Oscar G. Johnson VA Medical Center

Headache and ear symptoms directly dependent upon disturbed function of the mandibular joint frequently occur in cases showing sufficient pathology about the sinuses to otherwise account for them. There are so many medical, rhinologic and ophthalmologic reasons for headache distributed about the ears, vertex and occiput; and there are so many nasal changes to account for eustachian tube obstruction, that evulsion of the condyle of the mandible from overbite is not considered. Hearing tests show a mild type of catarrhal otitis with eustachian tube involvement, usually simple obstruction. This is due to pressure on its anterior membranous wall, transmitted through soft tissue from the relaxation of pterygoid muscles and associated sphenomandibular ligaments during overbite. The promptness with which the ears improve seems to controvert the idea that the ear condition is due to trauma or concussion of the labyrinth or tympanic structures from the condyle of the mandible. Cases of shock to the labyrinth from a blow on the chin are not within the scope of this paper. Attacks of dizziness in these cases are obviously due to changes in intratympanic pressure affecting the labyrinth. The effect is transient and recurrent, relieved by inflation of the eustachian tube, and not the picture seen in toxic labyrinthitis. The areas involved in the headache cases are typical of headache of posterior sinus origin and are easily taken for such. Persistence of the headache after indicated sinus surgery is sometimes due to mandibular joint pathology. The symptoms arise as a result of overaction of the joint at first, and later adds the regional effect of a loose, pathologic joint, produced by absorption of the meniscus, condyles and surrounding bone. The prognosis in a given case depends on these factors: (a) the accuracy with which refitted dentures relieve abnormal pressure on the joint; (b) the extent of injury to the tube and to the condyle, the meniscus, and the joint capsule. The mechanics of occlusion and dental problems are not included here. Only sufficient reference to the anatomy of the mandible and joint is made to clarify the ear or sinus diagnosis. Anatomic reasons are advanced to account for abnormal conditions of the eustachian tube, and for the distribution of pain toward the vertex, occiput, pharynx and tongue. It is barely possible that mandibular joint pathology may be an etiologic factor in glossopharyngeal neuralgia, the association of chorda tympani and auriculotemporal nerves with the ninth occurring via sensory connections to the otic ganglion.

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

The few previous measurements of the small change of apparent colour of a monochromatic light stimulus when its angle of incidence on the foveal retina is varied (or SC II effect), have been confined to changes of apparent hue. A differential, three-colour mixture method, with alternating instead of juxtaposed presentation of the test and comparison stimuli, has now been applied to determine the complete colour change, hue and saturation. For the main subject, the results show hue shifts of the expected kind and a small but significant supersaturation of the apparent colour of an obliquely, compared with a normally incident stimulus, in the wavelength range 485 to 510 mµ. From earlier qualitative observations, such a supersaturation appears to occur for most subjects. The SC II colour changes are attributable to differences in the directional response of the receptors associated respectively with the three colour systems of the trichromatic scheme. From the relative spectral sensitivities of these systems and the complete SC II colour changes, the variation with wavelength of the directional sensitivity of each system has been computed for the data of the main subject. The possibility of explaining the derived wavelength variation in terms of self-screening by visual pigment present in the receptors in sufficiently high density, is examined. Self-screening appears not to be a factor for the blue-sensitive system, and although for the red- and green-sensitive systems it predicts minima in the directional sensitivity v. wavelength curve, resembling those observed, the quantitative agreement is poor and there are other objections. The wave-mode disposition of light in the receptors, now being studied, should yield a better explanation.

BACKGROUND: Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes. METHODS: We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus. RESULTS: Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes. LIMITATIONS: The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies. CONCLUSIONS: EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable. TRIAL REGISTRATION: The protocol for this review is registered in PROSPERO (CRD42018093381).

Use of neuropsychological tests to identify HIV-associated neurocognitive dysfunction must involve normative standards that are well suited to the population of interest. Norms should be based on a population of HIV-uninfected individuals as closely matched to the HIV-infected group as possible and must include examination of the potential effects of demographic factors on test performance. This is the first study to determine the normal range of scores on measures of psychomotor speed and executive function among a large group of ethnically and educationally diverse HIV-uninfected, high-risk women, as well as their HIV-infected counterparts. Participants (n = 1,653) were administered the Trail Making Test Parts A and B (Trails A and Trails B), the Symbol Digit Modalities Test (SDMT), and the Wide Range Achievement Test-3 (WRAT-3). Among HIV-uninfected women, race/ethnicity accounted for almost 5% of the variance in cognitive test performance. The proportions ofvariance in cognitive test performance accounted for by age (13.8%), years of school (4.1%), and WRAT-3 score (11.5%) were each significant, but did not completely account for the effect of race (3%). HIV-infected women obtained lower scores than HIV-uninfected women on time to complete Trails A and B, SDMT total correct, and SDMT incidental recall score, but after adjustment for age, years of education, racial/ethnic classification, and reading level, only the difference on SDMT total correct remained significant. Results highlight the need to adjust for demographic variables when diagnosing cognitive impairment in HIV-infected women. Advantages of demographically adjusted regression equations developed using data from HIV-uninfected women are discussed.

Histological studies of the cases of three generations of deaf white cats are reported.

Background.. Intensive glycemic control confers increased risk of hypoglycemia and little benefit among older individuals with diabetes. The aim of this quality improvement project was to reduce the number of patients treated to A1C levels that might confer greater risk than benefit (i.e., potential overtreatment) in the VA New England Healthcare System. Methods.. A provider report and clinical reminder were created to identify potentially overtreated patients and prompt clinicians to consider treatment de-intensification. Potentially overtreated patients were defined as those on insulin or a sulfonylurea whose most recent A1C was <7.0% and who were >74 years of age or diagnosed with dementia or cognitive impairment. The numbers of patients screened and whose treatment was de-intensified using the clinical reminder were counted from January to December 2014. The number of high-risk veterans at baseline was compared with that 6 and 18 months after implementation using t tests. Results.. A total of 2,830 patients were screened using the clinical reminder; 9.6% had their glycemic treatment de-intensified. Among the 261 patients reporting hypoglycemia, 37% had their treatment de-intensified. Higher percentages of patients had treatment de-intensified when reported symptoms were more severe. The monthly average in the high-risk cohort declined from baseline by 18% at 6 months and by 22% at 18 months (both P <0.005). Conclusions.. A clinical reminder helps clinicians identify and reduce the number of potentially overtreated patients. The large number of screened patients whose treatment was not de-intensified suggests that a clinical reminder should be combined with provider education, national guidelines, and performance measures aligned in the interest of reducing potential overtreatment.

Summary1. Levels of glucose in cerebrospinal fluids of dogs with aseptic meningitis were normal, while incubation in vitro of such fluids resulted in consumption of glucose. Evidently, glucose is transported into the cerebrospinal fluid in vivo more rapidly than it is utilized by the leucocytes under these conditions. 2. Very large numbers of pneumococci growing rapidly in normal cerebrospinal fluid were needed in order to consume glucose at rates approximating those at which glucose is utilized in vitro by fluids of dogs with aseptic meningitis. 3. Consumption of glucose by leucocytes and bacteria does not appear to account for lowered levels of glucose in bacterial meningitis.

Periodic intravenous injections of the nitrogen mustard, bis beta-chloroethyl amine, suppressed both antibody formation and the development of vascular lesions in rabbits injected intravenously with a massive dose of horse serum. The incidence of vascular lesions was directly correlated with the amount of antibody produced, since all rabbits with terminal amounts of antibody in excess of 0.06 mg nitrogen per ml exhibited vascular lesions. Cutaneous hypersensitiveness failed to develop in rabbits which did not produce detectable amounts of anitbody.

Successful management of patients with diabetes requires individualizing A1C and treatment goals in conjunction with identifying and managing hypoglycemia risk. This article describes the Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI), a voluntary program that aims to reduce the occurrence of hypoglycemia through shared decision-making about deintensifying diabetes treatment in a dynamic cohort of patients identified as being at high risk for hypoglycemia and potentially overtreated. The CW-HSI incorporates education for patients and clinicians, as well as clinical decision support tools, and has shown decreases in the proportions of high-risk patients potentially overtreated and impacts on the frequency of reported hypoglycemia.

In order to determine the effect of fatigue on susceptibility to experimental poliomyelitis, mice were forced to run in a revolving drum during the day preceding and for 8 hours each day subsequent to the intra cerebral injection of the Lansing strain of virus. Control animals inoculated at the same time with the same amount of virus were allowed to rest in their cages. In all 7 experiments, the incidence of the disease as measured both by paralysis and by death was greater in the exercised animals than in the resting controls.

A histochemical reaction has been described which allows the investigator to distinguish between light and dark adapted retinal receptors. The incubation medium employed contained NBT, succinate, TC 199, and a buffer. The reactive process studied has its locus in the ellipsoid of the retinal receptor. Several response characteristics of this reaction have been reported, including the finding that this reactive process is dependent upon the absorption of energy by photosensitive pigment located in the neighboring receptor outer segment. In this paper, the recovery of the reactive process in the dark following exposure to light has been considered. Dark adapted albino rats were exposed to calibrated luminous stimuli (500 nm.). After exposure, varying time periods (in the dark) were allowed prior to dissecting the retina from the eye of the living animal. The dissected retina was incubated in the dark in our standard medium, the reaction was stopped, and the retina was examined for the presence (or lack) of a stained image of the instrument field stop. The retinal irradiance of the (initial) stimulus was determined for threshold detection of the (subsequently) stained latent image on the retina. A relatively simple semilogarithmic relationship was found between the stimulus magnitude necessary to induce a just noticeable stained image, and the time the animal was kept in the dark following light exposure (recovery time). The following added test conditions were considered: (1) The retina was dissected immediately after exposure and placed in normal saline in the dark for the test period; then, it was processed in the standard, manner. (2) The animal was killed immediately after exposure to the stimulus; the eye was left in situ during the recovery period; then, the retina was dissected and processed in the usual way.

ABSTRACT The handling of the unilateral aphakic patient is complex. A technique is described that allows the practitioner to take first steps toward restoring binocular vision in suitable cases. A reverse Galilezn telescope is partially incorporated in a contact lens placed in front of the aphakic eye. The negative portion of the telescope is incorporated in the spectacle frame. Several problems and fitting details are considered. An outline of the method employed is presented at the end of the article.

Alcohol is a commonly abused substance, and it is important that healthcare facilities properly manage alcohol withdrawal. Studies have found that the most efficient way to manage alcohol withdrawal is to use a symptom-triggered approach and only administer medications if symptoms surpass a specific threshold determined by a clinician administered rating scale. Alternatively, a standard fixed-dose medication regimen can be utilized. This study assessed if a new symptom-triggered protocol, utilizing the Clinical Institute Withdrawal for Alcohol, Revised (CIWA-Ar) scale for the assessment of symptoms, resulted in the anticipated patient outcomes of decreased length of hospital stay, less benzodiazepine administered per patient, and a shorter administration time from first dose of benzodiazepine given to last dose, when compared to the previous standard of care. A retrospective chart review was performed for 70 patients who had been treated for alcohol withdrawal. Patients who were treated with the symptom-triggered protocol had a decreased length of hospital stay when compared to the previous standard of care (−2.62 days, p = 0.0054). Both secondary efficacy outcomes were also statistically significant in favor of the symptom-triggered group. This retrospective chart review adds to the body of evidence supporting the use of symptom-triggered protocols as opposed to fixed-dose protocols in the management of alcohol withdrawal.