Tomah VA Medical Center

ABSTRACT This article describes how cross-border trade in West Nile, north-western Uganda to a large extent takes place outside of the legal framework. This does not mean that this trade is unregulated. We make use of the concept of ‘practical norms’ to show the existence of regulation within this trade, which diverges both from official norms and social norms (‘moral economy’). The article describes how these practical norms emerged and how they are enforced. First, it is shown how the moral economy of cross-border trade plays an important role in their articulation. Second, we ask which practical concerns play a role in sustaining these norms and how deviations from them activate open power struggles. And third, we show how concrete events have played a role in their emergence.

In the first half of the 19th century, European physicians-including Marshall Hall, Moritz Romberg, and Bernardus Brach-described loss of postural control in darkness of patients with severely compromised proprioception. Romberg and Brach emphasized the relationship between this sign and tabes dorsalis. Later, other neurologists evaluated the phenomenon, which is now known as Romberg's sign, in a broader range of neurologic disorders using a variety of simple but increasingly precise and sensitive clinical tests. In the late 19th century, neurologists also developed instruments to measure and record postural sway in patients with neurologic disease. Principal contributors included Philadelphia neurologist Silas Weir Mitchell and his trainees Morris Lewis and Guy Hinsdale. The efforts of these neurologists anticipated later physiologic studies and ultimately the development of computerized dynamic platform posturography.

In 1937, Heinrich Klüver and Paul Bucy described a dramatic behavioral syndrome in monkeys after bilateral temporal lobectomy. The full Klüver-Bucy syndrome (KBS) - hyperorality, placidity, hypermetamorphosis, dietary changes, altered sexual behavior, and visual agnosia - is evident within 3 weeks following operation. Some KBS features (i.e., hyperorality, placidity, hypermetamorphosis) persist indefinitely, whereas others gradually resolve over several years. Klüver and Bucy were initially unaware of an earlier report of KBS by Sanger Brown and Edward Schäfer in 1888. Human cases were recognized in the 1950s, as surgeons employed bilateral temporal lobectomies to treat seizures. Various attempts were made to localize the component features to specific areas of the temporal lobe, with mixed success. Bilateral ventral temporal ablations and bilateral temporal lobectomies produced marked impairment in visual discrimination, whereas lateral resections or unilateral lesions did not. Discrete bilateral lesions of the lateral amygdaloid nucleus produced a permanent "hypersexed state." By the 1970s, it was clear that the major symptoms of KBS are produced by destroying either the temporal neocortex or the amygdala bilaterally. KBS is now thought to be caused by disturbances of temporal portions of limbic networks that interface with multiple cortical and subcortical circuits to modulate emotional behavior and affect. The clinical features of KBS in man are similar to those in monkeys, but the full syndrome is rarely seen, probably because the anterior temporal lobe dysfunction is usually less severe than that following total temporal lobe ablation in monkeys. Human KBS does not occur in isolation, but is typically part of a complex behavioral syndrome that almost always includes amnesia and aphasia, and that may also include dementia and seizures. The treatment of KBS is difficult and often unsatisfactory.

Early in the 20th century during the Russo-Japanese War and World War I (WWI), some of the most important, lasting contributions to clinical neurology were descriptive clinical studies, especially those concerning war-related peripheral nerve disorders (eg, Hoffmann-Tinel sign, Guillain-Barré-Strohl syndrome [GBS]) and occipital bullet wounds (eg, the retinal projection on the cortex by Inouye and later by Holmes and Lister, and the functional partitioning of visual processes in the occipital cortex by Riddoch), but there were also other important descriptive studies concerning war-related aphasia, cerebellar injuries, and spinal cord injuries (eg, cerebellar injuries by Holmes, and autonomic dysreflexia by Head and Riddoch). Later progress, during and shortly after World War II (WWII), included major progress in understanding the pathophysiology of traumatic brain injuries by Denny-Brown, Russell, and Holbourn, pioneering accident injury studies by Cairns and Holbourn, promulgation of helmets to prevent motorcycle injuries by Cairns, development of comprehensive multidisciplinary neurorehabilitation by Rusk, and development of spinal cord injury care by Munro, Guttman, and Bors. These studies and developments were possible only because of the large number of cases that allowed individual physicians the opportunity to collect, collate, and synthesize observations of numerous cases in a short span of time. Such studies also required dedicated, disciplined, and knowledgeable investigators who made the most out of their opportunities to systematically assess large numbers of seriously ill and injured soldiers under stressful and often overtly dangerous situations.

The objective of this paper is to describe three cases of combat-related posttraumatic stress disorder (PTSD), largely refractory to standard medication treatment who responded well to psychostimulant treatment. Symptoms of PTSD potentially result from chronic, stress-induced dopaminergic dysfunction in the prefrontal cortex/basal ganglia system. Psychostimulants, by their relative propensity to enhance dopamine (DA) activity within these brain regions, may have particular value in targeting this dysfunction. Evidence of dopaminergic dysfunction following chronic stress is reviewed and possible mechanism of action of psychostimulants is explored. Psychostimulants appeared to be well tolerated and beneficial in the treatment of the cases of combat-related PTSD reported. General applicability of the use of psychostimulants in combat- and non-combat-related PTSD awaits further study. The potential implications of these findings in further delineating pathophysiology and treatment in PTSD deserve further exploration.

BACKGROUND: Previous studies have assessed the validity of the observational study design by comparing results of studies using this design to results from randomized controlled trials. The present study examined design features of observational studies that could have influenced these comparisons. METHODS: To find at least 4 observational studies that evaluated the same treatment, we reviewed meta-analyses comparing observational studies and randomized controlled trials for the assessment of medical treatments. Details critical for interpretation of these studies were abstracted and analyzed qualitatively. RESULTS: Individual articles reviewed included 61 observational studies that assessed 10 treatment comparisons evaluated in two studies comparing randomized controlled trials and observational studies. The majority of studies did not report the following information: details of primary and ancillary treatments, outcome definitions, length of follow-up, inclusion/exclusion criteria, patient characteristics relevant to prognosis or treatment response, or assessment of possible confounding. When information was reported, variations in treatment specifics, outcome definition or confounding were identified as possible causes of differences between observational studies and randomized controlled trials, and of heterogeneity in observational studies. CONCLUSION: Reporting of observational studies of medical treatments was often inadequate to compare study designs or allow other meaningful interpretation of results. All observational studies should report details of treatment, outcome assessment, patient characteristics, and confounding assessment.

OBJECTIVE: The current study examined facets of gender minority stress (nonaffirmation, internalized transphobia) and protective factors (community connectedness, transgender identity pride) as potential moderators of the relationship between sexual victimization and sleep disturbances among transgender and gender nonconforming (TGNC) adults. METHODS: TGNC adults (n = 191) were recruited through Amazon's Mechanical Turk. The average age was 30.28 years old (SD = 7.09; range 18-71) and the majority (55%) identified in the transfemale spectrum. RESULTS: Results demonstrated a significant two-way interaction between sexual victimization and internalized transphobia, such that sexual victimization was more strongly related to sleep disturbances when internalized transphobia was low (β = .14, p = .017) relative to high (β = -0.09, p = .221). CONCLUSIONS: This study is the first to establish the relationship between sexual victimization and sleep disturbances in TGNC individuals. Additional research is needed to replicate these findings longitudinally.

In the late 19th century, jumping (French Canadians in Maine, USA), miryachit (Siberia), and latah (Southeast Asia) were among a group of similar disorders described around the world, each of which manifests as an exaggerated startle response with additional late-response features that were felt by some to overlap with hysteria or tics. The later features following the exaggerated startle reaction variably include mimesis (e.g., echopraxia, echolalia) and automatic obedience. These reaction patterns tended to persist indefinitely in affected individuals. Because of their dramatic stimulus-driven behaviors, affected individuals were prone to be teased and tormented by being repeatedly and intentionally startled. Despite clinical overlap between jumping and Tourette syndrome, these entities are now recognized as distinct: in jumping, the key feature is an abnormal startle response, the abnormal reaction is always provoked, and tics are absent, whereas in Tourette syndrome, the key feature is spontaneous motor and vocal tics, although patients with Tourette syndrome may occasionally also have an exaggerated startle response. These disorders have been conceptualized from anthropological, psychodynamic, and neurobiologic perspectives, with no complete resolution to date. Attempts at treatment have been generally unsuccessful, including attempts with bromization and hypnosis, although anecdotal reports of successful deconditioning have been published. In population groups affected, these disorders are usually considered as behavioral peculiarities and not as diseases per se, and there is no apparent tendency to develop disabling mental illness or neurodegenerative disorders. The genesis of these disorders, their cultural and social components, and their interactions with the presumed underlying physiological substrate need further study. Careful descriptive and analytic epidemiological studies are also lacking for all of these disorders.

Abstract Principal components and common factors of the Wechsler Memory Scale-Revised (WMS-R) were derived from a clinical sample (N = 168) of males referred for neuropsychological evaluation at a rural Veterans Administration Medical Center. One general memory component accounting for 54% of the variance was consistently identified, whether the analyses included the eight immediate subtests alone, all 12 immediate and delayed-recall subtests, or the WMS-R and VIQ/PIQ combined. Minimal support for a second factor which contributed 9.4% of the total variance was found only after Verbal and Performance IQ scores were included in the analysis. The failure of these data to support previous reports of multiple WMS-R components is attributed in part to different factor retention criteria. Principal-component loadings nominally exceeded those derived by common factor analysis. Clinical implications of these findings are discussed.

Starting in 2016, we initiated a pilot tele-antibiotic stewardship program at 2 rural Veterans Affairs medical centers (VAMCs). Antibiotic days of therapy decreased significantly (P < .05) in the acute and long-term care units at both intervention sites, suggesting that tele-stewardship can effectively support antibiotic stewardship practices in rural VAMCs.

BACKGROUND: Telehospitalist services are an innovative alternative approach to address staffing issues in rural and small hospitals. OBJECTIVE: To determine clinical outcomes and staff and patient satisfaction with a novel telehospitalist program among Veterans Health Administration (VHA) hospitals. DESIGN, SETTING, AND PARTICIPANTS: We conducted a mixed-methods evaluation of a quality improvement program with pre- and postimplementation measures. The hub site was a tertiary (high-complexity) VHA hospital, and the spoke site was a 10-bed inpatient medical unit at a rural (low-complexity) VHA hospital. All patients admitted during the study period were assigned to the spoke site. INTERVENTION: Real-time videoconferencing was used to connect a remote hospitalist physician with an on-site advanced practice provider and patients. Encounters were documented in the electronic health record. MAIN OUTCOMES: Process measures included workload, patient encounters, and daily census. Outcome measures included length of stay (LOS), readmission rate, mortality, and satisfaction of providers, staff, and patients. Surveys measured satisfaction. Qualitative analysis included unstructured and semi-structured interviews with spoke-site staff. RESULTS: Telehospitalist program implementation led to a significant reduction in LOS (3.0 [SD, 0.7] days vs 2.3 [SD, 0.3] days). The readmission rate was slightly higher in the telehospitalist group, with no change in mortality rate. Satisfaction among teleproviders was very high. Hub staff perceived the service as valuable, though satisfaction with the program was mixed. Technology and communication challenges were identified, but patient satisfaction remained mostly unchanged. CONCLUSION: Telehospitalist programs are a feasible and safe way to provide inpatient coverage and address rural hospital staffing needs. Ensuring adequate technological quality and addressing staff concerns in a timely manner can enhance program performance.

Prey often reduce predation risk at the cost of lower resource intake. The cumulative effects of such tradeoffs can alter resource allocation, demography and evolutionary processes. We show how the accumulation of risk effects reduces the growth rate of wild North American porcupines Erethizon dorsatum , and simulate three evolutionary responses related to lifetime reproductive success. Individual porcupines experiencing predation risk from fishers Pekania pennanti grew slower and gave birth to fewer offspring. Simulations show that predation risk alone can lead to population declines, and that a female can replace herself by investing more energy into reproduction or adult survival; females that only invest energy in juvenile survival cannot. We show that the accumulation of predation risk can reduce lifetime reproductive success in natural ecosystems. Estimating the contribution of predation risk, and how evolutionary responses can mediate consequences associated with predation risk, is necessary to understand the evolution of predator–prey systems.

Functional weakness and sensory loss are common clinical problems with variable presentations. Functional weakness commonly presents as weakness of an entire limb, paraparesis, or hemiparesis, with observable or demonstrable inconsistencies and nonanatomic accompaniments. Documentation of limb movements during sleep, the arm drop test, the Babinski thigh-trunk test, Hoover tests, the Sonoo abductor test, and various dynamometer tests can provide useful bedside diagnostic information on functional weakness. Functional sensory loss typically affects all sensory modalities, either in a hemisensory distribution or affecting an entire limb. Although often inconsistent over serial examinations with nonanatomic features, many clinical findings reported to be helpful in diagnosing functional sensory loss are neither sensitive nor specific for functional sensory loss. The yes-no test, Bowlus-Currier test, and forced-choice tests can provide useful bedside diagnostic information on functional sensory loss. Clinicians must be prepared to make more than one diagnosis in some cases, including an organic neurological diagnosis and a diagnosis of functional overlay. Recent studies have reported relatively low rates (<5%) of misdiagnosis of functional weakness or sensory loss as indicated by subsequent diagnosis of neurological or psychiatric conditions that explained the presenting symptoms. Most neurologists find such patients more difficult to help than patients with organic disease. Management focuses on supportive psychotherapy and behavioral management, exploration of social and psychological issues, treatment of comorbid depression or anxiety, and facilitation of development of more appropriate and constructive coping methods. Many patients with functional weakness, and to a somewhat lesser extent functional sensory loss, have persisting or relapsing-remitting somatic symptoms and persistently impaired social/interpersonal, occupational, and psychological functioning.

In March 2020, the Veterans Health Administration (VA) responded to pandemic shutdowns with a rapid pivot toward providing services via telehealth. Using data on Veterans who received interventions from social workers between 2019 and 2020 at sites that participated in a national program to increase social work staffing in primary care, we examined changes in frequency and modality of social work encounters that occurred with the onset of the COVID-19 pandemic. We found that primary care social workers maintained a consistent level of engagement, with increases in telephone and video telehealth encounters as in-person visits decreased. Through front-line perspectives, we discuss the practical innovations and policies that enabled those changes in care from VA primary care social workers.

BACKGROUND: Since the description of athetosis in 1871 by American neurologist William Alexander Hammond (1828-1900) the disorder has been a source of controversy, as were many aspects of Hammond's career. METHODS: Primary sources have been used to review controversies in the 50-year period since the initial description of athetosis, in particular those concerning clinical features, differentiation from other movement disorders, associated conditions, and pathology. Controversies concerning treatment will be addressed in a subsequent article. RESULTS: Hammond struggled to establish athetosis as a distinct clinical-pathological entity, and had successfully predicted the striatal pathology in his initial case (albeit somewhat serendipitously). Athetosis was, nevertheless, considered by many neurologists to be a form of post-hemiplegic chorea or part of a continuum between chorea and dystonia. European neurologists, and particularly the French, initially ignored or discounted the concept. Additional controversies arose over whether the movements persisted during sleep, whether athetosis was, or could be, associated with imbecility or insanity, and how it should be treated. DISCUSSION: Some controversies concerning athetosis served to identify areas where knowledge was insufficient to make accurate statements, despite prior self-assured or even dogmatic statements to the contrary. Other controversies illustrated established prejudices, even if these biases were often only apparent with the greater detachment of hindsight.

To the Editor: I read the interesting article by Chio et al. concerning the Italian neuropsychiatrist Cesare Lombroso, his “keen findings” of developmental cerebral cortex lesions in epileptics, and his “odd theories” supporting a relationship between criminality, epilepsy, and genius.1 In addition to his work on epilepsy and criminology, Lombroso further developed and widely promoted the corn toxin theory of pellagra that had been initiated by others in Italy in the first half of the 19th century.2–5⇓⇓⇓ Lombroso wrote much in support of the concept that pellagra was caused by “an intoxication produced by poisons developed in spoiled corn through the action of certain micro-organisms in themselves harmless to man,” akin to ergotism produced by …

Studies of tremor in the 19th century were based initially on simple observation and later on the use of crude graphic recording devices that had been modified from instruments developed for other purposes. Like several European contemporaries, American investigators studying tremor used and adapted various existing instruments, including tambours and sphygmographs. A tambour used a drum-shaped pneumatic mechanism to transmit movements to a recording instrument, whereas the sphygmograph was a nonpneumatic mechanical device initially used to record the pulse. 19th-century American neurologists who used such devices included Frederick Peterson, Hobart Amory Hare, Charles Loomis Dana, and Augustus A. Eshner. Their measurements of tremor frequency were generally consistent with modern estimates for various types of tremor. Eshner, in particular, was frustrated by the overlap of frequency domains for tremors in different diseases, because this precluded use of tremor frequency alone as a differentiating feature for diagnosis. Peterson and Dana recognized the variation in tremor frequency in different body parts resulting from different natural resonance frequencies of these parts as a function of weight and elastic properties. Peterson, Dana, and Eshner also recognized that tremor amplitude and frequency are inversely related. Finally, these 19th-century investigators recognized that the tremor of Parkinson's disease is a relatively low-frequency rest tremor, suppressed by action, and generally synchronous in symmetric body parts, but varying in amplitude and frequency in different body parts or over time.

The correspondence between Scale 2 elevations on the MMPI-2 and SCID-diagnosed unipolar depression (major depression and dysthymia) and alcohol-induced depression was evaluated among 106 consecutive male admissions to an inpatient alcohol treatment unit. Valid profiles were obtained from 87 subjects, 15% of whom were diagnosed with unipolar depression and another 4.5% with presumed alcohol-induced depression. The sensitivity of Scale 2 (the probability that a depressed subject would obtain an elevated score) ranged from .19 to .42. Positive predictive power (the probability that a subject who obtained an elevated score had a depressive disorder) ranged from .23 to .38. Neither Scale 2 alone nor Scale 2 paired in 2-point code types predicted the presence or absence of comorbid depressive disorders among male alcoholics.

Importance: Palliative care improves quality of life for patients and families but may be underused. Objective: To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. Design, Setting, and Participants: This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. Exposures: The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. Main Outcomes and Measures: The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. Results: The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. Conclusions and Relevance: This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.

1. Mental and intellectual deterioration are typical for psychoses in advanced life. Thus, an approach based on logical argumentation fails to facilitate contact with the elderly psychotic. 2. The emotional sphere is often not so much affected as the intellectual. Therefore, any therapeutic technique in treatment and psychological management of elderly psychotics has to be based primarily on the utilization of preserved emotional faculties, among them the preserved or only partly impaired ability for group identification. 3. Psychological management and treatment based on these principles is divided into the following 4 phases: Group occupational therapy; group and individual psychotherapy; training in self-care both inside, and in case of release, outside the hospital; adjustment of the elderly psychotic to the environment and adjustment of the immediate environment to the elderly person. 4. This program, which is already in action, takes care of the reversible psychological symptoms but not of the irreversible pathophysiological ones. 5. Although still in an experimental stage, the program opens the way for a more satisfactory management of elderly psychotics. The use of the methods described has therefore been advocated.