 68.3%. Responders were not more likely to be seeing their primary care provider (PCP). Regression analysis revealed that 12% of patient satisfaction was associated with long-term continuity rates, 23% by PCP satisfaction, and 17% by how easy it was to make the appointment. For high clinic users (>10 visits/year), 78% of patient satisfaction is determined by PCP satisfaction and long-term continuity rates. A subset of patients (13%) values choice of appointment time or other providers over PCP continuity. Satisfaction is not diminished in this group despite low long-term continuity (P <.05 for all results). CONCLUSIONS: Patient satisfaction is associated with continuity, especially for high clinic users. Although continuity is important, a subset of patients values the ability to see other providers and to change providers.

INTRODUCTION: Clostridium difficile infection (CDI) is a common cause of nosocomial diarrhea. Metronidazole and vancomycin are the primary treatment options for CDI, but increasing rates of antimicrobial resistance and severe, refractory disease have prompted the need for alternative agents. Tigecycline has previously demonstrated favorable in vitro activity against C. difficile isolates, but clinical data on its use in the treatment of CDI are severely lacking. The objective of this study was to describe our experience using tigecycline in the treatment of severe and severe complicated CDI. METHODS: This was a retrospective case series of hospitalized patients with severe and severe complicated CDI who were treated with tigecycline. Disease severity assessments were determined according to current practice guidelines. Diagnosis of toxigenic CDI was confirmed by polymerase chain reaction and patients were excluded if they received tigecycline for <48 h. Data were collected by review of the electronic medical record. The primary outcome was clinical cure. Secondary outcomes were sustained response, hospital mortality, and 28-day all-cause mortality. RESULTS: A total of 7 cases of severe and complicated CDI were reviewed. Intravenous tigecycline administered as a 100-mg loading dose followed by 50 mg twice daily resulted in clinical cure in 85.7% (n = 6/7) of cases. The majority of patients (n = 4/5) were treated with the novel triple therapy combination of tigecycline, vancomycin, and metronidazole and resulted in clinical cure in 80% (n = 4/5) cases. Sustained response at 28 days was 100% among evaluable cases (n = 5/5). Hospital mortality did not occur in any patients, and 28-day all-cause mortality was 28.6% (n = 2/7). CONCLUSION: Tigecycline appears to be a reasonable addition to the therapeutic regimen in the treatment of severe or complicated CDI, including cases that are refractory to standard therapy. A prospective clinical trial confirming these observational findings is warranted.

BACKGROUND: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites. METHODS: In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites. RESULTS: From 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites. CONCLUSIONS: Implementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.