Hampton VA Medical Center

Ten data sets covering the period 1954–2000 are analyzed to show a 1%/yr increase in stratospheric water vapor. The trend has persisted for at least 45 years, hence is unlikely the result of a single event, but rather indicative of long‐term climate change. A long‐term change in the transport of water vapor into the stratosphere is the most probable cause.

Iron is essential for oxygen transport, oxidative metabolism, and cellular growth. Interactions between iron and other dietary factors play a significant role in determining the adequacy of iron nutrition and have important implications for food fortification in developing countries. Vitamin A and vitamin C deficiency states may affect iron transport, metabolism, and storage within the body.

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

Computed tomographic (CT) and magnetic resonance imaging (MRI) views of the brain were obtained in two adults and one child with hypertensive encephalopathy (HTE). Noncontrast CT was normal in one case and demonstrated decreased density posteriorly in two cases; MRI demonstrated focal, symmetric increased signal intensity in white matter and cortex, with occipital lobe involvement in each case. These lesions were better visualized on T2-weighted than on spin density images and were resolved on follow-up MRI four to five weeks later. These MRI studies support the concept that HTE is caused by the multifocal extravasation of fluid and proteins across the blood-brain barrier during "breakthrough" of cerebral autoregulation. We found that MRI appears more sensitive than CT and better defines the anatomy of cerebral involvement in HTE.

Serum concentration of hepatic enzymes are linked to liver dysfunction, metabolic and cardiovascular diseases. We perform genetic analysis on serum levels of alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) using data on 437,438 UK Biobank participants. Replication in 315,572 individuals from European descent from the Million Veteran Program, Rotterdam Study and Lifeline study confirms 517 liver enzyme SNPs. Genetic risk score analysis using the identified SNPs is strongly associated with serum activity of liver enzymes in two independent European descent studies (The Airwave Health Monitoring study and the Northern Finland Birth Cohort 1966). Gene-set enrichment analysis using the identified SNPs highlights involvement in liver development and function, lipid metabolism, insulin resistance, and vascular formation. Mendelian randomization analysis shows association of liver enzyme variants with coronary heart disease and ischemic stroke. Genetic risk score for elevated serum activity of liver enzymes is associated with higher fat percentage of body, trunk, and liver and body mass index. Our study highlights the role of molecular pathways regulated by the liver in metabolic disorders and cardiovascular disease.

Collaborative on Countering the US Opioid Epidemic [8] has been focusing on comprehensive and collaborative efforts to fundamentally address the opioid epidemic crisis.All of these major initiatives emphasize pain education as a key component in the fight against the dual crises of chronic pain and the opioid epidemic.I am honored to represent the AAPM on the HHS Pain Management Task Force and the NAM Action Collaborative and contribute to these important initiatives of our nation on your behalf.The AAPM emphasizes pain education as a strategic priority in its mission.In the coming years, we will focus on defining competencies and developing educational content for a spectrum of audiences, including patients, the public, and clinicians; further elevating the impact of our journal Pain Medicine; improving the educational programming of our annual meetings as long-standing cornerstones of the AAPM's education efforts; and promoting integration of educational efforts by various stakeholders, including the NIH, HHS, and NAM.We will place special emphasis on pain fellowship education, as today's fellows are tomorrow's leaders.We will also expand our membership to doctoral-level professionals specializing in pain medicine, who will not only contribute to multidisciplinary patient care but also play a key role in our educational and research efforts.We will identify major barriers to effective pain education and explore better and more innovative ways to improve pain education.We will need to define outcome metrics to measure the success or failure of pain education efforts.Pain medicine is a multidisciplinary specialty that has been constantly evolving and expanding in the last few decades and will continue to do so at accelerated rates.Pain education will inevitably evolve in terms of objectives, content, and delivery.But the purpose of pain education, to improve patient care, will never change.

Both of these myocutaneous flaps can supplant forehead and deltopectoral flaps, in certain indications. They are additional arterialized flaps for the armamentarium of the reconstructive surgeon, and can be useful in many repairs in the head and neck region.

This study examined the effects of increasing levels of dietary fat fed isocalorically on body weight, body composition, and adipose distribution. Adult male rats were weight matched into four groups. One group that was fed a low-fat diet (12%) served as reference controls. The other three groups were fed diets of 24, 36, or 48% fat in amounts to equal the energy intake of the control group. After 6 wk, body weights of the four groups were not significantly different. Intrascapular brown fat did not differ between groups. Total body fat and adipose depot weights, however, increased in proportion to the level of fat in the diet. Total body fat and retroperitoneal and mesenteric depot weights of the 48% fat group were greater than controls (P < 0.05). Mesenteric fat in this group was also significantly increased over all other groups (P < 0.05). These results show that high-fat diets fed to adult animals cause increased body fat in the absence of significant changes in body weight and that mesenteric fat is increased disproportionately.

A new method to impose boundary conditions for pseudospectral approximations to hyperbolic equations is suggested. This method involves the collocation of the equation at the boundary nodes as well as satisfying boundary conditions. Stability and convergence results are proven for the Chebyshev approximation of linear scalar hyperbolic equations. The eigenvalues of this method applied to parabolic equations are shown to be real and negative.

The experimental and epidemiological evidence demonstrating that Ca inhibits Fe absorption was reviewed, with the objectives of estimating the potential impact of variations in Ca intake on dietary Fe bioavailability and of providing some guidelines for predicting the effects on Fe status of recent recommendations for higher dietary Ca intake. In animal models Ca salts reduced both haem- and non-haem-Fe absorption, the effect being dependent on the amount of Ca administered rather than the Ca:Fe molar ratio; dairy products had a variable effect; factors other than Ca may have been important. In single-meal human absorption studies, both haem- and non-haem-Fe absorption was inhibited by Ca supplements and by dairy products, the effect depending on the simultaneous presence of Ca and Fe in the lumen of the upper small intestine and also occurring when Ca and Fe were given in the fasting state. The quantitative effect, although dose dependent, was modified by the form in which Ca was administered and by other dietary constituents (such as phosphate, phytate and ascorbic acid) known to affect Fe bioavailability. The mechanism by which Ca influences Fe absorption has not been elucidated. The effects of factors that modulate Fe bioavailability are known to be exaggerated in single-meal studies, and measurements based on several meals are more likely to reflect the true nutritional impact. The results of most multiple-meal human studies suggest that Ca supplementation will have only a small effect on Fe absorption unless habitual Ca consumption is very low. Outcome analyses showed that Ca supplements had no effect on Fe status in infants fed Fe-fortified formula, lactating women, adolescent girls and adult men and women. However it should be noted that the subjects studied had adequate intakes of bioavailable Fe and, except in one study, had relatively high habitual Ca intakes. Although cross-sectional analyses in Europe have shown a significant inverse correlation between Ca intake (derived primarily from dairy foods) and Fe stores, the quantitative effect was relatively small. The general conclusion is that dietary Ca supplements are unlikely to have a biologically significant impact on Fe balance in Western societies unless Ca consumption is habitually very low; however, increased consumption of dairy products may have a small negative effect that could be functionally important in pregnancy if Fe supplements are not taken. It is uncertain whether the inverse relationship between consumption of dairy products and Fe status is due entirely to increased Ca intake; substitution of milk proteins for meat may also have negative effects on Fe balance.

Abstract We examine the thermal structure of the mesosphere and lower thermosphere (MLT) using observations from 2002 through 2021 from the SABER instrument on the NASA TIMED satellite. These observations show that the MLT has significantly cooled and contracted between the years 2002 and 2019 (the year of the most recent solar minimum) due to a combination of a decline in the intensity of the 11‐year solar cycle and increasing carbon dioxide (CO 2 .) During this time the thickness of atmosphere between the 1 and 10 −4 hPa pressure surfaces (approximately 48 and 105 km) has contracted by 1,333 m, of which 342 m is attributed to increasing CO 2 . All other pressure surfaces in the MLT have similarly contracted. We further postulate that the MLT in the two most recent solar minima (2008–2009 and 2019–2020) was very likely the coldest and thinnest since the beginning of the Industrial Age. The sensitivity of the MLT to a doubling of CO 2 is shown to be −7.5 K based on observed trends in temperature and growth rates of CO 2 . Colder temperatures observed at 10 −4 hPa in 2019 than in the prior solar minimum in 2009 may be due to a decrease of 5% in solar irradiance in the Schumann‐Runge band spectral region (175–200 nm).

This randomized controlled trial was designed to determine if art therapy in conjunction with Cognitive Processing Therapy (CPT) was more effective for reducing symptoms of combat posttraumatic stress disorder (PTSD) than CPT alone. Veterans (N = 11) were randomized to receive either individual CPT, or individual CPT in conjunction with individual art therapy. PTSD Checklist–Military Version and Beck Depression Inventory–II scores improved with treatment in both groups with no significant difference in improvement between the experimental and control groups. Art therapy in conjunction with CPT was found to improve trauma processing and veterans considered it to be an important part of their treatment as it provided healthy distancing, enhanced trauma recall, and increased access to emotions.

BACKGROUND: In response to the opioid epidemic and new guidelines, many patients on high-dose long term opioid therapy (LTOT) for chronic pain are getting tapered off opioids. As a result, a unique clinical challenge is emerging: while many on LTOT have poor pain control, functional decline, psychiatric instability, aberrancies and misuse, these issues may often worsen with opioid tapering. Currently, a clear explanation and practical guidance on how to manage this perplexing clinical scenario is lacking. METHODS: We offer a commentary with our perspective on possible mechanisms involved in this clinical phenomena and offer practical management guidance, supported by available evidence. RESULTS: It is not well recognized that allostatic opponent process involved in development of opioid dependence can cause worsening pain, functional status, sleep and psychiatric symptoms over time, and significant fluctuation of pain and other affective symptoms due to their bidirectional dynamic interaction with opioid dependence ('affective dynamism'). These elements of complex persistent dependence (CPD), the grey area between simple dependence and addiction, can lead to escalating and labile opioid need, often generating aberrant behaviors. Opioid tapering, a seemingly logical intervention in this situation, may lead to worsening of pain, function and psychiatric symptoms due to development of protracted abstinence syndrome. We offer practicing clinicians management principles and practical guidance focused on management of CPD in addition to chronic pain in these difficult clinical scenarios. CONCLUSION: Awareness of the science of the neuroplasticity effects of repeated use of opioids is necessary to better manage these patients with complex challenges.

BACKGROUND: Buprenorphine has become the major treatment for opioid use disorder (OUD) but data on long treatment term retention and its correlates are sparse. METHODS: All veterans with OUD treated in Veterans Health Administration (VHA) facilities nationally in fiscal year (FY) 2012, and who began treatment with buprenorphine as indicated by a first prescription after the first 60 days of the year were identified with the date of and their last prescription from FY 2012-2015. Veterans were classified into four groups based on time from first to last prescription: (0-30 days, 31-365 days; 1-3 years; and more than 3 years). These groups were compared on socio-demographic, diagnoses and service, and psychotropic drug use. Kaplan-Meier curves and Cox proportional hazards models were used to identify variables independently associated with retention in buprenorphine treatment. RESULTS: Veterans newly started on buprenorphine (n = 3,151) were retained in treatment for a mean duration of 1.68 years (standard deviation [SD] 1.23), with 61.60% (n = 1,941) retained for more than a year and 31.83% (n = 1,003) for more than 3 years. Cox proportion hazards model showed that only black race (Hazards ratio [HR] 1.26; standard error [SE] .06; p.0003), the Charlson index (HR 1.03; SE .01; p.0132) and emergency room visits during FY 2012 (HR 1.03; SE .01; p < .0001) were the only available variables independently associated higher odds of buprenorphine discontinuation. CONCLUSIONS: Buprenorphine retention was substantial among veterans treated in VHA, but few individual characteristics correlated with retention. SCIENTIFIC SIGNIFICANCE: Future research focused on identifying further correlates of treatment retention is required to help devise interventions to improve treatment continuation. (Am J Addict 2017;26:572-580).

Lonergan, Robert P., III, J. Catsby Ware, Richard L. Atkinson, W. Christopher Winter, and Paul M. Suratt. Sleep apnea in obese miniature pigs. J. Appl. Physiol. 84(2): 531–536, 1998.—We postulated that three extremely obese Yucatan miniature pigs would have more sleep apnea than three nonobese Yucatan miniature pigs. Pigs were studied with the use of electroencephalograms, inductance plethysmography, oximetry, expired nasal CO 2 , or thermistors. All of the obese pigs, but none of the nonobese pigs, had both sleep apnea (8.5, 10.3, and 97.0 in obese pigs vs. 0 apnea + hypopnea/h in all nonobese pigs; P &lt; 0.05) and oxyhemoglobin desaturation episodes during sleep [9.4 ± 3.0 vs. 0 + 0.53 (SD) mean desaturation episodes/h in obese pigs vs. nonobese pigs, respectively; P &lt; 0.05]. Two of the extremely obese pigs had obstructive sleep apnea, whereas the third obese pig had central sleep apnea. We conclude that sleep apnea occurs in extremely obese Yucatan minipigs and suggest that this animal can be used as a model for sleep apnea in obesity.

Joiner's (2005) theory attributes suicide to an individual's acquired capability to enact self-harm, perceived burdensomeness, and thwarted belongingness. This study evaluated whether Joiner's theory could differentiate United States (US) Air Force (AF) personnel (n = 60) who died by suicide from a living active duty AF personnel comparison sample (n = 122). Responses from AF personnel on several scales assessing Joiner's constructs were compared to data from a random sample of postmortem investigatory files of AF personnel who died by suicide between 1996-2006. This research also introduced a newly designed measure, the Interpersonal-Psychological Survey (IPS), designed to assess the three components of Joiner's theory in one, easy-to-administer instrument. Analyses of the psychometric properties of the IPS support initial validation efforts to establish this scale as a predictive measure for suicide. Findings support that one's score on the Acquired Capability to Commit Suicide subscale of the IPS and the IPS overall score reliably distinguished between the two groups. The implications of these findings in relation to suicide prevention efforts in the US military are discussed.

This study uses data from a nationally representative epidemiologic survey, the National Comorbidity Survey Replication, to investigate the association of mental health and substance use disorders, along with other factors, with past homelessness. Approximately 5% of the 5,251 adults reported having been homelessness. Multivariate analysis showed the strongest independent risk factors for past homelessness were past receipt of welfare payments (odds ratio [OR]=5.7), incarceration for 27 or more days (OR=3.9), exposure to personal violence (OR=2.7), lifetime substance use disorder (OR=2.4), and Black race (OR=2.1). Several non-substance use psychiatric disorders were also significantly, if less strongly (OR 1.4 to 1.6), associated with past homelessness. Past homelessness is associated with a broad array of sociodemographic, economic, and mental health problems. While the association of both substance use and psychiatric disorders with past homelessness was quite strong, non-substance use psychiatric disorders was not as strong an independent risk factor as substance abuse disorders.

From a prospective study of tardive dyskinesia (TD), psychiatric patients with neuroleptically-induced "persistent" TD were contrasted with controls on a neuropsychological measure of abstracting ability. A significant association is demonstrated between impaired cognitive performance and TD, even when the neuropsychological measure was obtained in advance of TD onset.

The purpose of this report is to propose standards for the successful treatment of obesity. This process is somewhat arbitrary because obesity is a multifactorial disease and because standards need revision as diagnostic and treatment techniques improve. Weight loss, the classic standard of success, does not account for individual variability. Reduction in other measures of body size, such as body mass index, percentage of excess weight, and body fat, may be preferable. Improvement in known complications of obesity (diabetes mellitus, hypertension, hyperlipoproteinemia, sleep apnea, and psychosocial problems) are equally valid measures of success. Because obesity is a chronic disease, maintenance of weight loss is included as a standard of success. Response to obesity treatment varies, and thus criteria to define minimal, intermediate, and full success for each variable are necessary.

Tropospheric vertical structure was analyzed using in situ measurements of O 3 , CO, CH 4 , and H 2 O taken on board the NASA DC‐8 aircraft during three Pacific Exploratory Missions (PEMs): PEM‐West A, September‐October 1991 in the western Pacific; PEM‐West B, February‐March 1994 in the western Pacific; and PEM‐Tropics A, September‐October 1996 in the central and eastern Pacific. PEM‐Tropics A added measurements from the NASA P3‐B aircraft. We used a new mode‐based method to define a background against which to find layers. Using only O 3 and H 2 O, we found 472 layers in PEM‐Tropics A (0.72 layers per vertical kilometer profiled), 237 layers in PEM‐West A (0.54 layers/km), and 158 layers in PEM‐West B (0.41 layers/km). Using all constituents, we found 187 layers in PEM‐Tropics A (0.43 layers/km), 128 layers in PEM‐West A (0.29 layers/km), and 80 layers in PEM‐West B (0.21 layers/km). Stratospheric air, sometimes mixed with trapped pollution, was the dominant layer source in all three missions. The larger number of layers per kilometer in PEM‐Tropics A was probably due to repeated profiling of several “superlayers” visible in many of the mission lidar and potential voracity profiles. The thickness of the superlayers was of order 1 km, and the horizontal extent was of order 1000 km. We found that layers have an important effect on the thermal structure. An example based on ozonesonde data from Tahiti is shown, where a dry, subsiding layer was stabilized by much greater radiative cooling at the base than at the top. The stabilized layer can trap pollution and force vertical plumes to spread into horizontal layers.