Marion VA Medical Center

Objective: To examine the reasons contributing to the physician shortage in the country’s medically underserved areas using the state of Delaware as a focus state. Method: A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. A review of the “Conrad 30 J1 VISA waiver program,” the most important and primary supplier of physicians to underserved areas of the state was performed. A survey interviewing the physicians recruited through this program to identify any challenges faced by them was designed and conducted. Results: The number of primary care physicians providing direct patient care in Delaware in 2018 had declined about 6% from 2013. The average wait time to see a PCP was 8.2 days in 1998 as compared to 23.5 days in 2018. Forty-six percent of physicians serving in HPSAs in Delaware are IMGs recruited through the J1 VISA waiver program. Eighty percent of these IMGs are actively considering leaving the United States due to anxieties around physician immigration policies, mainly “Immigration backlog.” Conclusion: The existing programs to recruit physicians to underserved areas seem to be inadequate. The state and the hospital systems should be able to utilize the J1 program to its full potential and focus on retaining these physicians after their assigned services. As the challenges of IMGs continue to worsen every day; the medical societies, hospitals, the state and federal government should advocate for policies that resolve these challenges.

The purpose of this study was to determine the accuracy of referenced statements in review articles focused on drug therapy. Review articles published between January and December 1987 in Clinical Pharmacy, DICP, Drugs, and Pharmacotherapy were used. Ninety-nine references from these articles were randomly selected and pulled to determine if the published study results were in agreement with the review article statement. These references accounted for 165 statements. Thirty-nine of 165 statements in the review articles (24 percent) were found to be inappropriate when compared with the original references. These inappropriate quotations were classified as either wrong, misleading, or deriving from only the discussion section of the original article. There is a need for increased awareness by authors to differentiate between reported results, article hypothesis, and their own interpretations, as well as for accuracy in quotation.

Bronfenbrenner's (1979) ecological transition model provides a framework to study coming out in lesbians. The model takes into account activities such as sexual behavior, perceptions of the behavior, and social context in which behavior takes place. The importance of context makes this model useful in identifying possible connections between sexual identity alterations and larger social forces. Interventions based on this framework can reduce stress and promote health during coming out.

The effects of a D-methionine-containing solution (DMCS) on the nutritional status of AH109A hepatomabearing rats receiving total parenteral nutrition were studied. The DMCS solution inhibited the decrease of transferrin in the plasma of tumor-bearing rats when compared with the effect of an L-methionine-containing solution. The survival time was also significantly prolonged in the DMCS-treated rats. These results indicate that DMCS had a beneficial effect on the malnutrition induced in tumor-bearing rats and would be a useful amino acid solution for the nutritional support of cancer patients.

Content Native communities of herbivores have evolved fundamental dietary niches that avoid or minimise competition; the introduction of exotic species can change dietary niches, cause overlap in resource use, and result in competition for resources. Aims We compared niche breadth, overlap in diet, and quality of diet between introduced sika deer and native white-tailed deer in Maryland, USA. We investigated these changes in free-ranging populations where both species are allopatric as well as when they are sympatric. Methods We used microhistological analysis of faecal samples to determine the percentage of resources used by sika deer and white-tailed deer, as measured between geographical areas of similar habitat quality. We compared resource use specifically by controlling for harvest pressure and resource availability, which are known to alter resource use other than the presence of an additional deer species. Key results We observed a significant resource overlap (range 63–88%) between species. In the presence of sika deer, white-tailed deer displayed an increased niche breadth (108%) and a lower diet quality (17%). Sika deer consumed the same resources that comprised 78% of white-tailed deer diet. Unlike other native ungulates that have dietary overlap with white-tailed deer, sika deer is neither temporally nor geographically segregated in habitat use. Conclusions Resource overlap and changes in niche breadth and diet quality during sympatry strongly denote dietary competition between sika deer and white-tailed deer. This competition results in white-tailed deer altering the dietary selection, thereby consuming lower-quality forage. Implications White-tailed deer are concentrate selectors and require higher diet quality than do sika deer, which can tolerate diets higher in fibre, consistent with their classification as intermediate feeders. A decrease in the nutritional quality of resources used by white-tailed deer could contribute to the decline of white-tailed deer over time and allow the continued spread of sika deer.

Choroidal hemangioma is a rare congenital ocular tumor that can present as either circumscribed or diffuse. Circumscribed choroidal hemangioma (CCH) typically manifests as a red-orange mass within the posterior pole and appears similar to other ocular conditions, such as choroidal melanoma and choroidal metastasis. Proper diagnosis is crucial and is aided by the use of ancillary testing. CCH itself is benign but can cause secondary complications such as subretinal fluid accumulation and subsequent retinal detachment. If these conditions should arise, several treatment options are available. El hemangioma coroideo es un raro tumor ocular congénito que puede presentarse de manera circunscrita o difusa. El hemangioma circunscrito de coroides (CCH) se manifiesta típicamente como una masa rojizo-anaranjada en el interior del polo posterior, y parece similar a otras situaciones oculares, tales como el melanoma coroideo y la metástasis coroidea. El diagnóstico adecuado es esencial, y viene asistido por el uso de pruebas complementarias. El CCH en sí mismo es benigno, aunque puede originar complicaciones secundarias tales como la acumulación de fluidos sub-retinianos y el subsiguiente desprendimiento de retina. En caso de producirse dichas situaciones, existen diversas opciones de tratamiento.

We investigated the association of endothelial nitric oxide synthase (NOS3) polymorphisms rs2070744 (-786T> C), 27-bp repeat 4b/4a, rs1799983 (Glu298Asp), rs3918188 (-734C> A), and rs743507 (113G> A) with idiopathic recurrent miscarriage (IRM). This was a case-control study involving women with confirmed IRM (n = 296), and 305 age- and ethnically matched control women. NOS3 rs2070744, rs1799983, rs3918188, and rs743507 genotyping was done by TaqMan assays; NOS3 4b/4a genotyping was done by PCR-ASA. A higher frequency of -786C and 298Asp alleles was seen in IRM cases, which remained associated independently with IRM on multivariate analysis. Allele and genotype distribution of 4b/4a, rs3918188 (-734C> A) and rs743507 (113A> G) were comparable between IRM cases and control women. Taking homozygous wild-type genotype as a reference, regression analysis confirmed the association of Glu298Asp and -786T/C, and rs743507 homozygous carriers with IRM risk. Marked linkage disequilibrium was seen between tested NOS3 variants, thus allowing the construction of 5-locus [-786T> C/4b4a/Glu298Asp/-734C> A/113G> A] haplotypes. Taking the common T4bGCA haplotype as a reference, multivariate analysis confirmed the positive association of C4bTCG haplotype with IRM, after controlling for traditional covariates. Genetic variation at the NOS3 locus represents a genetic risk factor for increased susceptibility to IRM.

EXECUTIVE SUMMARY: This article reports on a data-driven methodology for decision-making at a Veterans Affairs medical center (VAMC) to improve patient outcomes, specifically the 30-day standardized mortality ratio (SMR30). The quarterly strategic analytics for improvement and learning (SAIL) reports are used to visualize the data, study trends, provide actionable recommendations, and identify potential consequences.A case study using more than 4 years of data demonstrates the power of the methodology. After reviewing data and studying trends at other VAMCs, a decision is made to reduce the SMR30 value by 1%. In running correlation algorithms, in-hospital complications (IHC) are shown to be most closely correlated with SMR30. Modeling the results from 17 quarters' worth of data shows that a desired 1% change in SMR30 would require a targeted 18.6% decrease in IHC. This change, if accomplished, would yield good consequences on methicillin-resistant Staphylococcus aureus mitigation but potentially unintended consequences with catheter-associated urinary tract infections and patient safety indicators that would need to be monitored. This knowledge could enable healthcare leaders to make informed decisions of both potentially positive and unintended consequences that can be monitored and minimized. This study lays the groundwork for a healthy discussion among leaders, staff, and clinicians on the path forward, resources required, and-most importantly-a dashboard that reflects the progress each week rather than a quarterly SAIL report.

Because many military veterans face mental health issues, it is important to research and practice alternative treatments including therapeutic recreation. The purpose of this study was to examine the effects of a single 45-minute adaptive scuba diving session on veterans’ psychological well-being, specifically state-level mindfulness (Brown & Ryan, 2003) and contentment (Taylor, 2015). A one-group pretest-posttest evaluation was conducted with 28 veteran divers. Of them, 16 had mental health issues (e.g., posttraumatic stress disorder), while 11 had physical impairments (e.g., spinal cord injuries). Statistical results indicated that the post-dive mindfulness and contentment levels were significantly higher than their pre-dive counterparts (p = .007 and < .001, respectively). Moreover, the changes in mindfulness through scuba diving were positively correlated with the changes in contentment. The significant increases in mindfulness were present only among veterans with mental or physical health issues. These findings are discussed in relation to the literature on scuba diving, therapeutic recreation, mindfulness, and contentment.Subscribe to TRJ

Background Physician shortage and healthcare access are serious issues in rural states like Kentucky and further worsened during the coronavirus disease 2019 (COVID-19) pandemic. International Medical Graduates (IMGs) serve the underserved communities of Kentucky to fill in the physician gap. However, uncertainties surrounding immigration policies added significant challenges to physicians and the rural communities served by them during the pandemic. Methods A survey was created using the data collection platform "SurveyMonkey" and sent to IMG physicians practicing on a visa to understand their role and their immigration-related challenges. Only the physicians practicing in Kentucky were included in this study. Results It was found that 84% practice in primary care specialties like internal medicine, pediatrics, or family medicine, 92.9% practice in Medically Underserved Areas or Health Professional Shortage Areas, and 71.4% practice in rural settings. Also, 61.5% practice in a "frontline" COVID-19 specialty and 92.3% were involved in direct care of COVID-19 infected or suspected patients. Of the physicians, 88.5% were in an "immigration backlog"; 92.6% of them were the primary visa holders of their families and 88.9% expressed concern that their families face hardship if they have a disability during the pandemic. It was reported by 92.3% of them that visa-related restrictions limited them from providing additional coverage in these places. Conclusions Lack of physician access is a critical issue facing many rural states in America like Kentucky, and IMG physicians play a valuable role in taking care of this underserved population and fighting the COVID-19 pandemic. The challenges surrounding the immigration backlog are contributing to significant hardships and remain a hurdle to expand healthcare access to the rural and medically underserved communities.

This is a case report of a spontaneous remission of depression after an attempted suicide by hanging. The patient suffered from cardiopulmonary arrest and anoxic encephalopathy, but recovered without apparent neurologic sequelae. The authors review the literature and explore the possible effects of hypoxia and hypercapnea on the locus ceruleus and the limbic system which could contribute to the patient's remission of symptoms. Also discussed are the psychosocial factors affecting patients' moods after a suicide attempt.

The purpose of this study was to examine relationships among gender-role preference, self-esteem and employment category (full-time, part-time, homemaker) while controlling for the effects of income and religion. Data were collected from 79 White married women using the Rosenberg Self-Esteem Scale and a gender-role preference scale developed by the author. Findings indicated that: (a) there are significant differences in gender-role preference among categories of employment, with full-time workers having more modern views; (b) category of employment did not influence self-esteem; and (c) women with mixed gender-role preference had lower self-esteem than those with modern gender-role preference. The strength of the relationship between self-esteem and gender-role preference varied by category of employment. Gender-role preference made a significant contribution as a predictor of self-esteem (above and beyond the effects of income and religion) for full-time workers only.

We studied the effects of the new amino acid solution MRX-III on the nutritional status and nitrogen metabolism of rats with chronic renal failure (CRF) in comparison with those of a general amino acid solution (MPR-F). The essential amino acids/non-essential amino acids ratio was 3.21 for MRX-III and 1.09 for MPR-F. Rats with CRF, induced by 7/8 renal ablation, were divided into 6 groups of 8 rats each receiving total parenteral nutrition (TPN) containing MRX-III or MPR-F at a non-protein calorie/nitrogen ratio (Cal/N) of 300, 600 or 900 for 7 d. The rats were infused with test solutions containing the same amounts of non-protein calories. The cumulative nitrogen balance, as a nutritional index, in the MRX-III group was significantly higher than that in the MPR-F group at the Cal/N of 600 or 900, and the plasma albumin level at the Cal/N of 300. The plasma transferrin levels at the Cal/N of 900 in the MRX-III groups were significantly higher than those in the corresponding MPR-F groups. At all Cal/N, the MRX-III groups showed low levels of blood urea nitrogen and urinary excretion of ammonia and urea nitrogen as compared with the MPR-F groups at the same Cal/N. The plasma amino acid concentration profiles in the MRX-III groups after TPN showed greater similarity to that in the Normal group as compared with the profiles in the corresponding MPR-F groups. No aggravation of renal failure was observed in any TPN groups during TPN. These results indicate that, in rats with CRF undergoing hyperalimentation, the effects of MRX-III on the nutritional status and nitrogen metabolism are superior to those of the general amino acid solution, MPR-F. It is suggested that MRX-III could safely provide adequate amounts of nitrogen during hyperalimentation.

Investigates the engineering and economic feasibility of retrofitting two small industrial boilers (32 hp and 52 hp, respectively) for firing green wood fuels.Subjects covered include fuel requirements and costs; availability, storage, and handling of wood fuels; and designs, specifications, stack emissions, cost estimates, and economic feasibility.The economics of boiler conversion projects are heavily dependent on annual savings in fuel costs.Analyses of variables affecting annual fuel savings determined that the boiler utilization rate (BUR) and the price of fuel oil had the greatest impact on the economic feasibility of this project.

Excerpt Refinements in roentgenological technic making possible the rapid, inexpensive chest survey of large groups have stimulated considerable interest in the old problem of tuberculosis among the insane. The authors have made a primary survey in Southwestern State Hospital and have derived certain impressions from their experience in the subsequent management of the tuberculous patients so segregated. The initial survey has been followed by similar studies of all patients admitted since the original survey. It is felt that those now engaged in this work, or who plan work of a similar character, may be interested in our findings and observations. RELATED

Purpose: The purpose of this project was to implement the American Diabetes Association (ADA) Diabetes Risk screening tool and measure adherence to the Diabetic Plate patient education protocol in a rural, primary care clinic in North Carolina (NC). Sample: The setting of the project was a small, outpatient, rural primary care clinic in Western NC that serves a town population of 7,492 persons. Those of any age with a BMI > 25 were eligible for screening. During implementation, 334 patients were seen, and 157 met eligibility criteria. Method: The participating healthcare provider and medical assistants administered the ADA screening tool to eligible patients during their visits. If the patient scored a five or higher, indicating high risk for diabetes, the provider would then provide ADA Diabetes Plate education to inform patients of early T2DM prevention techniques. Completed screening tools were collected bi-weekly and charts reviewed to assess provider and staff adherence with screening. Findings: Out of the 157 eligible patients, 89 patients were screened utilizing the diabetes risk assessment tool. Of the patients screened, 41 were deemed “high risk” and 32 of them received diabetes plate education from the provider. The participating provider and clinic were able to screen eligible patients utilizing the diabetes risk screening tool with a 56.69% success rate and 78.04% of high-risk patients received diabetes plate education. Conclusions: Limitations of the project included inconsistent screening and discrepancies between paper screening forms and EHR documentation. Despite limitations, final data suggests that implementation of the ADA diabetes risk assessment tool could be beneficial in rural regions where ease of access and affordability is paramount. Additionally, implementation of this easy-to-use tool within an existing EHR would likely improve staff screening compliance and improve patient follow-up.

= 0.007). No differences were observed based on sex. No difference in pain scores was observed. Nalbuphine resulted in less pain control in opioid-tolerant patients. Nalbuphine may represent an alternative first-line parenteral opioid in the acute care setting.

Electric aviation is a much-needed technical advancement in this era. Most developed nations are shifting towards cleaner and greener energy solutions, and developing electric aircraft is part of that initiative. This work conducts a comprehensive study on the development of high-voltage electrical architectures for small- to medium-range electrical aircraft. The process follows defining KPIs based on which the architectures will be assessed. Starting from basic structures, the study systematically grows the basic design into more extensive and more general architecture families, each representing fundamentally unique configurations and features. Each proposed architecture was critically reviewed to identify its strengths and limitations, particularly in terms of redundancy, scalability, and performance under different operational scenarios. The final step involved evaluating the architectures against set criteria for a comparative review to guide future applications and development in the design of high-voltage electrical aircraft.