VA Illiana Health Care System

Although amitriptyline relieves pain in many patients with painful diabetic neuropathy, side effects often preclude effective treatment. Desipramine has the least anticholinergic and sedative effects of the first generation tricyclic antidepressants. We compared a 6 week course of desipramine (mean dose, 201 mg/day) to active placebo in 20 patients with painful diabetic neuropathy in a double-blind crossover trial. Pain relief with desipramine was statistically significant in weeks 5 and 6. Eleven patients reported at least moderate relief with desipramine, compared to 2 with placebo. Pain relief tended to be greater in depressed patients, but relief was also observed in patients who did not show an antidepressant effect. We conclude that desipramine relieves pain in many patients with painful diabetic neuropathy, offering an alternative for patients unable to tolerate amitriptyline. Blockade of norepinephrine reuptake, an action shared by desipramine, amitriptyline, and other antidepressants proven effective in neuropathic pain, may mediate this analgesic effect.

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Behavioral studies show that women's stage of readiness to adopt mammography screening affects their screening rates and that beliefs about breast cancer and screening affect stages of screening. The purposes of this study were to determine, first, the relationship between particular health and cultural beliefs and stage of mammography screening adoption in urban African American women, and second, whether demographic and experiential characteristics differed by stage. Data were analyzed from 344 low-income African American women nonadherent to mammography screening who participated in a 21-month trial to increase screening. At baseline, these women were randomized into 1 of 3 groups: tailored interactive computer instruction, targeted video, or usual care. Participants were categorized by stage of mammography screening adoption at 6 months as precontemplators (not planning to have a mammogram), contemplators (planning to have a mammogram), or actors (had received a mammogram). Although demographic and experiential variables did not differentiate stages of screening adoption at 6 months postintervention, some health and cultural beliefs were significantly different among groups. Actors were more preventive-health-oriented than precontemplators and had fewer barriers to screening than did contemplators. Precontemplators had more barriers, less self-efficacy, and greater discomfort with the mammography screening environment than did contemplators or actors. These results will be useful, not to change cultural beliefs, but to guide the design of health education messages appropriate to an individual's culture and health belief system. Cancer 2007. (c) 2006 American Cancer Society.

OBJECTIVE: Processing speed alters the traditional Stroop calculations of interference. Consequently, alternative algorithms for calculating Stroop interference have been introduced to control for processing speed, and have done so in a multiple sclerosis sample. This study examined how these processing speed correction algorithms change interference scores for individuals with idiopathic Parkinson's disease (PD, n = 58) and non-PD peers (n = 68). METHOD: Linear regressions controlling for demographics predicted group (PD vs. non-PD) differences for Jensen's, Golden's, relative, ratio, and residualized interference scores. To examine convergent and divergent validity, interference scores were correlated with standardized measures of processing speed and executive function. RESULTS: PD-non-PD differences were found for Jensen's interference score, but not Golden's score, or the relative, ratio, and residualized interference scores. Jensen's score correlated significantly with standardized processing speed but not executive function measures. Relative, ratio, and residualized scores correlated with executive function but not processing speed measures. Golden's score did not correlate with any other standardized measures. CONCLUSIONS: The relative, ratio, and residualized scores were comparable for measuring Stroop interference in processing speed-impaired populations. Overall, the ratio interference score may be the most useful calculation method to control for processing speed in this population.

OBJECTIVES: The main purpose of the authors' research was to compare the 3- and 5-year mortality rates of diabetic patients who have undergone a lower-extremity amputation, evaluating the proximity of the amputation in 3 groups (toe and foot amputation, BKA, and AKA), the timing of the amputation (within or after 2 years of the onset of the foot ulcer), and the effect of glycemic control at the time of amputation, regardless of the level of amputation. METHODS AND DESIGN: The subjects were 80 male inpatients at Illiana Veterans Health Care System who had diabetes, diabetic neuropathy, peripheral vascular disease, and a diabetic foot ulcer that resulted in an amputation. Of the 80 patients, 29 had a toe amputation, 30 had a BKA, and 21 had an AKA. The mean age in all 3 groups was 68.5 years+/-7.2 years. The authors used the hemoglobin A1C (Hgb A1C) level to assess glycemic control. MAIN OUTCOME MEASURES: Several chi tests were used to compare the 3- and 5-year mortality rates among the amputation groups. An Hgb A1C level of 8% or less defined good glycemic control; an Hgb A1C level of more than 8% defined poor glycemic control. A chi test was used to compare glycemic control, the level of amputation, and the mortality rate. A chi test was also used to evaluate the length of time between ulcer formation and amputation, the level of amputation, and the mortality. All statistics were done using SPSS 10.0 student version. CONCLUSIONS: The research revealed a statistically significant difference in mortality among the 3 groups at 3 and 5 years. No statistically significant difference in mortality in patients with good glycemic control and patients with bad glycemic control was found. At 3 years, a statistically significant difference in mortality existed between patients who had an amputation within 2 years of ulcer formation and those who had an amputation after 2 years. At 5 years, no statistically significant difference existed between these 2 groups.

This study examined the neuropsychological performance of 125 outpatient Operation Enduring Freedom/Operation Iraqi Freedom combat veterans with posttraumatic stress disorder (PTSD) and nonacute mild traumatic brain injury (TBI) (n = 66) and PTSD (n = 59) across multiple cognitive domains to determine whether mild TBI results in greater impairment among those with PTSD. Profile analyses revealed that veterans with PTSD and mild TBI did not differ significantly from those with just PTSD across domains, suggesting that comorbid mild TBI does not result in an additive effect. A norms-based comparison also revealed that neither group demonstrated impaired performance on any of the objective neuropsychological measures examined. However, both groups endorsed moderately elevated symptoms of depression and anxiety, indicating that comorbid psychopathology may contribute to subjective cognitive complaints.

OBJECTIVE: This pilot study examined whether substance use or mental illness was more stigmatizing among individuals with co-occurring mental health and substance abuse problems. METHODS: This study included 48 individuals with co-occurring substance use and mental health problems enrolled in a Substance Abuse and Mental Health Services funded treatment program. Subjects received a baseline assessment that included addiction, mental health, and stigma measures. RESULTS: The sample consisted primarily of White males with an average age of 38 years. Substance abuse was found to be more stigmatizing than mental illness, F(1, 47) = 14.213, p < .001, and stigma varied across four different levels of stigma (Aware, Agree, Apply, and Harm), F(2.099, 98.675) = 117.883, p < .001. The interaction between type and level of stigma was also significant, F(2.41, 113.284) = 20.250, p < .001, indicating that differences in reported stigma between types varied across levels of stigma. Post hoc tests found a significant difference between all levels of stigma except for the comparison between Apply and Harm. Reported stigma was significantly higher for substance abuse than mental illness at the Aware and Agree levels. In addition, pairwise comparisons found significant differences between all levels of stigma with the exception of the comparison between Apply and Harm, indicating a pattern whereby reported stigma generally decreased from the first level (Aware stage) to subsequent levels. CONCLUSIONS: These results have important implications for treatment, suggesting the need to incorporate anti-stigma interventions for individuals with co-occurring disorders with a greater focus on substance abuse.

Understanding how players navigate through virtual worlds can offer useful guidance for map and level design of video games. One way to handle large-scale movement data obtained within games is by modelling movement as a sequence of visited locations instead of focusing on raw trajectory data. In this paper, we introduce a visualization approach for movement analysis based on semantic trajectories derived from a user-guided segmentation of the game environment. Based on this concept, the visualization offers an aggregated view of movement patterns together with the possibility to view individual paths for detailed inspection. We report on a user study with six experts from the game industry and compare the insights they have gleaned from the visualization with feedback from players. Our results indicate that the approach is successful in localizing problematic areas and that semantic trajectories can be a valuable addition to existing approaches for player movement analysis.

= 2,620) from a VHA VR program in the Veterans Integrated Service Network 12 network were obtained for the purpose of the present study and consisted of veterans enrolled from 2012 to 2018. Findings showed that veterans without SUDs were more likely to exit with employment, and veterans enrolled in transitional work and community-based employment were more likely to exit with employment compared to those within supported employment (SE). Given that SE helps to serve veterans with the most severe psychological or medical conditions (e.g., active psychosis, schizophrenia, bipolar disorder, spinal cord injury, traumatic brain injury), findings suggest veterans are more successful with less serious mental health conditions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A dipstick method for bacteriologic screening of urine using a combination of leukocyte esterase and nitrite indicators, Chemstrip LN, was evaluated in a male inpatient geriatric population. Three hundred seventy-five urine samples from 198 symptomatic patients (age range, 45 to 98 years; mean, 69.6) were tested by LN and cultured using standard methods. LN showed 169 negatives, but in 7 of these cases, the culture was positive (greater than or equal to 5 X 10(4) col/mL). Organisms recovered from these cultures were Candida (not albicans), Group B Streptococcus, Staphylococcus aureus, and in four cases, Pseudomonas aeruginosa. In the four cases of missed Pseudomonas the patients were receiving aminoglycoside therapy for 2 to 6 days and/or drugs that dye the urine. Despite the fact that many patients were on medications known to interfere with the test strips, the negative predictive value was still 96.0% showing that the strips may be suitable for use with this population given the understanding that certain antibiotics and/or substances that dye the urine may give false negative results.

Introduction: Research has shown that Veterans with Substance/Alcohol Use Disorders (SUDs/AUDs) are at a greater risk for employment-related issues (eg, lower labor force participation rates), and interventions such as Vocational Rehabilitation (VR) have been used as a tool to reduce employment obtainment and maintenance. The purpose of the current study was to evaluate acceptance rates and employment rates at closure for Veterans with SUDs/AUDs prior to the implementation of VHA Policy Directive 1163 (mandated that Veterans are not refused services based on prior or current SUD/AUDs). SUD/AUDs were coded to reflect DSM 5-TR criteria of active use and in-remission. Methods: Data from a VHA Vocational Rehabilitation program in the Veterans Integrated Service Network 12 network were obtained for the purpose of the current study. Results: Findings showed that Veterans with AUDs were less likely to be accepted for VR services prior and after implementation of VHA Policy Directive 1163. Conclusions: When examining active and inactive SUDs/AUDs, findings showed that implementation of VHA Policy Directive 1163 was not effective for Veterans with AUDs. One factor that was not explored but could explain disparities in program acceptance rates is duration of program entry. If a Veteran has a consult placed for VHA Vocational Rehabilitation services, and their program entry date (date accepted) is a significant duration, then perhaps Veterans with active AUDs start drinking again given that they are waiting for vocational assistance. Thus, it would be important to assist Veterans with active AUDs into services in a timely manner (perhaps prior them being discharged from SUD treatment).

BACKGROUND: Optic nerve head drusen was recognized histologically in 1858 by Heinrich Muller The majority of optic nerve head drusen cases have been benign in nature. However, optic nerve head drusen can be visually devastating. CASE REPORTS: Two patients were diagnosed with optic nerve head drusen. They were similar in age and each had a best-corrected visual acuity of 20/20 OU. Although the diagnosis was the same, the disease affected each person very differently. One is currently asymptomatic; the other is legally blind secondary to severely constricted visual fields. These cases demonstrate the diversity of visual effects produced by optic nerve head drusen. Appropriate ocular workup, including visual fields, B-scan ultrasonography, computed tomography, and other tests, are presented. CONCLUSION: There is no existing treatment for optic nerve head drusen. Proper diagnosis and patient education is the best-available modality of care. Patients need to be aware of potential complications which, while rare, can affect vision. Visual-field testing can aid in monitoring for subtle changes in vision.

Wound care, infection treatment, and pressure relief are the cornerstones of managing diabetic foot ulcers. A multidisciplinary approach to prevention and patient education are essential components of care.

BACKGROUND: Harm reduction strategies can decrease morbidity and mortality associated with substance use. Various barriers limit conversation around substance use between clinicians and patients. Graphic medicine techniques can inform and encourage patient-centered conversations about substance use. We describe the co-development of a harm reduction-focused graphic medicine comic that depicts the infectious risks associated with injection drug use and patient-centered approaches to providing education about potential risk mitigation strategies. METHODS: We formed a co-design group of veterans with lived experience with substance use, physicians, health services researchers, and community-based harm reduction leaders. Over the course of ten sessions, the co-design team developed a storyline and key messages, reviewed draft content and worked with a graphic designer to develop a comic incorporating the veterans' input. During each session, co-design leads presented drafts of the comic and invited feedback from the group. The comic was edited and adapted via this iterative process. RESULTS: The comic depicts a fictionalized clinical vignette in which a patient develops an injection-related abscess and presents to their primary care provider. The dialogue highlights key healthcare principles, including patient autonomy and agency, and highlights strategies for safer use, rather than emphasizing abstinence. Feedback from co-design group participants highlights lessons learned during the development process. DISCUSSION: Graphic medicine is ideally suited for a patient-centered curriculum about harm reduction. This project is one of several interventions that will be integrated into VA facilities nationally to support incorporation of harm reduction principles into the care of persons who inject drugs.

Oropharyngeal candidiasis caused by Candida albicans is one of the most common opportunistic infections in patients with advanced HIV infection [1,2]. Azoles, such as fluconazole, are commonly used to treat these infections; however, resistance of C. albicans to azoles is problematical [2–4]. Treatment options for azole-resistant oral and esophageal candidiasis remain limited. Caspofungin, an echinocandin with activity against Candida species targeting the synthesis of beta-1, 3-glucan in the fungal cell wall [5], expands the treatment options for azole-resistant oral–esophageal candidiasis in patients with AIDS [4,5]. Resistance to caspofungin remains uncommon. A patient with AIDS and azole-resistant oral–esophageal candidiasis caused by C. albicans is described who developed clinically significant resistance to caspofungin despite conflicting minimum inhibitory concentration (MIC) results. A 44-year-old man with advanced HIV/AIDS infection presented with azole-resistant oral–esophageal candidiasis caused by C. albicans. The patient had previously been treated sequentially with oral nystatin solution, fluconazole, and itraconazole solution without a favorable response. The patient's CD4 cell count had been less than 10 cells/μl for more than 4 years, and the viral load was greater than 100 000 copies/ml. HIV genotyping and phenotyping showed significant resistance to all three main classes of antiretroviral agents. Additional co-morbidities included hepatitis B infection, perianal human papillomavirus infection and squamous cell carcinoma, hypertension, and renal insufficiency (estimated creatinine clearance 75 ml/min). Caspofungin treatment was begun with a loading dose of 70 mg intravenously once, followed by 50 mg intravenously a day for 14 days. The patient tolerated the medication well and examination showed marked clearing of the oral lesions. His appetite improved and he gained weight. Caspofungin treatment was re-initiated 3 months later as a result of a recurrence of symptoms. After his second course, he again showed improvement, which persisted a few months. He subsequently received five additional 2-week treatment courses, administered over one year. These treatment courses were periodically interrupted and prematurely terminated as a result of missed infusion appointments. The clinical effectiveness of the medication gradually diminished. After the seventh and final course of caspofungin, the plaques showed no change and the patient experienced no clinical improvement. Shortly thereafter the patient moved to a new geographical area. Only C. albicans was cultured from oral swabs taken periodically throughout the patient's treatment course; all isolates showed high-level resistance to fluconazole. The MIC of caspofungin calculated from the first sample obtained before the initiation of therapy was 0.13 μg/ml or less, comparable to that seen in fluconazole-resistant and caspofungin-susceptible C. albicans[6]. Susceptibility testing showed an MIC of 0.03 μg/ml after the fourth course of caspofungin (approximately 11 months after the first treatment), at which time resistance was clinically suspected, and an MIC of 1.0 μg/ml during the sixth treatment course, approximately 16 months after beginning treatment. At both points in time the patient showed increasing numbers of persistent oral plaques despite caspofungin treatment, in contrast to his response during his initial course. After his seventh and final course of caspofungin, approximately 19 months after his first course, the MIC was less than 0.03 μg/ml. This patient with AIDS and azole-resistant oral–esophageal candidiasis demonstrated clinically progressive resistance to caspofungin, despite conflicting susceptibility results. It is possible, and likely, that this patient's treatment interruptions, incomplete treatment courses, and the prolonged duration of treatment hastened the onset of treatment failure and clinical resistance. Before treatment, the caspofungin MIC was low as expected, and was consistent with that found in C. albicans strains known to be caspofungin susceptible. Testing performed later continued to show an unexpectedly low MIC, despite the fact that the patient showed signs suggestive of treatment failure. Caspofungin-resistant Candida species typically have an MIC at least greater than 1.0 μg/ml (L.C. Sadowski, personal communication). Hernandez et al. [7] described a caspofungin MIC greater than 64 μg/ml in the setting of caspofungin treatment failure in an AIDS patient with C. albicans esophagitis. Kartonis et al. [8] also reported no correlation between caspofungin MIC levels and clinical outcomes in patients with esophageal candidiasis or invasive candidiasis. Although it is possible that pharmacokinetic variability was a factor in this patient, the patient's initial positive response, the standardized dosing, and the length of time between dose administrations suggest that this would be unlikely. This report highlights the importance of recognizing the possibilities of clinical resistance of C. albicans to caspofungin and the lack of a close relationship between MIC levels and clinical resistance. Genetic and enzymatic analysis of C. albicans isolates in patients failing caspofungin treatment could further the understanding of mechanisms of resistance and susceptibility testing methodologies, and provide new directions for the development of novel therapies.

Pharmacists are uniquely poised for harm reduction work due to their accessibility, medication expertise, and direct patient interaction. They can provide non-prescription syringes, dispense naloxone and medication for opioid use disorder, offer human immunodeficiency virus and hepatitis C virus testing, administer vaccines for hepatitis B virus and human papillomavirus, and prescribe pre- and post-exposure prophylaxis. Despite these advancements, ongoing barriers such as restrictive pharmacy policies and stigma persist, and gaps in education contribute to the problem. Currently, harm reduction education is underrepresented in the Doctor of Pharmacy curriculum. This commentary highlights existing gaps in pharmacist training, emerging pilot programs, and makes practical recommendations for integration of harm reduction education, including minimal competencies, curricular mapping, and implementation strategies to facilitate uptake.

African American women have a lower rate of regular mammography screening, resulting in higher incidence of advanced-stage breast cancer at diagnosis and a lower 5-year survival rate as compared with white women. Researchers have demonstrated that several health beliefs relate to mammography screening in African American women, but little attention has been paid to the importance of religiousness. Although some authors have attempted to determine a link between religiousness and health, we lack a valid and reliable instrument to measure religiousness that can be found in the context of health behaviors. The purpose of this article is to describe the development and psychometric testing of the Wagle Health-Specific Religiousness (WHSR) scale, an instrument used to measure religious beliefs and the influence of those beliefs on mammography screening for African American women. A sample of 344 low-income African American women who were nonadherent to mammography at accrual participating in a randomized trial completed the WHSR. Data from this trial were used to determine the validity and reliability of the WHSR. The 19-item WHSR scale had a Cronbach alpha of. 94. Construct validity was supported via factor analysis and analysis of theoretical relationships. Although further testing is warranted, this analysis indicates that the concept of religiousness is an important component of mammography behavior in African American women.

Given increasing rates of fatal overdoses in the United States and the rapidly changing drug supply, overdose prevention centers (OPCs; also known as safe consumption sites) have been identified as a vital, evidence-based strategy that provide people who use drugs (PWUD) the opportunity to use drugs safely and receive immediate, life-saving overdose support from trained personnel. In addition to providing a safe, supervised space to use drugs, OPCs can house further essential harm reduction drop-in services such as sterile supplies, social services, and medical care. There are established national and international data demonstrating the lifesaving services provided by OPCs, inspiring a groundswell of advocacy efforts to expand these programs in the United States. Thus, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) endorses OPCs, in addition to other harm reduction strategies that protect PWUD. Ultimately, it is imperative to increase access to OPCs across the United States and support key policy changes at the local, state, and federal levels that would facilitate urgent expansion.

OBJECTIVES: This analysis examined the clinical and histopathological characteristics of white and red oral mucosal lesions and patient lifestyle behaviors to understand how the lesions changed over 19-23 years, including among patients who developed oral and pharyngeal cancer. MATERIALS AND METHODS: Seventy-five individuals with red and/or white oral mucosal lesions with clinical diagnoses of smokeless tobacco lesions, leukoplakia, erythroplakia, lichen planus, ulcer, and virus-associated lesions were identified in six Veterans Affairs Medical Center Dental Clinics (VAMC) from 1996 to 2001. Biopsy results and patients' sociodemographic, medical, and tobacco/alcohol use characteristics were obtained. Study dentists used standardized forms to capture information about the lesions. Study participants were re-examined at intervals through January 2002. In 2020, a retrospective review of VAMC and public records ascertained whether participants developed oral cancer or died. RESULTS: The most common red or white oral mucosal lesions among the 75 study participants were leukoplakia (36.0%), smokeless tobacco lesions (26.7%), virus-associated lesions (18.7%), and lichen planus (16.0%). Lesions in 11% of participants with leukoplakia and one-third of participants with lichen planus persisted for 5 years or more. Dysplasia was present in four participants with leukoplakia. Seventeen percent of participants developed a new white or red oral mucosal lesion. Five patients (6.1%) developed oral or pharyngeal cancer, four among participants with leukoplakia (one with prior dysplasia) and one among participants with lichen planus. Four of the cancers developed 6-20 years after enrollment, and only one was at the original lesion site. CONCLUSIONS: The occurrence of oral and pharyngeal cancers in some study participants with white and red oral mucosal lesions many years after enrollment reinforces the need for patients, dentists, and health care systems to have better methods to identify and assess the malignant potential of oral lesions, monitor patients over time, and intercept high-risk oral lesions before they become cancerous.

Scores on the Negative Treatment Indicators content scale from the MMPI-2 were not significantly correlated with 5 measures of treatment outcome among 108 male patients on methadone maintenance. These results and those from other studies using this content scale as an independent variable with substance abusers suggest that the scale has yet to demonstrate consistent predictive validity with this population.