Erie VA Medical Center

Because of the lack of valid evidence to support the current recommendations for the management of mild traumatic brain injury (concussion), many physicians, athletic trainers, coaches, and athletes have called into question the way concussions are treated in athletics. This review article discusses the current evidence for the management of concussion in high school, college, and professional sports. A complete review of the epidemiologic and neuropsychological studies to date is presented and critically reviewed, as are other assessment and management tools in concussion. The appropriate use of neuropsychological testing, grading scales, and return-to-play recommendations are discussed in depth based on the current evidence. Additionally, areas requiring further research are identified and future trends are briefly discussed.

Laryngomalacia is the most common congenital laryngeal anomaly. Patients present with different degrees of stridor and feeding problems that usually resolve by 18 months of age. A small number present with severe feeding problems, failure to thrive, stridor with cyanosis, and apnea, which may result in cardiopulmonary disease. These infants require surgical intervention, usually a hyomandibulopexy or tracheotomy. We present a new procedure, epiglottoplasty, that is performed endoscopically and involves excision of redundant mucosa over the lateral edges of the epiglottis, aryepiglottic folds, arytenoids, and corniculate cartilages. Ten patients have undergone this procedure with good results. Epiglottoplasty represents an alternative to tracheotomy in severe laryngomalacia. Indications, techniques, postoperative management, and complications are presented.

In this observer-blind study (NCT00423046), women (N=1,106), stratified by age (18-26, 27-35, 36-45 y), were randomized (1:1) to receive the HPV-16/18 vaccine (Cervarix®, GlaxoSmithKline Biologicals, Months 0, 1, 6) or the HPV-6/11/16/18 vaccine (Gardasil® Merck & Co., Inc., Months 0, 2, 6). Month 7 results were previously reported; we now report Month 24 results. In the according-to-protocol cohort for immunogenicity (seronegative and DNA-negative at baseline for HPV type analyzed), seropositivity rates of neutralizing antibodies (nAbs) [pseudovirion-based neutralization assay] were, across all age strata, 100% (HPV-16/18 vaccine) and 97.5-100% (HPV-6/11/16/18 vaccine) for HPV-16, and 99.0-100% (HPV-16/18 vaccine) and 72.3-84.4% (HPV-6/11/16/18 vaccine) for HPV-18. Corresponding geometric mean titers (GMTs) were 2.4-5.8-fold higher for HPV-16 and 7.7-9.4-fold higher for HPV-18 with the HPV-16/18 vaccine versus the HPV-6/11/16/18 vaccine; HPV-16 and HPV-18 GMTs were significantly higher with the HPV-16/18 vaccine than the HPV-6/11/16/18 vaccine (p< 0.0001) in the total vaccinated cohort (received ≥1 vaccine dose, irrespective of baseline sero/DNA-status). Similar results were obtained using enzyme-linked immunosorbent assay (ELISA). Positivity rates and GMTs of antigen-specific IgG antibodies in cervicovaginal secretions (ELISA) were not significantly different between vaccines. At Month 24, CD4⁺ T-cell responses for HPV-16 and HPV-18 were higher with the HPV-16/18 vaccine; memory B-cell response was higher for HPV-18 with the HPV-16/18 vaccine and similar between vaccines for HPV-16. Both vaccines were generally well tolerated. Although an immunological correlate of protection has not been defined, differences in the magnitude of immune response between vaccines may represent determinants of duration of protection.

Protection against oncogenic non-vaccine types (cross-protection) offered by human papillomavirus (HPV) vaccines may provide a significant medical benefit. Available clinical efficacy data suggest the two licensed vaccines (HPV-16/18 vaccine, GlaxoSmithKline Biologicals (GSK), and HPV-6/11/16/18 vaccine, Merck & Co., Inc.) differ in terms of protection against oncogenic non-vaccine HPV types -31/45. The immune responses induced by the two vaccines against these two non-vaccine HPV types (cross-reactivity) was compared in an observer-blind study up to Month 24 (18 mo post-vaccination), in women HPV DNA-negative and seronegative prior to vaccination for the HPV type analyzed (HPV-010 [NCT00423046]). Geometric mean antibody titers (GMTs) measured by pseudovirion-based neutralization assay (PBNA) and enzyme-linked immunosorbent assay (ELISA) were similar between vaccines for HPV-31/45. Seropositivity rates for HPV-31 were also similar between vaccines; however, there was a trend for higher seropositivity with the HPV-16/18 vaccine (13.0-16.7%) versus the HPV-6/11/16/18 vaccine (0.0-5.0%) for HPV-45 with PBNA, but not ELISA. HPV-31/45 cross-reactive memory B-cell responses were comparable between vaccines. Circulating antigen-specific CD4+ T-cell frequencies were higher for the HPV-16/18 vaccine than the HPV-6/11/16/18 vaccine (HPV-31 [geometric mean ratio [GMR] =2.0; p=0.0002] and HPV-45 [GMR=2.6; p=0.0092]), as were the proportion of T-cell responders (HPV-31, p=0.0009; HPV-45, p=0.0793). In conclusion, immune response to oncogenic non-vaccine HPV types -31/45 was generally similar for both vaccines with the exception of T-cell response which was higher with the HPV-16/18 vaccine. Considering the differences in cross-protective efficacy between the two vaccines, the results might provide insights into the underlying mechanism(s) of protection.

The recurrent laryngeal nerve is at risk of iatrogenic injury during surgical procedures in which its anatomical location is exposed. Borrowing from biotechnology currently available for facial nerve monitoring, we have developed a method of electrophysiologically assessing the function of the recurrent laryngeal nerve during technically difficult neck surgeries. Electromyographic as well as nerve action potential recordings are monitored using the Xomed-Treace Nerve Integrity Monitor-2 (NIM-2). This method differs from those previously published in that it is much less cumbersome and time-consuming. The technique as well as an illustrative case are reported.

BACKGROUND: Chronic Achilles tendinopathy may require tendon transfer for treatment. Relatively few studies have reported the clinical outcome for flexor hallucis longus (FHL) transfer for chronic Achilles tendinopathy. Both single and double incision techniques have been reported. We present our series of a single incision technique. MATERIALS AND METHODS: A retrospective study measured the clinical outcomes of 19 patients with chronic Achilles tendinopathy treated with single incision FHL transfer. Patients were evaluated with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot instrument, AOFAS hallux instrument as well as pre and postoperative visual analog scales (VAS) for pain. RESULTS: Average AOFAS ankle/hindfoot score was 96.4 +/- 5.7. Average AOFAS hallux score was 92.4 +/- 6.6. Average pre and postoperative VAS was 7.5 +/- 2.7 and 0.6 +/- 1.0, respectively. No tendon reruptures, wound complications or hallux deformities occurred. CONCLUSION: Excellent clinical outcomes with significant decrease in pain are possible with single incision technique for FHL transfer for chronic Achilles tendinopathy.

In the study, we introduce a new technique, sparse spectrum with uniform wave vectors (SU), for generation of phase screen samples. In a manner similar to the known sparse spectrum (SS) technique, it uses a trigonometric series with random discrete spectral support. However, in contrast to the SS technique, random wave vectors are uniformly distributed on individual segments of the wave vector plane partition in the SU technique. We compare the accuracy and computational effectiveness of the SU technique with the subharmonics complemented discrete Fourier transform (DFT) technique, SS technique, and randomized DFT technique [ J. Opt. Soc. Am. B36, 3249 (2019)JOBPDE0740-322410.1364/JOSAB.36.003249]. The SU and SS techniques generate unbiased samples and indicate superior computational effectiveness for 1 MP and larger screens.

A series of 150 consecutive compound fractures has been treated by primary suture, partly with and partly without the advantage of the bacteriostatics, a blood bank, and a high-protein diet. In respect to wound healing, bony union, prompt restoration of function, and the salvaging of extremities, the results have been superior to those obtained by previous methods. Improved results are attributed, first, to the compression dressing; second, to immediate coverage of the surface defect with skin or a split-skin graft; and third, to immediate or delayed internal hairline reduction, with metallic fixation when indicated. The hazard of primary suture is greatly reduced by penicillin and the availability of whole blood. Healing by first intention has been more frequent since the adoption of more radical excision of partly or wholly devitalized skin flaps. Temporary removal of the tourniquet has been found to be the only dependable aid in evaluating the vitality of the skin. A thorough knowledge of and versatility in skin-plastic surgery are important for selection of the optimum covering of the individual skin defect. Preference is given to the approximation of relaxed flaps, whenever possible. Defects caused by relaxing incisions are covered, immediately or later, by split grafts. Evaluation of the end results of compound fractures is facilitated by photographs of the external wound, made at the time of the usual admission roentgenogram, and repeated two weeks later at the time of the first dressing. An attempt has been made to evaluate the therapeutic indications of each case on admission and to determine the factors which require immediate treatment. Definitive fracture treatment should frequently be postponed. It is usually advantageous to carry out simultaneously the treatment of shock and a careful débridement, followed immediately by elosure of the skin and the application of a compression dressing.

Two-dimensional (2D) organic-inorganic hybrid perovskites, which possess outstanding optical and electrical properties, are promising semiconductor materials that have attracted significant interest in widespread applications. The frictional behavior of 2D perovskite materials with other transparent conductive materials, such as indium tin oxide (ITO), offers promising developments in optoelectronic devices. Therefore, the understanding of this frictional behavior is essential. Atomic force microscopy (AFM) is employed here to measure the frictional behavior between the (001) plane of the 2D organic-inorganic hybrid (C4H9NH3)2PbBr4 perovskite and the (111) plane of the ITO. The experimental analyses characterizing the nature of the friction in a single-crystalline heterojunction are reported. Based on the results of the analyses of interfaces between 2D monolayer perovskites and ITO, a strong anisotropy of friction is clearly demonstrated. The anisotropy of friction is observed as a four-fold symmetry with low a frictional coefficient, 0.035, in misaligned contacts, and, 0.015, in aligned contacts in the heterojunction configuration. In addition, atomistic simulations reveal underlying frictional mechanisms in the dynamical regimes. A new phenomenon discovered in the studies establishes that the measured frictional anisotropy surprisingly depends on the number of atomic layers in the 2D perovskite. The frictional anisotropy decreases significantly with the increase in the number of layers up to 16 layers, and then it becomes independent of the thickness. Our results are predicted to be of a general nature and should be applicable to other 2D hybrid perovskite heterojunction configurations, and thus, furthers the development of adaptive and stretchable optoelectronic nanodevices.

This study examined the direct effect of gender, controlling for years of experience, job role, and other variables, in a sample of 359 Pennsylvania social workers. Men social workers received significantly more yearly salary (an estimated 3,665 dollars more) than women social workers. A path analysis suggested that the salary advantage for men that was attributable to their acquiring more experience and management positions was slightly larger than the direct effect of gender. The ability of merit variables to explain salary was somewhat greater for men than women. Other variables that mediated the effect of gender on salary were MSW specialization, working in a social work or a related area, and practice area (children and youths, health, mental health, or other area). The results suggest that substantial gender disparity continues to exist in social worker salaries.

Ferguson, Albert B. Jr.; Donaldson, William F.; Goodman, Marvin C.; Rodriguez, Ervin E.; Skovron, Michael; Gartland, John J. Author Information

Transantral internal maxillary ligation for epistaxis is becoming more and more popular. The intention of this paper is to bring home three points: 1. only the arterial trunk need be ligated to obtain the anticipated results, 2. by following certain guidelines the operating time can be cut down by at least 45 minutes, and 3. if the procedure is carried out in time, it can be cost-effective. As time goes on, more and more patients will be added to this analysis and eventually reported.

OBJECTIVES: During the early months of the COVID-19 pandemic, virtual and telephone visits rapidly replaced most in-person care within the Veterans Health Administration (VA) to reduce the virus spread. To address the emerging mental health needs of older Veterans (e.g., social isolation) in the context of chronic underlying mental health needs (e.g., trauma), we developed an 8-week virtual group treatment manual. This article describes the results from a survey of geriatric mental health clinicians who used the COVID group manual to determine its acceptability and feasibility in these settings. METHODS: Clinicians across three VA integrated care settings (home-based primary care, community living centers, and geriatric primary care) were surveyed about their experiences implementing this treatment (n = 21). RESULTS: Clinicians found this intervention to be effective with their patients and useful and adaptable beyond the early pandemic period. CONCLUSIONS: This group teletherapy intervention was feasible and acceptable when treating Veterans in integrated geriatric healthcare settings. Despite technical challenges experienced by older Veterans, clinicians found this manual to be effective in addressing COVID-related worry and social isolation. CLINICAL IMPLICATIONS: This rapid response manual has remained clinically useful in geriatric mental health care settings beyond the initial weeks of the pandemic.

Fall prevention in the elderly is a multifaceted task that encompasses both the number of risk factors and their modification methods. Fall risk factors have been identified as intrinsic, such as decreased strength, impaired balance, and number (>4) of medications taken, and extrinsic, such as poor lighting and slippery floors. As the number of risk factors increases, an individual's risk increases linearly. Interventions are being used to decrease risk factors, but the essential and adequate components are not clearly understood. Combinations of treatment interventions aimed at modifying risk factors presently are the most sufficient way of addressing fall prevention.

BACKGROUND: Alkalinized Viokase pancreatic enzyme tablets restored patency to 71.9% of occluded Dobhoff tubes in a prospective study. After removal of Viokase tablets from the US market, the hospital protocol for unclogging enteral feeding tubes was adapted to use Creon pancreatic enzyme delayed-release capsules, despite the lack of published data. OBJECTIVE: To evaluate the effectiveness of a Creon-based protocol to clear occluded enteral feeding tubes. METHODS: This retrospective study included all adult and pediatric patients seen in the emergency department or in an inpatient setting who received Creon 12 000 units lipase delayed-release capsule dissolved in a solution of sodium bicarbonate 650 mg and sterile water for clearing occluded enteral feeding tubes between May 1 and November 30, 2010. The Creon protocol was deemed effective if tube clearance was documented in the medical record or if enteral feedings were resumed with no note regarding tube replacement. RESULTS: Alkalinized Creon delayed-release capsules were administered to 83 patients with a total of 118 clogged tubes. Three poorly documented cases and 5 tubes with mechanical clogs were excluded from data analysis. Patency was restored to 53 of 110 (48.2%) occluded tubes. More than 1 treatment course was attempted in 5 cases, with success in 3. CONCLUSION: An alkalinized Creon pancreatic enzyme protocol was effective in clearing approximately half of the occluded enteral feeding tubes in this retrospective study, an efficacy rate much less than that previously reported in the literature with a Viokase-based protocol.

This article describes the inception and evolution of a 3-month immersion experience between hospital and nurse leaders where sociological principles were applied to support nurse leader succession. Unique to this program, the bedside nurse joins the nursing executive team full time to participate in all organizational leadership activities as part of the experience.

Background Clinical care team members in Department of Veterans' Affairs (VA) facilities nationwide are working to integrate the use of Secure Messaging (SM) into care delivery and identify innovative uses. Identifying best practices for proactive use of SM is a key factor in its successful implementation and sustained use by VA clinical care team members and veterans. Objectives A collaborative project solicited input from VA clinical care teams about their local practices using SM to provide access to proactive patient-centered care for veterans and enhance workflow. Methods This project implemented a single-item cross-sectional qualitative electronic survey via internal e-mail to local coordinators in all 23 Veterans Integrated Service Networks (VISNs). Content analysis was used to manage descriptive data responses. Descriptive statistics described sample characteristics. Results VA clinical care team members across 15 of 23 VISNs responded to the questionnaire. Content analysis of 171 responses produced two global domains: (1) benefits of SM and (2) SM best practices. Benefits of SM use emphasize enhanced and efficient communication and increased access to care. Care team members incorporate SM into their daily clinical practices, using it to provide services before, during, and after clinical encounters as a best practice. SM users suggest improvements in veteran care, clinical team workflow, and efficient use of health resources. Clinical team members invested in the successful implementation of SM integrate SM into their daily practices to provide meaningful and useful veteran-centered care and improve workflow. Conclusion VA clinical care team members can use SM proactively to create an integrated SM culture. With adequate knowledge and motivation to proactively use this technology, all clinical team members within the VA system can replicate best practices shared by other clinical care teams to generate meaningful and useful interactions with SM to enrich veterans' health care experience.

PURPOSE: The initiation of a pharmacist-managed clinic to ensure appropriate use of erythropoietin-stimulating agents (ESAs) at a Veterans Affairs medical center is described. SUMMARY: A drug-use evaluation (DUE) in 2005 showed that ESA therapy met all of the institution's usage criteria in only 2 of 49 patients receiving ESAs. A protocol was developed and approved for pharmacist management of ESA therapy; physicians refer all patients beginning or currently receiving ESAs to a clinic established for pharmacist management of this therapy. The clinic initiated iron therapy when a patient's transferrin saturation (TSAT) was <20% and serum ferritin concentration was <100 ng/ mL, indicating low iron stores. Hemoglobin, TSAT, and ferritin levels at baseline and after four months of clinic management were compared for 35 patients, as were the costs of ESA therapy before and after clinic enrollment. Hemoglobin levels improved significantly within one month, and cost savings were substantial. Six months after clinic implementation, ESA therapy for 27 of 29 patients was in compliance with DUE criteria. CONCLUSION: Pharmacist management of patients receiving ESA therapy was effective in improving hemoglobin levels and compliance with criteria for ESA use, and it achieved substantial cost savings.

Guided abduction is a form of overhead traction conceptually similar to the Pavlik harness. It is used in older children or in children in which the Pavlik harness has failed. The results of 27 congenitally dislocated hips treated by guided abduction traction from December 1979 to June 1989 were reviewed. Ages ranged from 1 month to 28 months. Twenty (74%) of the 27 hips underwent a gentle, often spontaneous, closed reduction, followed by abduction casting and bracing. Two hips developed radiographic evidence of avascular necrosis; five hips developed temporary irregular ossification. Closed reduction was unobtainable in any child older than 24 months. Two children needed additional reconstructive procedures, one an innominate pelvic osteotomy and the other a valgus derotation osteotomy. Both had had open reductions. Recent reports stated that preliminary traction in the treatment of congenitally dislocated hips is of no value. We consider guided abduction traction a valuable treatment modality resulting in a reduced incidence of open reduction. When comparing our results with those of a Salt Lake City study performed without preliminary traction, our incidence of open reduction is lower (26 versus 49%). Our study supports the use of preliminary traction to decrease the need for open reduction in congenitally dislocated hips.

We report a case of a 71-year-old woman who presented with a ruptured wide-necked proximal anterior cerebral artery (ACA) aneurysm that was successfully embolized using Neuroform stent-assisted coiling.