Perry Point VA Medical Center

BACKGROUND AND METHODS: The role of colonoscopy in screening for colorectal cancer is uncertain. At 13 Veterans Affairs Medical Centers, we performed colonoscopy to determine the prevalence and location of advanced colonic neoplasms and the risk of advanced proximal neoplasia in asymptomatic patients (age range, 50 to 75 years) with or without distal neoplasia. Advanced colonic neoplasia was defined as an adenoma that was 10 mm or more in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. In patients with more than one neoplastic lesion, classification was based on the most advanced lesion. RESULTS: Of 17,732 patients screened for enrollment, 3196 were enrolled; 3121 of the enrolled patients (97.7 percent) underwent complete examination of the colon. The mean age of the patients was 62.9 years, and 96.8 percent were men. Colonoscopic examination showed one or more neoplastic lesions in 37.5 percent of the patients, an adenoma with a diameter of at least 10 mm or a villous adenoma in 7.9 percent, an adenoma with high-grade dysplasia in 1.6 percent, and invasive cancer in 1.0 percent. Of the 1765 patients with no polyps in the portion of the colon that was distal to the splenic flexure, 48 (2.7 percent) had advanced proximal neoplasms. Patients with large adenomas (> or = 10 mm) or small adenomas (< 10 mm) in the distal colon were more likely to have advanced proximal neoplasia than were patients with no distal adenomas (odds ratios, 3.4 [95 percent confidence interval, 1.8 to 6.5] and 2.6 (95 percent confidence interval, 1.7 to 4.1], respectively). However, 52 percent of the 128 patients with advanced proximal neoplasia had no distal adenomas. CONCLUSIONS: Colonoscopic screening can detect advanced colonic neoplasms in asymptomatic adults. Many of these neoplasms would not be detected with sigmoidoscopy.

BACKGROUND: Fecal occult-blood testing and sigmoidoscopy have been recommended for screening for colorectal cancer, but the sensitivity of such combined testing for detecting neoplasia is uncertain. At 13 Veterans Affairs medical centers, we performed colonoscopy to determine the prevalence of neoplasia and the sensitivity of one-time screening with a fecal occult-blood test plus sigmoidoscopy. METHODS: Asymptomatic subjects (age range, 50 to 75 years) provided stool specimens on cards from three consecutive days for fecal occult-blood testing, which were rehydrated for interpretation. They then underwent colonoscopy. Sigmoidoscopy was defined in this study as examination of the rectum and sigmoid colon during colonoscopy, and sensitivity was estimated by determining how many patients with advanced neoplasia had an adenoma in the rectum or sigmoid colon. Advanced colonic neoplasia was defined as an adenoma 10 mm or more in diameter, a villous adenoma, an adenoma with high-grade dysplasia, or invasive cancer. Classification of subjects according to the findings was based on the most advanced lesion. RESULTS: A total of 2885 subjects returned the three specimen cards for fecal occult-blood testing and underwent a complete colonoscopic examination. A total of 23.9 percent of subjects with advanced neoplasia had a positive test for fecal occult blood. As compared with subjects who had a negative test for fecal occult blood, the relative risk of advanced neoplasia in subjects who had a positive test was 3.47 (95 percent confidence interval, 2.76 to 4.35). Sigmoidoscopy identified 70.3 percent of all subjects with advanced neoplasia. Combined one-time screening with a fecal occult-blood test and sigmoidoscopy identified 75.8 percent of subjects with advanced neoplasia. CONCLUSIONS: One-time screening with both a fecal occult-blood test with rehydration and sigmoidoscopy fails to detect advanced colonic neoplasia in 24 percent of subjects with the condition.

The objective of this observational field study was to validate the relationship of serum concentrations of nonesterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), and calcium with disease in early lactation across different management systems. Fifty-five Holstein freestall dairy herds located across the United States and Canada were selected and visited weekly for blood sample collection from 2,365 cows. Only diseases that were consistently recorded across herds and blood samples collected before the disease occurred were considered. Metabolite concentrations in serum in wk -1 relative to calving were considered as predictors of retained placenta (RP) and metritis, and metabolite concentrations in serum in wk -1 and wk +1 relative to calving were considered as predictors of displaced abomasum (DA). For each disease, each metabolite, and week of sampling in the case of DA, a critical threshold was calculated based on the highest combined sensitivity and specificity and used to categorize the serum concentrations into high and low risk categories. Multivariable logistic regression models were built for each disease of interest and week of sampling, considering cow as the experimental unit and herd as a random effect. Cows with precalving serum NEFA concentrations ≥ 0.3 mEq/L were more likely to develop RP [odds ratio (OR) = 1.8; 95% confidence interval (CI) = 1.3 to 2.6] and metritis (OR = 1.8; 95% CI = 1.5 to 2.9) after calving than cows with lower NEFA concentrations. Precalving NEFA ≥ 0.5 mEq/L (OR = 2.4; 95% CI = 1.5 to 3.7), postcalving NEFA ≥ 1.0 mEq/L (OR = 2.7; 95% CI = 1.7 to 4.4), and postcalving calcium ≤ 2.2 mmol/L (OR = 3.1; 95% CI = 1.9 to 5.0) were associated with subsequent risk of DA. In conclusion, elevated serum NEFA concentrations within 1 wk before calving were associated with increased risk of RP, metritis, and DA after calving. Serum NEFA and calcium concentrations in the 2 wk around calving in combination were associated with the risk of DA.

The NOSIE-30 is a highly sensitive ward behavior rating scale. Final item selection includes the best 30 of an original pool of 100 items, tested on a sample of 630 chronic schizophrenic patients. Both status (pre-treatment) and change (post minus pre-treatment) item responses were factor analyzed. Six factor scores are obtained: Social Competence, Social Interest, Personal Neatness, Irritability, Manifest Psychosis, and Retardation. Cross-validation of these six factor scores and a composite score, Total Patient Assets, was obtained in an independent, double-blind drug study conducted by the NIMH-Psychopharmacology Service Center. The NOSIE-30, especially designed for use by subprofessional personnel, provides an economical and accurate means of systematically assessing patient status and change.

Aim This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use. Methods A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Structure Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

The objective was to examine the associations of peripartum concentrations of nonesterified fatty acids (NEFA), β-hydroxybutyrate (BHBA), and calcium with milk production in early lactation and pregnancy at the first artificial insemination (AI) across different management systems. Fifty-five Holstein freestall dairy herds located across the United States and Canada were visited weekly for blood sample collection from 2,365 cows. For each week of sampling (from wk -1 through wk 3 relative to calving) and for each metabolite, serum concentrations were dichotomized at various thresholds to identify the thresholds with the best negative associations with milk production and pregnancy at first AI. These thresholds were used to categorize the serum concentrations into higher and lower risk categories. Repeated-measures ANOVA and multivariable logistic regression were conducted for milk production and pregnancy at the first AI data, respectively, considering cow as the experimental unit and herd as a random effect. In the week before calving, serum NEFA ≥ 0.5 mEq/L, BHBA ≥ 600 μmol/L, and calcium ≤ 2.1 mmol/L were associated with 1.6 to 3.2 kg/d milk loss across the first 4 Dairy Herd Improvement Association (DHIA) milk tests. High levels of NEFA and BHBA in wk 1 and 2 after calving (≥ 0.7 and ≥ 1.0 mEq/L for NEFA, and ≥ 1,400 and ≥ 1,200 μmol/L for BHBA), and low levels of calcium (≤ 2.1 mmol/L) in wk 1, 2 and 3 after calving were associated with milk loss at the first DHIA milk test. Serum concentrations of NEFA and BHBA were not associated with pregnancy at first AI in any sampling week, whereas calcium <2.2 to 2.4 mmol/L from wk 1 through wk 3 postpartum were associated with reduced pregnancy at first AI. In conclusion, high serum concentrations of NEFA, BHBA, and low concentrations of calcium around parturition were associated with early lactation milk loss, and low calcium concentration around parturition was associated with impaired early lactation reproduction.

BACKGROUND: To our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation. METHODS: Forty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and L'Insalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded. RESULTS: At an average of 2.7 years, the median ASES and L'Insalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or L'Insalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness. CONCLUSIONS: Our findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports.

BACKGROUND: Many expert panels recommend colorectal cancer screening for average-risk asymptomatic individuals older than 50 years of age. Recent studies have found that 24% to 64% of primary care providers use only the digital fecal occult blood test (FOBT) as their primary screening test. The effectiveness of a single digital FOBT is unknown. OBJECTIVE: To compare the sensitivity and specificity of digital FOBT and the recommended 6-sample at-home FOBT for advanced neoplasia in asymptomatic persons. DESIGN: Prospective cohort study. SETTING: 13 Veterans Affairs medical centers. PATIENTS: 3121 asymptomatic patients 50 to 75 years of age. INTERVENTION: 2665 patients had 6-sample at-home FOBT and digital FOBT, followed by complete colonoscopy. MEASUREMENTS: We measured the sensitivity of digital and 6-sample FOBT for advanced neoplasia and the specificity for no neoplasia. We calculated predictive values and likelihood ratios for advanced neoplasia, defined as tubular adenomas 10 mm or greater, adenomas with villous histology or high-grade dysplasia, or invasive cancer. RESULTS: Of all participants, 96.8% were men; their average age was 63.1 years. The 6-sample FOBT and the single digital FOBT had specificities of 93.9% and 97.5%, respectively, as defined by studying 1656 patients with no neoplasia. Sensitivities for detection of advanced neoplasia in 284 patients were 23.9% for the 6-sample FOBT and 4.9% for the digital FOBT. The likelihood ratio for advanced neoplasia was 1.68 (95% CI, 0.96 to 2.94) for positive results on digital FOBT and 0.98 (CI, 0.95 to 1.01) for negative results. LIMITATIONS: Most patients were men. CONCLUSIONS: Single digital FOBT is a poor screening method for colorectal neoplasia and cannot be recommended as the only test. When digital FOBT is performed as part of a primary care physical examination, negative results do not decrease the odds of advanced neoplasia. Persons with these results should be offered at-home 6-sample FOBT or another type of screening test.

The objective was to identify herd-level indicators expressed as a proportion of sampled animals with increased nonesterified fatty acids (NEFA) or β-hydroxybutyric acid (BHBA), or decreased calcium in wk -1 and wk +1 relative to calving that were associated with herd-level incidence of retained placenta, metritis and displaced abomasum, milk production, and probability of pregnancy at the first artificial insemination (AI). Fifty-five Holstein freestall dairy herds in the United States and Canada were visited weekly. Blood was collected from 2,365 cows around parturition, and serum concentrations of NEFA, BHBA, and calcium were determined. Different cow-level metabolite thresholds associated with detrimental health or productivity in previous studies were used to classify animals into high- and low-risk metabolite concentration groups. For wk -1 and wk +1 relative to calving, a herd-level threshold was determined as the proportion of sampled animals in the high-risk metabolite concentration groups with the strongest association with increased incidence of disease, milk loss, or decreased pregnancy at the first AI. The odds of displaced abomasum after calving were higher in herds that had ≥ 25% of the animals with BHBA ≥ 1,400 μmol/L in wk +1 [odds ratio (OR)=2.1; 95% confidence interval (CI)=1.0-4.2)] or ≥ 35% of the animals with calcium ≤ 2.1 mmol/L in wk +1 (OR=2.4; CI=1.3-4.3). Herd-level thresholds of ≥15% of the cows with BHBA ≥ 800 μmol/L in wk -1 and ≥ 15% of the cows with calcium ≤2.1mmol/L in wk +1 were associated with milk loss (±SE) of 4.4±1.7 and 3.8 ± 1.4 kg/d per cow, respectively. When only multiparous cows were considered, herds with ≥30% of the multiparous cows with NEFA ≥0.5 mEq/L in wk -1 were associated with a 3.0 ± 1.5 kg/d per cow milk loss. The odds of pregnancy at first AI were lower in herds that had ≥ 5% of the cows with calcium ≤ 2.1 mmol/L in wk -1 (OR=0.7; CI=0.5-1.0), or ≥ 30% of the cows with NEFA ≥ 1.0 mEq/L (OR=0.6; CI=0.4-0.9) or ≥ 25% of the cows with calcium ≤2.1 mmol/L in wk +1 (OR=0.7; CI=0.5-0.9). When only multiparous cows were considered, the odds of pregnancy at first AI were lower in herds that had ≥50% of multiparous cows with NEFA ≥0.5 mEq/L in wk -1 (OR=0.5; CI=0.2-0.9). In conclusion, several herd-level thresholds for the proportion of cows with increased NEFA or BHBA, or decreased calcium in the week before and after calving were associated with higher risk of displaced abomasum, milk loss at the first Dairy Herd Improvement Association test, and decreased pregnancy at first AI. The association found between precalving BHBA and milk production is promising due to the availability of several cow-side tests for measuring BHBA. Some of the herd-level associations differed from the previously described cow-level associations, suggesting the potential of interpreting periparturient metabolic challenges at the herd level, where changes in diet and management are generally implemented.

An eye movement phenomenon, which is thought to be related to the shifting of attention and personal ways of handling anxiety, is described and discussed in relation to certain research hypotheses.

This study was designed to determine the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders among a community sample of adolescent and young adult refugees from Afghanistan. The study also measured the correlation of their current psychiatric disorders with the number of traumatic events experienced, parental acculturation and distress, and other important demographic factors. Thirty-eight refugees between 12 and 24 years of age were interviewed with the Structured Clinical Interview for DSM-III-R. Five subjects met DSM-III-R criteria for PTSD, 11 subjects met the criteria for major depression, and 13 had either PTSD or major depression or both. Significant positive correlations were found between the subjects' psychiatric diagnosis and the total number of traumatic events experienced and the parental level of psychological distress (especially maternal distress). There were negative correlations between children's symptomatology and a measure of maternal acculturation. These results suggest that a significant proportion of adolescent and young adult Afghan refugees in the community suffer from severe but undiagnosed psychiatric disorders.

Medication noncompliance occurs among as many as one-third to one-half of all medical and psychiatric outpatients. Noncompliance has serious consequences for individuals diagnosed with schizophrenia, often resulting in higher rates of relapse and rehospitalization, and poorer community adjustment. Health education interventions have been shown to be effective in promoting compliance among patients with chronic medical illness such as hypertension or diabetes, but there have been few randomized trials of this approach among patients with chronic psychiatric disorders. This paper presents the results of an application of health education among a group of male psychiatric outpatients. Two interventions were developed which used health education techniques to 1) engage families or significant others as active participants in the aftercare process, and 2) train patients to become effective health care consumers. A total of 418 individuals participated in a six-month trial over a four-year study. Both interventions significantly improved medication compliance among those who received them. The results show that comparatively brief interventions can significantly alter medication compliance behavior and improve the quality of life for patients with chronic psychiatric disorders.

This study compared the effects of repeated novel stressors on 'depressive behaviors', defined by the forced-swim and open-field tests, in Sprague-Dawley (S-D) and Wistar Kyoto (WKY) rats. Since stress appears to alter brain norepinephrine (NE) activity, this study also investigated the effects of the stressors on beta-adrenoceptors (beta-ARs), alpha 2-adrenoceptors (alpha 2-ARs) and NE transporter (NET) sites in S-D and WKY rats. Stress did not alter 125I-iodopindolol (125I-PIN) binding to beta-ARs, nor [3H]idazoxan ([3H]IDAZ) binding to alpha 2-ARs in S-D rats, compared to non-stressed controls. However, WKY-stressed rats showed a significant reduction in 125I-IPIN binding to beta-ARs in the cortex, hippocampus, amygdala and hypothalamus, and a reduction in [3H]IDAZ binding to alpha 2-ARs in the amygdala. [3H]nisoxetine ([3H]NIS) binding to NET sites in WKY-stressed rats was also reduced in the cortex, hippocampus and amygdala. When both strains were compared, the most surprising finding was a significantly higher density of NET sites in the hippocampus and amygdala in WKY rats compared to S-D rats. The results of this study indicate that stress, not only exacerbates depressive behavior in WKY rats, but also selectively alters beta-ARs, alpha 2-ARs and NET sites in limbic brain regions. Thus, the WKY strain may serve as a useful animal model for depressive behavior and for the investigation of novel antidepressant drugs.

Physicians are often faced with the problem of determining whether long-stay schizophrenics require continuous treatment with tranquillizers. Prolonged ingestion of ataractics has both physical and economic disadvantages. Recent reports on oculo-cutaneous changes (3, 13, 20, 27, 28), persistent dyskinesia (6, 18) and sudden deaths (16, 25) have focused attention on the potential dangers of prolonged use of tranquillizing medication. On the other hand, discontinuation of medication may lead to recurrence of acute psychotic behaviour. The literature on drug withdrawal provides no solution to the dilemma. The results from drug discontinuation studies are complex and contradictory. Some investigators report extremely high relapse rates while others report little deterioration even when drugs are withdrawn for long periods of time. A brief review of the literature will give some indication of the contradictory nature of results.

The lifetime co-morbidity of major psychiatric disorders among male alcoholics was examined with the structured Psychiatric Diagnostic Interview (PDI), which was administered to 928 patients undergoing alcoholism treatment at six Veterans Administration Medical Centers. Thirty-eight percent were positive for alcoholism only; 62% fulfilled inclusive lifetime diagnostic criteria for at least one other additional psychiatric syndrome. Thirty percent satisfied criteria for one additional syndrome; 16% for two additional syndromes; 12% for three; and 4% for four or more disorders in addition to alcoholism. Depression and antisocial personality were the most frequently identified co-occurring syndromes (36% and 24%, respectively) followed by drug abuse and mania (17% each). The additional psychiatric syndromes in this sample were clearly not randomly distributed; instead, certain disorders tended to cluster together such as: drug abuse and antisocial personality; mania and depression; depression and anxiety disorder; and schizophrenia and affective disorder. Implications for classification and treatment are discussed.

Association of crystalline point defects in chlorinated Cu-doped CdTe PV absorbers studied to assess its impact on performance and stability.

Delirium is a neuropsychiatric syndrome characterized by impairment of consciousness, changes in cognition, or perceptual disturbances. In addition, delirium is often accompanied by delusions, hallucinations, and agitation. In this study, 12 older patients with delirium were treated for neuropsychiatric symptoms with quetiapine. The mean duration for stabilization was 5.91 +/- 2.22 days, and the mean dose was 93.75 +/- 23.31 mg/day. None of the 12 patients developed extrapyramidal symptoms. There were significant improvements on all measures used in this study. Interestingly, the Delirium Rating Scale scores along with scores of the Mini-Mental State Examination and Clock Drawing Test continued to improve throughout the 3-month study period. In our study, we found that quetiapine was a safe and effective treatment in hospitalized older patients with delirium.

In 1968, the Veterans Administration and the National Institute of Mental Health organized a multi-hospital collaborative study on the effectiveness of lithium carbonate in acute mania. Two hundred and fifty five newly-admitted patients with this disorder were randomly assigned to lithium or chlorpromazine treatment for a three-week period. Patients were classified as highly active or mildly active on the basis of hyperactivity shown at admission. Results have been reported in a previous paper (7). Briefly, it was found that chlorpromazine was significantly superior to lithium in treating the highly active patient: chlorpromazine acted more quickly than lithium, produced significantly fewer treatment failures, and had a lower incidence of severe side effects. The difference between treatments was less clear-cut with mildly active patients, although lithium appeared to be the better treatment. Both drugs effectively reduced manic symptomatology, but lithium produced fewer severe side effects and left the patient less sluggish and fatigued. The poor results with lithium among highly active patients were attributed to the drug's relatively slow onset of action. As a group, highly active patients on lithium showed relatively little change in manic behaviour during the first week; it was ten days before some patients showed any improvement. Almost 40 per cent of the highly active patients had to be taken off lithium before the end of three weeks because of unmanageable behaviour or toxicity. In contrast, chlorpromazine, with its quick onset of action, generally controlled manic symptoms

The Global Enteric Multicenter Study (GEMS) is an investigation of the burden (number of cases and incidence) of moderate-to-severe diarrhea (MSD) in children <60 months of age at 7 sites in sub-Saharan Africa and South Asia. The population attributable fraction for a putative pathogen, either unadjusted or adjusted for other pathogens, is estimated using the proportion of MSD cases from whom the pathogen was isolated and the odds ratio for MSD and the pathogen from conditional logistic regression modeling. The adjusted attributable fraction, proportion of MSD cases taken to a sentinel health center (SHC), number of cases presenting to an SHC, and the site's population are used to estimate the annual number of MSD cases and MSD incidence rate attributable to a pathogen or group of pathogens. Associations with death and nutritional outcomes, ascertained at follow-up visits to case and control households, are evaluated both in MSD cases and in the population.

In Experiment 1, Wistar-Kyoto (WKY), Wistar, and Fischer-344 (F-344) rats were tested on two passive-avoidance tasks: a platform step-down task and a one-way avoidance task. Wistars had shorter response latency scores in the step-down task, whereas F-344 rats had shorter scores in the one-way task. A subsequent ulcerogenic water-restraint stress produced significantly fewer ulcers in Wistar rats as compared to WKY and F-344 rats. In Experiment 2, rearings, grooming, ambulation, defecation, and response ambivalence behaviors were recorded in the one-way avoidance task in addition to response latency. WKY rats defecated more and produced lower scores on the three activity measures as compared to Wistar and F-344 rats. Response latency and ambivalence scores were higher for WKY rats. The subsequent ulcerogenic procedure also produced more ulcers in WKY rats. These data verify the ulcer susceptibility of WKY rats and underscore the assertion that their predominant stress coping behaviors are immobility and freezing. High ambivalence scores in WKY rats suggest behavioral inhibition, which is readily elicited by stressors. These behaviors resemble depressive behavior and suggest that WKY rat may be a useful animal model of depression.