Mann-Grandstaff VA Medical Center

Several studies have examined the usefulness of the Warrington Recognition Memory Test-Words as a measure to detect suspect effort, although samples have generally been small and/or comprised of simulators rather than "real world" credible and noncredible patients. The current study examined the Warrington Recognition Memory Test-Words total score and response time of "real world" noncredible patients (as determined by motive to feign, failure on > or =2 independent measures of response bias, low cognitive scores inconsistent with normal ADLs; n = 190) versus credible patients (as determined by no motive to feign, failure of < or =1 measure of response bias; n = 124) derived from an archival database of individuals from the Harbor-UCLA Medical Center, Department of Psychiatry, Outpatient Neuropsychology Service, and the private practice of the second author. Noncredible patients obtained significantly lower total scores and longer times to complete the task. A total correct cutoff of < or =42 was found to have excellent specificity (91.9%) and sensitivity (88.9%), whereas a time cutoff of > or =207'' was associated with 65.5% sensitivity at 90.7% specificity, and when the time cut-score was used in combination with the total score cutoff, an additional 5% of the noncredible participants were captured, raising overall sensitivity to 93.7% (at 87.1% specificity). Thus, the Warrington Recognition Memory Test-Words, although not originally created for the purposes of measuring suspect effort, appears to be an excellent measure for detecting response bias on neuropsychological testing.

The assessment of response validity during neuropsychological evaluation is an integral part of the testing process. Research has increasingly focused on the use of "embedded" effort measures (derived from standard neuropsychological tasks) because they do not require additional administration time and are less likely to be identified as effort indicators by test takers because of their primary focus as measures of cognitive function. The current study examined the clinical utility of various WMS-III Logical Memory scores in detecting response bias, as well as the Rarely Missed Index, an embedded effort indicator derived from the WMS-III Logical Memory Delayed Recognition subtest. The Rarely Missed Index cut-off only identified 24.1% of 63 non-credible participants (at >/=90% specificity in 125 credible patients), and cut-offs for other Logical Memory variables were in fact found to be more sensitive to non-credible performance. A new indicator, consisting of the weighted combination of the two most sensitive Logical Memory subtest scores (Logical Memory II raw score and Logical Memory Delayed Recognition raw score), was associated with 53% to 60% sensitivity, and thus may be an effective adjunct when utilized in conjunction with other validated effort indicators and collateral information in identifying non-credible performance.

The occurrence of a hymen-like ring of mucosa, muscularis mucosae, and submucosa causing partial obstruction within the stomach appears to be exceedingly rare, and it is for this reason that the following case is being reported. R. C., a 35-year-old woman, was first seen on Jan. 12, 1951, complaining of intermittent vomiting of several years duration, aggravated by solid food, and partially relieved by a liquid diet. She experienced a sensation of fullness in the upper abdomen, but no pain. The patient had been married for fourteen years and had three children living and well. Because of symptoms similar to those of which she now complained, an appendectomy and four pelvic operations, including bilateral salpingo-oophorectomy and total hysterectomy, had been performed without producing relief. The physical examination revealed no significant pathological change. The abdominal examination was entirely non-contributory; no abdominal mass, tenderness, or rigidity was present. The liver and spleen were not palpable. Urinalysis was normal. The red blood cell count was 4,750,000; white cell count 6,000; hemoglobin 14 gm. 95 per cent. X-ray examination following a barium meal showed the stomach to be normal down to the gastric antrum, approximately 3 cm. beyond the angularis. There a persistent linear defect with sharp margins was demonstrable in all possible projections and regardless of the position of the patient (Fig. 1). The barium passed by this partial occlusion without significant delay, showing the prepyloric antrum, pylorus, duodenal bulb, and duodenal loop to be entirely normal, with no evidence of pathological change of the small bowel. The exact nature of the diaphragm-like process could not be determined at this time. A second examination revealed exactly similar findings (Fig. 2). Operation was performed chiefly because of the persistent symptoms. Under endotracheal anesthesia a right paramedian incision was made through the moderately thick abdominal wall. Upon opening the peritoneum, exploration revealed dense adhesions in the pelvis from previous laparotomies. The large and small bowel were negative to palpation. The gallbladder was thin-walled, without stones, and emptied with pressure. The liver edge was sharp, and the liver was normal in consistency. The kidneys were normal in size, shape, and position. The gastrocolic ligament was opened and the pancreas found to be normal throughout. The stomach appeared normal. The duodenum was mobile, without evidence of previous disease. It was opened, and 2 cm. above the pylorus there was demonstrated a thin structure 2 to 3 mm. in thickness, with a small stellate perforation 3 to 4 mm. in diameter. The opening in the membrane was situated slightly off-center, so that pressure of the latter against the pylorus closed both openings (Fig. 3).

Practice guidelines recommend the use of multiple performance validity tests (PVTs) to detect noncredible performance during neuropsychological evaluations, and PVTs embedded in standard cognitive tests achieve this goal most efficiently. The present study examined the utility of the Comalli version of the Stroop Test as a measure of response bias in a large sample of "real world" noncredible patients (n = 129) as compared with credible neuropsychology clinic patients (n=233). The credible group performed significantly better than the noncredible group on all trials, but particularly on word-reading (Stroop A) and color-naming (Stroop B); cut-scores for Stroop A and Stroop B trials were associated with moderate sensitivity (49-53%) as compared to the low sensitivity found for the color interference trial (29%). Some types of diagnoses (including learning disability, severe traumatic brain injury, psychosis, and depression), very advanced age (⩾80), and lowered IQ were associated with increased rates of false positive identifications, suggesting the need for some adjustments to cut-offs in these subgroups. Despite some previous reports of an inverted Stroop effect (i.e., color-naming worse than color interference) in noncredible subjects, individual Stroop word reading and color naming trials were much more effective in identifying response bias.

Fine needle aspirates from one of multiple liver nodules revealed a large number of discohesive malignant cells with abundant vacuolated cytoplasm. The patient had had left eye enucleation the year before, for a melanoma with focal areas of clear cell change. Pap stained preparations from the liver FNA displayed well the nuclear features of balloon cell melanoma, including anisonucleosis, prominent nucleoli and intranuclear inclusions. Diff-Quik stain demonstrated best the cytoplasmic features such as distinct cell margins and finely dispersed and sharply delineated clear vacuoles. No pigmentation was noted but melanoma was suspected after the history prompted comparison with the enucleated specimen resected a year previously. A multimodal battery of ancillary methods including electron microscopy (EM) and immunocytochemistry (ICC) allowed the confirmation of balloon-cell melanoma, a rare variant not previously described in the eye. By EM, abundant lipids were identified along with melanin-containing structures resembling melanosomes. S-100 positivity along with negativity for epithelial, lymphohistiocyte and germ cell markers was compatible with melanoma. These findings are consistent with the view that cytologic detection of poorly cohesive, hypervacuolated cells does not exclude the possibility of melanoma. This rare example of a lipid-containing melanoma stresses the value of obtaining good clinical history, comparing FNAs to any pre-existing material and utilizing a multimodal approach to cytologic diagnosis in select cases.

Health care technologies have the ability to bridge or hinder equitable care. Advocates of digital mental health interventions (DMHIs) report that such technologies are poised to reduce the documented gross health care inequities that have plagued generations of people seeking care in the United States. This is due to a multitude of factors such as their potential to revolutionize access; mitigate logistical barriers to in-person mental health care; and leverage patient inputs to formulate tailored, responsive, and personalized experiences. Although we agree with the potential of DMHIs to advance health equity, we articulate several steps essential to mobilize and sustain meaningful forward progression in this endeavor, reflecting on decades of research and learnings drawn from multiple fields of expertise and real-world experience. First, DMHI manufacturers must build diversity, equity, inclusion, and belonging (DEIB) processes into the full spectrum of product evolution itself (eg, product design, evidence generation) as well as into the fabric of internal company practices (eg, talent recruitment, communication principles, and advisory boards). Second, awareness of the DEIB efforts-or lack thereof-in DMHI research trials is needed to refine and optimize future study design for inclusivity as well as proactively address potential barriers to doing so. Trials should incorporate thoughtful, inclusive, and creative approaches to recruitment, enrollment, and measurement of social determinants of health and self-identity, as well as a prioritization of planned and exploratory analyses examining outcomes across various groups of people. Third, mental health care advocacy, research funding policies, and local and federal legislation can advance these pursuits, with directives from the US Preventive Services Taskforce, National Institutes of Health, and Food and Drug Administration applied as poignant examples. For products with artificial intelligence/machine learning, maintaining a "human in the loop" as well as prespecified and adaptive analytic frameworks to monitor and remediate potential algorithmic bias can reduce the risk of increasing inequity. Last, but certainly not least, is a call for partnership and transparency within and across ecosystems (academic, industry, payer, provider, regulatory agencies, and value-based care organizations) to reliably build health equity into real-world DMHI product deployments and evidence-generation strategies. All these considerations should also extend into the context of an equity-informed commercial strategy for DMHI manufacturers and health care organizations alike. The potential to advance health equity in innovation with DMHI is apparent. We advocate the field's thoughtful and evergreen advancement in inclusivity, thereby redefining the mental health care experience for this generation and those to come.

In the present study a large sample of credible patients (n = 172) scored significantly higher than a large sample of noncredible participants (n = 195) on several WAIS-III Picture Completion variables: Age Adjusted Scaled Score, raw score, a "Rarely Missed" index (the nine items least often missed by credible participants), a "Rarely Correct" index (nine items correct <26% of the time in noncredible participants and with at least a 25 percentage-point lower endorsement rate as compared to credible participants), and a "Most Discrepant" index (the six items that were the most discrepant in correct endorsement between groups-at least a 40 percentage point difference). Comparison of the various scores showed that the "Most Discrepant" index outperformed all the others in identifying response bias (nearly 65% sensitivity at 92.8% specificity as compared to at most 59% sensitivity for the other scores). While no differences in Picture Completion scores were observed between less-educated (<12 years) and better-educated (≥12 years) credible participants, noncredible participants with <12 years of education scored significantly poorer than noncredible participants with 12 or more years of education. On the "Most Discrepant" index, 76.7% of less-educated noncredible participants were detected as compared to 58.3% of better-educated noncredible participants. Results of the current study suggest that the Picture Completion subtest of the WAIS-III is an effective measure of response bias, and that it may have a unique role in identifying suboptimal effort in less-educated test takers.

Pleomorphic hyalinized angiectatic tumor of soft parts is a recently described neoplasm that most commonly affects the lower extremities. It is locally aggressive but has not been known to metastasize. This article presents a case of a softball-sized tumor on the dorsum of the foot that was identified as pleomorphic hyalinized angiectatic tumor of soft parts. Previously, it would have been misdiagnosed and treated as either a neurilemoma or a malignant fibrous histiocytoma.

Patients' vulnerability is a core concern in nursing. However, the nurse's endeavor to succeed may precipitate her vulnerability. Involving master students, 14 nurses' experiences of vulnerability in their professional roles were explored with a descriptive phenomenological approach. Vulnerability among nurses showed to be a latent feeling that manifests via bodily reactions including being overwhelmed by one's feelings and struggling to avoid being hurt. These experiences were evident in situations with patients and relatives, but also coworkers and working conditions, the latter suggests that the exposure of vulnerability may be possible to reduce by organizational awareness.

Spinal cord stimulation (SCS) is a therapeutic modality for the treatment of various chronic pain conditions that has rapidly evolved over the past 50 years. Unfortunately, over time, patients implanted with SCS undergo a habituation phenomenon leading to decreased pain relief. Consequently, the discovery of new stimulation waveforms and SCS applications has been shown to prolong efficacy and reduce explantation rates. This article explores various SCS waveforms, their applications, and proposes a graded approach to habituation mitigation. We suspect the neural habituation phenomenon parallels that seen in pharmacology. Consequently, we urge further exploration of the early introduction of these stimulation strategies to abate spinal cord stimulation habituation.

Abstract There is a growing interest in the healthcare community to focus on the healthcare needs of lesbian, gay, bisexual, transgender, or genderqueer (LGBTQ) patients, particularly transgender and gender diverse (TGD) patients. TGD individuals have historically experienced rejection and mistreatment by healthcare providers yet have significant health needs, highlighting the need for providing affirming care. Medication therapy for TGD individuals involves many nuances and special considerations for managing concomitant therapies and drug interactions. Additionally, approaches to caring for TGD patients involve both medical interventions as well as social and legal processes. Pharmacists can assist and facilitate the care for TGD patients through a variety of mechanisms. This narrative review describes strategies to recognize and address many aspects of the care for TGD individuals, including destigmatizing care, affirmation strategies, and an overview of therapeutic misconceptions and concerns. Ultimately, this manuscript serves as a guide for pharmacists to care holistically for TGD patients.

BACKGROUND: Lower expression of secretoglobin and transferrin has been found in the bronchoalveolar lavage fluid (BALF) of a small number of horses with experimentally induced signs of recurrent airway obstruction (RAO) compared to healthy controls. HYPOTHESIS/OBJECTIVES: Secretoglobin and transferrin BALF expression will be similarly decreased in horses with naturally occurring clinical signs of RAO and in horses with experimentally induced clinical signs of RAO as compared to healthy controls and intermediate in horses with inflammatory airway disease (IAD). ANIMALS: Recurrent airway obstruction-affected and control horses were subjected to an experimental hay exposure trial to induce signs of RAO. Client-owned horses with a presumptive diagnosis of RAO and controls from the same stable environments were recruited. METHODS: Pulmonary function and BALF were evaluated from control and RAO-affected research horses during an experimental hay exposure trial (n = 5 in each group) and from client-owned horses (RAO-affected horses, n = 17; IAD-affected horses, n = 19; healthy controls, n = 5). The concentrations of secretoglobin and transferrin in BALF were assessed using Western blots. RESULTS: Naturally occurring and experimentally induced RAO horses had similar decreases in BALF transferrin expression, but secretoglobin expression was most decreased in naturally occurring RAO. Secretoglobin and transferrin expression were both lower in BALF of RAO-affected horses than in IAD-affected and control horses. CONCLUSIONS AND CLINICAL IMPORTANCE: Secretoglobin and transferrin expression is decreased in BALF of RAO-affected horses after both experimental and natural exposure. Secretoglobin and transferrin likely play clinically relevant roles in the pathophysiology of RAO, and may thus be used as biomarkers of the disease.

BACKGROUND: Our aim in this study was to compare the long-term outcomes of three different surgical procedures for the treatment of hallux rigidus (ie, cheilectomy, decompressive osteotomy, and arthrodesis) between active duty military and non-active duty patients. METHODS: A retrospective review of 80 patients (95 feet) undergoing surgical treatment for hallux rigidus was performed. Telephone survey was used to obtain postoperative outcome measures and subjective satisfaction. Additional data recorded and analyzed included age, sex, status of patient (active duty or non-active duty), grade of hallux rigidus, surgical procedure performed, date of surgery, time to return to full activity, ability to return to full duty, and follow-up time postoperatively. RESULTS: The decompressive osteotomy group had the highest return-to-duty rate, satisfaction rate, and Maryland Foot Scores of all three surgical groups, although these differences were not statistically significant. Active duty and non-active duty patients did not have statistically significant differences in outcomes measures (ie, time to return to full activity, ability to return to full duty, satisfaction, or postoperative Maryland Foot Score) in any of the three surgical groups. CONCLUSIONS: Decompressive osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis are all reliable and effective procedures for treatment of hallux rigidus in both active duty military and non-active duty patients. Active duty military personal have a high rate of returning to their prior military activities after surgical treatment of hallux rigidus.

Schwannomas originating in the kidney are extremely rare with very few cases documented in the literature. It is difficult to distinguish them from other common renal masses based on clinical symptoms and imaging characteristics alone, as both are non-specific for this pathology. Thus, the final diagnosis of schwannoma is typically made only after surgical resection and histologic examination. We present the case of a 66-year-old female who was initially evaluated for flank pain and referred to us after a renal mass was found on CT imaging. A partial nephrectomy was performed, and subsequent pathological examination confirmed the diagnosis of renal schwannoma.

Multiple myeloma (MM) is a clonal plasma cell disorder. Chromosome and FISH studies are used to provide prognostic information that is useful for refining risk stratification and therapeutic response [1]. Frequently, chromosome study is limited by the inability of plasma cells to proliferate in vitro, and FISH is restricted to small probe panels. To alleviate this problem, we have implemented a protocol of magnetic activated cell sorting (MACs) to isolate abnormal plasma cells followed by high-density single nucleotide polymorphism (SNP) microarray testing to improve our ability to clearly resolve chromosomal copy number abnormalities and to identify loss of heterozygosity (LOH) and copy number-neutral LOH (CNN-LOH). LOH/CNN-LOH have been shown to be important in cancer biology where they can lead to tumor suppressor gene inactivation [2]. By applying this methodology we have been able to increase our diagnostic yield and provide prognostic information on these clonal populations that previously would have been masked by the normal cells in the patient samples. Three consecutive MM patients with enough bone marrow volume were used for this study. They had plasma cell ratios ranging from 16% to 77% based on morphology and from 4% to 20% based on flow cytometry (Table 1). All patients had normal karyotype results by chromosome studies. Interphase MM FISH panel including probe sets of D13S319/13q34, IGH/FGFR3, P53/CEP17, and MLL break-apart (Abbott Molecular) revealed only 1-2 anomalies per sample (Table 1). After MACs enrichment treatments (Stem Cell Technologies), SNP microarray was performed on both the plasma-enriched and the plasma-depleted fractions with a total of 2.6 million probes (Affymetrix CytoscanHD array). The microarray result of the plasma-depleted fraction was normal with no pathogenic deletions or duplications; however, microarray results of the plasma-enriched fraction revealed 8 - 12 chromosomal abnormalities. Follow-up FISH studies confirmed microarray findings using CBFB break-apart, LSI 1p36/1q25, BCR, LSI 21, and centromere probes (CEP) for X, 2, 3, 5, 7, 9, 11, 15, 17, 19 (Abbott Molecular) (Table 1) . Table 1 Summary of patients’ clinical, karyotype (chromosome), FISH and SNP microarray data Microarrays were also performed on the total cell fraction of specimens from Patients 1 and 3 because of their high clonal plasma cell population (77% and 27% by morphology, respectively). By comparing microarray data between the total cell and plasma-enriched fractions of patients 1 and 3 (T and P+ in Table 1, respectively), it is evident that a more refined and accurate profile of chromosome copy number abnormalities is revealed from the plasma-enriched fraction than from the total fraction. For example, for chromosomes 5, 9, and 15 in patient 1, microarray revealed the presence of both trisomies and tetrasomies in the plasma-enriched fraction compared to only trisomies observed in the total cell fraction. Chromosomes 3, 7, 11, 17, 19, and 21 in patient 1 that were clearly trisomies in the plasma-enriched fraction dissolved into partial gain signals in the total cell fraction that were much more difficult to interpret with accuracy. For patient 3, microarray data from the total cell fraction only found the presence of mosaic loss of chromosome 13 and missed other eight additional changes, which were revealed by microarray data from the plasma-enriched fraction (Table 1). In all cases, the prognostic information from the microarray of plasma-enriched factions exceeded that of chromosome and FISH combined. According to microarray data, Patients 1 and 2 represent hyperdiploidy while Patient 3 is an example of hypodiploidy with 1q triplication that is also associated with a poor prognosis [3]. Besides identification of submicroscopic duplications or deletions, SNP microarrays can reveal abnormal allelic imbalances including LOH and CNN-LOH, which cannot be recognized by chromosome and FISH. CNN-LOH is the occurrence of LOH in the absence of allelic loss (copy number ≥ 2) and mosaic CNN-LOH is the mixture of normal and abnormal cells with CNN-LOH (Fig. 1a). Mosaic CNN-LOH of 16q was identified in Patient 2 (Fig. 1b), which has been associated with adverse prognosis [4]. Patient 3 was found to have complex abnormalities at chromosome 11q including mosaic deletion at 11q14.1-q22.1, a deletion at 11q22.1-q22.3, and mosaic CNN-LOH at 11q22.3-qter (Fig. 1c). Thus, plasma enrichment and SNP microarray provides a clear improvement in identification unbalanced chromosome abnormalities, LOH and CNN-LOH. Figure 1 Regions of CNN-LOH by SNP microarray. a Examples of different allele peak patterns determined by the ChAS software (Affymetrix). b Mosaic CNN-LOH at 16q in patient 2. c Complex 11q abnormalities in patient 3. del. = Deletion In summary, SNP microarray testing of MACs isolated abnormal plasma cells in our MM patients provided a much more comprehensive overview of the genome-wide chromosome copy number abnormalities compared to chromosome and FISH studies. SNP Microarray testing is useful in clinical practice to refine our diagnostic and prognostic indicators. This technique can be easily incorporated into every cytogenetic laboratory. Although SNP microarray testing cannot reveal any balanced structural abnormalities such as IGH-FGFR3 fusions, FISH on MACs isolated abnormal plasma cells will increase detection rate of clinically relevant genomic abnormalities to overcome the overall low percentage of plasma cells present in primary bone marrow aspirates. Therefore, combination of SNP microarray results of MACs enriched plasma cells and FISH/chromosome results will present a more complete picture of chromosome abnormalities and provide insights into understanding mechanisms of MM formation and development.

BACKGROUND: Botulinum neurotoxin type A (BoNT-A) is an effective treatment for many chronic conditions, but the economic implications of repeated treatments can be a burden on patients. The 3 commercial preparations of BoNT-A types available today are onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA, but no clear differences have been found in clinical efficacy between these 3 type A toxins in blinded comparative studies. OBJECTIVE: To conduct a cost-minimization analysis in a cohort of patients with chronic neurologic conditions who switched treatment from onabotulinumtoxinA to incobotulinumtoxinA. METHODS: The study was a single-center, retrospective review of data from a large, private, neurological practice in Spokane, WA. A comprehensive patient chart review was conducted of all patients who were switched from established onabotulinumtoxinA therapy to incobotulinumtoxinA therapy between 2012 and 2019. The patients were switched at a 1:1-unit ratio. All patients had commercial insurance or Medicare coverage. Dosage, injection intervals, wastage, treatment costs, switchback data, and patient savings program eligibility were evaluated for the period of 1 year before and 1 year after the switch from onabotulinumtoxinA to incobotulinumtoxinA therapy. RESULTS: The most frequently treated indication was cervical dystonia (N = 61; 54.5%), followed by chronic migraine (N = 36; 32.1%). After switching to incobotulinumtoxinA therapy, botulinum toxin wastage was reduced by 87.3% (from 150.9 units to 19.1 units), and the cost was reduced by 32.2% (from $5108 to $3461) per patient annually. A total of 14,635 units in unavoidable wastage and $182,792 in annual botulinum toxin costs were saved as a result of the switch in therapy. Patients remained at consistent dosing intervals after switching to incobotulinumtoxinA therapy. A total of 8 patients switched back to onabotulinumtoxinA treatment during this review, including 3 patients who switched back because of insurance reasons, and 5 who had self-reported efficacy concerns. The 70 commercially insured patients in the study who were eligible for the patient savings program for each of the 2 therapies saved an average of $2076 (241.5%) in annual costs after switching from onabotulinumtoxinA to incobotulinumtoxinA. CONCLUSION: Our findings showed that switching from onabotulinumtoxinA to incobotulinumtoxinA at similar intervals and dosages achieved considerable cost-savings, with a low incidence of switching back.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Plasmablastic lymphoma (PBL) is a rare form of diffuse large B-cell lymphoma characterized by weak/absent expression of conventional B-cell markers and strong expression of plasma cell markers. It is strongly associated with human immunodeficiency virus (HIV) and Epstein Barr virus infection, and shows an unusual tropism to the oral cavity. Herein we describe a patient with AIDS who presented with weight loss and dysphagia owing to a large gastroesophageal mass. His radiographic and endoscopic findings and long history of cigarette consumption suggested carcinoma. Biopsy demonstrated a poorly differentiated tumor stained negatively to routine lymphoid markers including CD20. However, gene rearrangement studies confirmed a B-cell process and a more detailed immunohistochemical analysis revealed the cells stained positively for CD138 (plasma cell antigen). These findings were diagnostic of PBL. Our report reviews the wide differential diagnosis of PBL and underscores the importance of a broad array of viral and molecular studies needed to establish this diagnosis.

In Brief In 2004, practice standards for electrocardiographic (ECG) monitoring were published to address the need for an expanded use of ECG monitoring beyond heart rate and basic rhythm determination. This article reports the data collected from a survey distributed throughout the Veterans Healthcare Administration hospitals to determine the extent to which practice standards have been adopted. Survey data were used to identify the differences between actual practice and evidence-based standards. The results were divided into ECG electrode application, lead selection, alarm limits, monitoring capabilities, monitoring during patient transport, and education and competencies. The results confirm the need for improvement, including a thorough evaluation of facility practices and education. The data demonstrate the differences among actual practice and evidence-based recommendations. In 2004, practice standards for electrocardiographic (ECG) monitoring were published to address the need for an expanded use of ECG monitoring beyond heart rate and basic rhythm determination. This article reports the data collected from a survey conducted to determine the extent to which practice standards have been adopted.

Background: Adolescents with asthma are vulnerable to poor asthma outcomes due to inadequate self-management skills and nonadherence to medications. Mobile health (mHealth) apps have shown promise in improving asthma control, medication adherence, and self-efficacy. However, existing mHealth asthma apps lack personalization and real-time feedback and are not tailored for at-risk adolescents. Objective: This study aimed to design, develop, and test a smartphone-based mHealth Asthma Action Plan for adolescents, called Pulmonary Education and Knowledge Mobile Asthma Action Plan (PEAK-mAAP), in preparation for a large-scale randomized controlled trial. Methods: We employed user-centered design principles to develop our app, leveraging our previous work and following guidelines from the National Heart, Lung, and Blood Institute. The app consists of a patient-facing mobile app and a provider-facing portal. A convenience sample of 13 adolescents (aged 12-20 years) was recruited from the Arkansas Children's Research Institute database or direct health care provider referrals. Participants underwent a task-based usability assessment followed by the System Usability Scale assessment to measure user satisfaction, interface effectiveness, and overall system usability. Results: PEAK-mAAP integrates 7 core modules supporting personalized asthma self-management, symptom monitoring, medication tracking, and real-time feedback. The mean System Usability Scale score was 83/100 (SD 5.54), indicating high user satisfaction and system usability. Notably, older adolescents (>17 years) reported higher usability scores (87.5) than younger users (77.5), suggesting potential age-related differences in app navigation and engagement. Conclusions: The results demonstrate that PEAK-mAAP is a feasible and user-friendly mHealth intervention for adolescent asthma self-management. While the high usability score reflects a positive user experience, some participants encountered initial usability challenges, highlighting the need for minor refinements and user training materials. The integration of personalized self-management tools and real-time feedback distinguishes PEAK-mAAP from existing asthma apps, addressing key barriers to adherence and engagement. Moving forward, an ongoing randomized controlled trial will assess its clinical effectiveness, long-term engagement, and impact on asthma outcomes, providing further insights into its potential as a scalable solution for adolescent asthma care.