Jack C. Montgomery VA Medical Center

BACKGROUND: The Alzheimer's Disease Assessment Scale-cognitive (ADAS-cog) is a commonly used measure for assessing cognitive dysfunction in patients with Alzheimer's disease (AD). The measure has 11 subscales, each of which captures an important aspect of cognitive dysfunction in AD. Traditional scoring of the ADAS-cog involves adding up the scores from the subscales without regarding their varying difficulty or their strength of relationship to AD-associated cognitive dysfunction. The present article analyzes problems associated with this approach and offers solutions for gaining measurement precision by modeling how the subscales function. METHODS: We analyzed data collected at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic from 1240 patients diagnosed with varying degrees of dementia. Item response theory was used to determine the relationship between total scores on the ADAS-cog and the underlying level of cognitive dysfunction reflected by the scores. RESULTS: Results revealed that each total score corresponded to a spectrum of cognitive dysfunction, indicating that total scores were relatively imprecise indicators of underlying cognitive dysfunction. Furthermore, it was common for two individuals with the same total score to have significantly different degrees of cognitive dysfunction. CONCLUSIONS: These findings suggest that item response theory scoring of the ADAS-cog may measure cognitive dysfunction more precisely than a total score method.

High rates of substance use and related problems have been long recognized as critical health issues for Native American adolescents. Unfortunately, no manualized interventions address the specific needs of Native American adolescents in a culturally appropriate manner. In 2006, the Cherokee Nation partnered with the University of Colorado to employ a community-based participatory research process to develop an intervention for Native American adolescents with substance use problems. The resulting intervention, Walking On, is an explicit blend of traditional Cherokee healing and spirituality with science-based practices such as cognitive behavioral therapy and contingency management and is designed to address the specific needs and worldviews of Native American adolescents with substance use problems and their families. Each individual and family session includes a brief assessment, a skill-building component, and a ceremony. A Weekly Circle (multifamily group) promotes sobriety and builds a community of healing. Early pilot study results suggest that Walking On is feasible for use in tribal substance abuse treatment programs. While Walking On shows early promise, the intervention will require further study to examine its efficacy.

Importance: Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair. Objective: To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive. Design, Setting, and Participants: In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021. Interventions: Presurgical consultation using a decision aid vs usual care. Main Outcomes and Measures: The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios. Results: Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70). Conclusions and Relevance: Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures. Trial Registration: ClinicalTrials.gov Identifier: NCT03115346.

BACKGROUND/AIMS: An item response theory (IRT)-based scoring approach to the Clinical Dementia Rating Scale (CDR) can account for the pattern of scores across the CDR items (domains) and their differential abilities to indicate dementia severity. In doing so, an IRT-based approach can provide greater precision than other CDR scoring algorithms. However, neither a good set of item parameters nor an easily digestible set of instructions needed to implement this approach is readily available. METHODS: Participants were 1,326 patients at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Clinic. RESULTS: The item parameters necessary for an IRT-based scoring approach were identified (a parameters ranged from 3.01 to 6.22; b parameters ranged from -2.46 to 2.07). CONCLUSION: This study provides, and demonstrates how to easily apply, IRT-based item parameters for the CDR

BACKGROUND/AIMS: To investigate the effectiveness of an item response theory (IRT)-based approach to staging dementia. METHODS: IRT estimates of dementia severity in 1,485 patients were used to stage dementia and then compared to dementia staging using the classic Clinical Dementia Rating Scale (CDR) algorithm and the Sum of the Boxes (SOB) approach. RESULTS: Measurement imprecision was highest when dementia stages were determined based on the classic algorithm (48% of sample), lower when they were determined based on the SOB approach (12%), and lowest when determined using IRT-based staging (0%). CONCLUSION: The classic CDR algorithm weights boxes largely according to clinical experience. The SOB approach weights all boxes equally. The IRT approach weights boxes according to their actual ability to identify dementia severity and therefore provides the most precise information for staging dementia.

Abstract Background Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. Methods A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5–10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Results Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. Conclusions We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

There is increasing interest in the development of economical and accurate approaches to identifying persons in the community who have mild, undetected cognitive impairments. Computerized assessment systems have been suggested as a viable approach to identifying these persons. The validity of a computerized assessment system for identification of memory and executive deficits in older individuals was evaluated in the current study. Volunteers (N = 235) completed a 3-hr battery of neuropsychological tests and a computerized cognitive assessment system. Participants were classified as impaired (n = 78) or unimpaired (n = 157) on the basis of the Mini Mental State Exam, Wechsler Memory Scale-III and the Trail Making Test (TMT), Part B. All six variables (three memory variables and three executive variables) derived from the computerized assessment differed significantly between groups in the expected direction. There was also evidence of temporal stability and concurrent validity. Application of computerized assessment systems for clinical practice and for identification of research participants is discussed in this article.

BACKGROUND/AIMS: To investigate whether an item response theory (IRT) approach to measuring variations of dementia severity within Clinical Dementia Rating (CDR) stages is associated with activities of daily living (ADLs). METHODS: IRT estimates of dementia severity within CDR stages in 1,181 patients were correlated with ADLs and analyzed. RESULTS: IRT-determined dementia severity was significantly correlated with ADLs in three of four impaired dementia stages. CONCLUSION: An IRT approach shows considerable advantages over traditional scoring practices of the CDR not only because it increases precision in dementia measurement, but also because it enables one to discover more precise associations with functional outcomes such as ADLs.

Orientation to time and place is frequently assessed in conditions such as Alzheimer's disease (AD). Despite the ubiquitous nature of orientation screening in mental status examinations, relatively little is known about the psychometric properties of orientation subscales. This article seeks to provide detailed psychometric information about the orientation items on the Mini Mental State Examination (MMSE) in individuals with AD. Orientation responses from 1,238 patients with AD (mean age = 75.5 years, SD = 8.4, range = 39 to 94) were examined within an item response theory (IRT) framework. Responses revealed that orientation items on the MMSE functioned differently across the spectrum of cognitive ability, with spatial orientation items tapping the breadth of cognitive impairment better than temporal items, which tended to have overlapping properties. Key clinical implications such as choosing appropriate items for different clinical purposes are highlighted.

OBJECTIVES: To summarize adaptations due to COVID-19 for VA Problem Solving Training (PST) for clinicians serving medically complex patients and to compare patient mental health outcomes in the year before (2019) and during COVID-19 (2020). METHODS: Clinicians attended a multi-day workshop and up to 6 months of small-group consultation for two training cases. In 2019 and 2020, 122 Veteran patients completed baseline and posttreatment measures of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 item), and negative problem-solving beliefs (Negative Problem Orientation Questionnaire). Qualitative data were collected on clinician's pandemic-related treatment implementation challenges. RESULTS: Program adaptations during COVID-19 addressed challenges due to delivering treatment by telephone, video, or in person; Veteran patient recruitment barriers; and privacy issues for telephone and video. Veterans in both pre-pandemic and COVID-19 cohorts had significant improvements in depression, anxiety, and negative problem-solving beliefs, with no significant differences in the amount of improvement between the two cohorts. CONCLUSIONS: Flexibilities afforded to clinicians delivering the PST training program during the pandemic addressed key obstacles and barriers to recruitment, and implementation did not diminish the effectiveness of the intervention. CLINICAL IMPLICATIONS: Findings support continued implementation of the PST training program with added flexibility to treatment delivery beyond the pandemic.

We describe the case of a 33-year-old man, a chronic user of powder cocaine, who presented with dyspnea, fever, night sweats, and significant weight loss. Chest HRCT revealed centrilobular nodules, giving an initial impression of miliary tuberculosis. Therefore, he was started on an empirical, four-drug antituberculosis treatment regimen. Four weeks later, despite the tuberculosis treatment, he continued to have the same symptoms. We then performed transbronchial lung biopsy. Histopathological analysis of the biopsy sample revealed birefringent foreign body granuloma. A corroborative history of cocaine snorting, the presence of centrilobular nodules, and the foreign body-related histopathological findings led to a diagnosis of pulmonary foreign body granulomatosis. This report underscores the fact that pulmonary foreign body granulomatosis should be included in the differential diagnosis of clinical profiles resembling tuberculosis.

Valproate sodium is an anticonvulsant medication, which has also been shown to be effective in the treatment of bipolar disorder. We report a case of valproate-induced tinnitus that was initially misinterpreted as increasing psychotic symptoms, which began approximately 2 days after initiation of valproate therapy. Tinnitus worsened during the next 6 days of treatment until it was recognized that this symptom was related to valproate. After discontinuance of the medication, the tinnitus gradually resolved over a period of 10 days with no residual effects. Although it is a rare adverse effect, valproate-induced tinnitus should be included in the differential diagnosis for tinnitus in patients receiving this medication. Tinnitus may be difficult to recognize in patients with active psychosis or mania.

The objective was to find an association between abnormal glycosylation, represented by Tn and STn antigens on mucin (MUC) proteins, in primary tumor specimens with lymph node metastasis or recurrence of cervical cancer patients. Prospectively collected specimens were obtained from the NRG Oncology/GOG clinical trial GOG 0221 patients with previously untreated stage IB-IVA primary cervical cancer, who underwent surgical resection and removal of associated para-aortic and pelvic lymph nodes. Immunohistochemical staining for mucin 1 and 4 (MUC1 and MUC4) proteins and surface glycoproteins Tn and Sialyl Tn were performed on sections cut from formalin-fixed, paraffin-embedded specimen blocks. Loss vs no loss, of immunohistochemical stain upon neuraminidase treatment was used to verify STn vs Tn positivity, respectively, in patient specimens and in colon tissue from wild-type and T-synthase knockout transgenic mice, which served as STn positive versus STn negative controls, respectively. H-scores of staining intensity and percentage of cells stained was performed by experienced gynecologic pathologists. An experienced gynecologic pathologist also selected photographed regions of interest associated with these cases. The photomicrographs presented in this data set highlight the spectrum of morphologic expression and variability in glycoprotein expression in primary tumors and cancer-positive lymph node specimens. Findings may prove useful in furthering the understanding of cervical cancer glycoproteins, creation of artificial intelligence immunohistochemical scoring systems, and the development of targeted drug therapy.

Exoffenders represent a population with unique concerns related to high unemployment. Betz and Hackett’s (1981 Betz, N. E., & Hackett, G. (1981). The relationship of career-related self-efficacy expectations to perceived career options in college women and men. Journal of Counseling Psychology, 28(5), 399–410.[Crossref], [Web of Science ®] , [Google Scholar]) career decision self-efficacy theory suggests that efficacy is an important component of career development. The differences in career decision self-efficacy between exoffenders and nonoffenders before and after a career development workshop were examined. Prior to the workshop, both groups were similar in overall career decision self-efficacy, self-appraisal, goal setting, planning, and problem solving, but exoffenders had lower occupational information. After the workshop, there were no significant differences between exoffenders and nonoffenders. Findings indicate that the entire sample experienced growth in all areas except for planning.

Sporothrix schenckii is a fungus commonly found in soil and on plants, wood splinters, rosebush thorns, and decaying vegetation. It is also carried by some wild and domestic animals and rodents. When this organism penetrates the skin of individuals handling contaminated substances, the cutaneous manifestation may be lymphangitic or fixed. The treatment of choice for the cutaneous form of the disease (sporotrichosis) is potassium iodide. If iodides are contraindicated or not tolerated, itraconazole may be used. Sporotrichosis can persist for years if unrecognized and can progress to systemic forms, including osteoarticular, pulmonary (may occur when the organism is inhaled), and meningeal involvement. Systemic forms can be life-threatening and very difficult to treat. Primary care providers must be familiar with this disorder and its presentation because it is easily mistaken for a bacterial infection and inappropriately treated.

Magnesium as a pharmacologic treatment has aroused a great deal of interest in recent years. Clinical studies using intravenous magnesium have been done for asthma, chronic obstructive pulmonary disease, acute myocardial infarction, and supraventricular and ventricular dysrhythmias. Studies on the mechanism of action of magnesium in these conditions have also been performed. Whereas treatment of dysrhythmias with magnesium is becoming accepted practice, the results of studies on asthma and myocardial infarction have been conflicting and have engendered controversy. This review discusses the major clinical studies that have been performed. Magnesium is safe (when used judiciously), inexpensive, easy to administer, and effective for at least some patients with acute airflow obstruction. At the present time, it is not possible to predict which patients with this condition are likely to benefit from this treatment, and its use in acute airflow obstruction is considered controversial. In view of the disappointing results of the ISIS-4 trial, magnesium should not be used to treat myocardial infarction. Magnesium is efficacious for multifocal atrial tachycardia, torsade de pointes, and ventricular dysrhythmias associated with heart failure and myocardial infarction and those occurring after cardiac surgery. It should be prescribed for these dysrhythmias, particularly torsade de pointes. A variety of dosing schedules have been used. In most instances, it need not be given more rapidly than 1 g per 5 minutes.