VA Butler Healthcare

Groups of 70 male and 70 female Charles River CD (Sprague-Dawley-derived) rats were exposed whole body to styrene vapor at 0, 50, 200, 500, or 1000 ppm 6 h/day 5 days/week for 104 weeks. The rats were observed daily, body weights and food and water consumption were measured periodically, and a battery of hematologic and clinical pathology examinations was conducted at weeks 13, 26, 52, 78, and 104. Nine or 10 rats per sex per group were necropsied after 52 weeks of exposure and the remaining survivors were necropsied after 104 weeks. Control and high-exposure rats received a complete histopathologic examination, while target organs, gross lesions, and all masses were examined in the lower exposure groups. Styrene had no effect on survival in males, but females exposed to 500 or 1000 ppm had a dose-related increase in survival. Levels of styrene in the blood at the end of a 6-h exposure during week 95 were proportional to exposure concentration. Levels of styrene oxide in the blood of rats exposed to 200 ppm or greater styrene were proportional to styrene exposure concentration. There were no changes of toxicologic significance in hematology, clinical chemistry, urinalysis, or organ weights. Males exposed to 500 or 1000 ppm gained less weight than the controls during the first year and maintained the difference during the second year. Females exposed to 200, 500, or 1000 ppm gained less weight during the first year; those exposed to 500 or 1000 ppm continued to gain less during months 13–18. Styrene-related non-neoplastic histopathologic changes were confined to the olfactory epithelium of the nasal mucosa. There was no evidence that styrene exposure caused treatment-related increases of any tumor type in males or females or in the number of tumor-bearing rats in the exposed groups compared to controls. In females, there were treatment-related decreases in pituitary adenomas and mammary adenocarcinomas. Based on an overall evaluation of eight onco-genicity studies, there is clear evidence that styrene does not induce Cancer in rats.

The purpose of this qualitative study was to gain an understanding of the personal experiences of 10 rural women dealing with fibromyalgia based on the theoretical frameworks of adaptation to chronic illness and social support. The data were gathered from a nursing intervention that provided computer-based peer support and encouragement. The women described themes of pain, fatigue, depression, and sleep disturbances; expressed views on the experience of rural isolation; and shared positive philosophies of dealing with this disease. With this understanding, professionals and significant others can compassionately respond to the needs of sufferers of fibromyalgia.

Butler, Paris D. MD, MPH; Britt, L. D. MD, MPH, FACS; Green, Michael L. Jr MD, FACS; Longaker, Michael T. MD, MBA, FACS; Geis, Peter W. MD, FACS; Franklin, Morris E. Jr MD, FACS; Ruhalter, Aaron MD, FACS; Fullum, Terrence M. MD, FACS Author Information

While an emerging body of evidence suggests that medical homes may yield more benefits than traditional care models do, the role of social workers within medical homes has yet to be evaluated separately. We assessed the impact of an initiative to add social workers to rural primary care teams in the Veterans Health Administration on patients' use of social work services, hospital admissions, and emergency department visits. We found that introducing a social worker increased social work encounters by 33 percent among all veterans who received care. Among high-risk patients, we observed a 4.4 percent decrease in the number of veterans who had any acute hospital admission and a 3.0 percent decrease in veterans who had any emergency department visit, after the introduction of a social worker. Investing in social workers is a key strategy for addressing the social determinants of health and managing care coordination for high-risk, high-need populations.

OBJECTIVE: To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG). METHODS: We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP. RESULTS: 316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids. CONCLUSIONS: Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

OBJECTIVE: Patients with chronic pain have been shown to be more frequent utilizers of primary care, a contributor to increased health care costs. This study aimed to clarify which patient factors predict primary care utilization among veterans with chronic pain. DESIGN: Data were gathered from the electronic medical records of veterans who used Veterans Affairs primary care services from 2003 to 2009 in upstate New York. Chronic pain cases (N = 792) were those veterans diagnosed with a musculoskeletal condition of the hip, knee, or lower back during two or more primary care encounters over a period ≥ 3 months. Cases were frequency matched by age to controls, or those veterans who did not have a chronic musculoskeletal condition of the hip, knee, or lower back. Demographic information, medical and psychiatric diagnoses, medication use, and other health-related factors were used in regression models to predict primary care utilization. RESULTS: Cases consistently accrued more primary care encounters than controls during each year of the observation period. Cases also accrued more encounters from specialty medicine clinics, chronic pain clinics, and behavioral health clinics co-located in primary care. The contribution of mental health factors to care utilization differed by case-control status. Diagnosis of depression and substance use disorders were predictors of care utilization only among controls, whereas anxiety disorders, use of anxiolytics, and adjustment disorders were predictors only among cases. Cases with a co-occurring anxiety disorder had a greater than twofold increased risk (odds ratio = 2.36, 95% confidence interval = 1.32-4.22) of being in the top 10% of the distribution of total primary care utilization. CONCLUSIONS: Mental health conditions that commonly co-occur with chronic musculoskeletal pain contribute to greater health care utilization. Improved screening and early intervention for these disorders in primary care may improve patient outcomes and stem high rates of care utilization of veterans.

BACKGROUND: Taping is a common treatment modality used by many rehabilitation providers. Several types of tapes and taping methods are used in the treatment of musculoskeletal dysfunction and pain. PURPOSE: To summarize and map the evidence related to taping methods used for various joints and conditions of the musculoskeletal system, and to provide clinicians and researchers with a user-friendly reference with organized evidence tables. DATA SOURCES: The PEDro, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register for Controlled Trials, PubMed, and PROSPERO databases were searched from inception through October 31, 2019. STUDY SELECTION: Eligible studies were selected by two independent reviewers and included either systematic reviews (SRs) or randomized controlled trials (RCTs) and included a musculoskeletal complaint using a clinical outcome measure. DATA EXTRACTION: Data was extracted by two investigators independently. Risk of bias and quality were assessed using A MeaSurement Tool to Assess systematic Reviews (AMSTAR) for SRs or the Physiotherapy Evidence Database (PEDro) scale for RCTs. The protocol was registered with PROSPERO (CRD42019122857). DATA SYNTHESIS: Twenty-five musculoskeletal conditions were summarized from forty-one SRs and 127 RCTs. There were 6 SRs and 49 RCTs for spinal conditions. Kinesio tape was the most common type of tape considered. Four evidence tables representing the synthesized SRs and RCTs were produced and organized by body region per condition. LIMITATIONS: Inclusion of only English language studies. Also, the heterogeneous nature of the included studies prevented a meta-analysis. CONCLUSIONS: There is mixed quality evidence of effectiveness for the different types of taping methods for different body regions and conditions. All of the SRs and RCTs found during our search of the taping literature have been organized into a series of appendices. A synthesis of the results have been placed in evidence tables that may serve as a useful guide to clinicians and researchers.

(1963). The Effect of Visual Imagery upon Spelling Performance. The Journal of Educational Research: Vol. 56, No. 7, pp. 370-372.

Two hybridoma-derived monoclonal antibodies have been developed that react with an antigen of molecular weight 92,000 daltons on the surface of human endothelial cells. Cultured human umbilical vein endothelial cells were used for immunization, but the antigen is present on arterial, venous and capillary endothelium, as determined by biotin-avidin immunoperoxidase staining of tissue sections. With this technique, other cell types in the tissues which were examined were not reactive, except for scattered fibroblasts and histiomonocytic cells, trophoblastic cells of the placenta, and benign immature mesenchymal cells in a renal cystadenocarcinoma. By cytofluorography, the antibodies were found to be unreactive with granulocytes, T lymphocytes, B lymphocytes, and the majority of monocytes. Fibroblasts were reactive with the antibodies, but the fluorescence tracings indicated a lower density of antigen on these cells than on endothelial cells. Immunoreactivity of fibroblasts could be decreased by treatment of the cells with thrombin, trypsin, or neuraminidase, whereas these enzymes did not affect the immunoreactivity of endothelial cells. The reactive antigen (E92) does not appear to be any of several previously described endothelial cell proteins, because of its molecular weight and its absence on other cell types. The presence of E92 on trophoblastic cells of the placenta and immature mesenchymal cells, as well as fibroblasts and endothelial cells, may indicate that it is a primitive antigen of mesodermal tissue that is lost by most cell types during differentiation.

We studied the effects of the death of a child by suicide ( N = 34) versus non-suicide ( N = 46) on family dynamics of forty-one parents and thirty-nine surviving siblings. Participants were solicited through bereavement groups, flyers, and newspaper advertisements. Participants completed a demographic questionnaire, the Bloom Family Interaction Scale, and a Closeness/Distance questionnaire about four years post death. Results included: 1) disengaged or conflicted families experienced greater distance while cohesive or expressive families reported more closeness; 2) sibling survivors felt closer to their fathers after the death than before and reported more family conflict than did parents; 3) there were no differences between suicide survivors and non-suicide survivors in perceived closeness between family pairs before or after the death.

ABSTRACT A preliminary report on the effect of the time element on the apparent strength of glass is given. Tests have been run on bottle glass from three seconds to 30 minutes duration and on polished plate and drawn window glass (in the form of laths) from five seconds to several hours.

BACKGROUND: Among women aged 50 to 59 years at baseline in the Women's Health Initiative (WHI) Estrogen-Alone (E-Alone) trial, randomization to conjugated equine estrogen-alone versus placebo was associated with lower risk of myocardial infarction and mortality, and, in an ancillary study, the WHI-CACS (WHI Coronary Artery Calcification Study) with lower CAC, measured by cardiac computed tomography ≈8.7 years after baseline randomization. We hypothesized that higher CAC would be related to post-trial coronary heart disease (CHD), cardiovascular disease (CVD), and total mortality, independent of baseline randomization or risk factors. METHODS AND RESULTS: WHI-CACS participants (n=1020) were followed ≈8 years from computed tomography scan in 2005 (mean age=64.4) through 2013 for incident CHD (myocardial infarction and fatal CHD, n=17), CVD (n=69), and total mortality (n=55). Incident CHD and CVD analyses excluded women with CVD before scan (n=89). Women with CAC=0 (n=54%) had very low age-adjusted rates/1000 person-years of CHD (0.91), CVD (5.56), and mortality (3.45). In comparison, rates were ≈2-fold higher for women with any CAC (>0). Associations were not modified by baseline randomization to conjugated equine estrogen-alone versus placebo. Adjusted for baseline randomization and risk factors, the hazard ratio (95% confidence interval) for CAC >100 (19%) was 4.06 (2.11, 7.80) for CVD and 2.70 (1.26, 5.79) for mortality. CONCLUSIONS: Among a subset of postmenopausal women aged 50 to 59 years at baseline in the WHI E-Alone Trial, CAC at mean age of 64 years was strongly related to incident CHD, CVD, and to total mortality over ≈8 years, independent of baseline randomization to conjugated equine estrogen-alone versus placebo or CVD risk factors. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000611.

BACKGROUND: Patients with advanced cancer often require complex symptom management. At Dana-Farber/Brigham and Women's Cancer Center, the intensive palliative care unit (IPCU) admits symptomatic oncology patients with uncontrolled symptoms throughout the trajectory of illness. Patients are uniquely managed by an interdisciplinary team of clinicians who focus on symptom management and advance care planning. OBJECTIVE: The purpose of our analysis was to investigate goals-of-care outcomes and healthcare utilization after admission to the IPCU. DESIGN: We retrospectively reviewed 74 oncology patients admitted to the IPCU in August and September, 2013. RESULTS: A total of 67 IPCU patients who were admitted received palliative intent treatment, whereas 7 patients received curative intent care. All patients were engaged in a goals-of-care discussion during admission. Of the palliative intent patients, 58% were transferred to the IPCU from medical oncology and 42% were directly admitted. Forty-eight percent of the patients were diagnosed with metastatic lung, genitourinary, or gastrointestinal cancer. Eighty-seven percent of patients reported pain as the chief complaint at admission. Twenty-five patients experienced a change in code status from Full Code to do-not-resuscitate/do-not-incubate. A total of eight patients died in the IPCU, and 50% experienced a code status change. Eighty-eight percent of patients were discharged alive. Of those, 49% were discharged to home hospice, general inpatient hospice, or an inpatient hospice facility. The risk of 30-day readmission was 4%. CONCLUSIONS: Among advanced cancer patients, our findings suggest that an inpatient palliative care unit helps clarify goals of care, aids in appropriate hospice referrals, and decreases hospital readmissions.

OBJECTIVE: Although depression screening in primary care is recommended by the U.S. Preventive Services Task Force, it may increase the duration of primary care physician visits that are often at or exceeding capacity. This study was conducted to evaluate the relationship between depression screening and physician visit duration in community-based, primary care physician office visits while controlling for important covariates. METHODS: Cross-sectional data from the 2005-2007 National Ambulatory Medical Care Survey were used to examine the relationship between physician-indicated depression screening and office visit duration among adults (≥18 years of age) with multivariable, ordered logistic regression. Predicted probabilities of visit duration (by 15-minute increments of one to 15, 16-30, 31-45, and 46-60 minutes) were estimated for visits where depression screening was and was not documented. RESULTS: In a sample of 14,736 physician office visits, representing an estimated population of more than 641 million visits, depression screening was significantly associated with increased visit duration (adjusted odds ratio=3.66, 95% confidence interval=2.25-5.95). A prominent shift in the proportion of visits that were from one to 15 minutes long to visits that were at least 16-30 minutes long was observed when depression screening was documented. CONCLUSIONS: Depression screening may increase the duration of physician visits. Given demands on physicians' time, the impact of increased depression screening, including the costs and benefits of using alternative methods and technologies to reduce physician time burden associated with depression screening, should be evaluated.

This collaborative statement from the Digital Health Committee of the Heart Rhythm Society provides everyday clinical scenarios in which wearables may be utilized by patients for cardiovascular health and arrhythmia management. We describe herein the spectrum of wearables that are commercially available for patients, and their benefits, shortcomings and areas for technological improvement. Although wearables for rhythm diagnosis and management have not been examined in large randomized clinical trials, undoubtedly the usage of wearables has quickly escalated in clinical practice. This document is the first of a planned series in which we will update information on wearables as they are revised and released to consumers.

Each year 35,000 cardiac ablation procedures are performed to treat atrial fibrillation through the use of catheter systems. The success rate of this treatment is highly dependent on the force which the catheter applies on the heart wall. If the magnitude of the applied force is much higher than a certain threshold the tissue perforates, whereas if the force is lower than this threshold the lesion size may be too large and is inconsistent. Furthermore, studies have shown large variability in the applied force from trained physicians during treatment, suggesting that physicians are unable to manually regulate the levels of the force at the site of treatment. Current catheter systems do not provide the physicians with active means for contact force control and are only at most aided by visual feedback of the forces measured in situ. This paper discusses a novel design of a robotic end-effector that integrates mechanisms of sensing and actively controlling of the applied forces into a miniaturized compact form. The required specifications for design and integration were derived from the current application under investigation. An off-the-shelf miniature piezoelectric motor was chosen for actuation, and a force sensing solution was developed to meet the specifications. Experimental characterization of the actuator and the force sensor within the integrated setup show compliance with the specifications and pave the way for future experimentation where closed-loop control of the system can be implemented according to the contact force control strategies for the application.

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.

Cannabis products that contain the tetrahydrocannabinol (THC) cannabinoid are emerging as promising therapeutic agents for the treatment of medical conditions such as chronic pain. THC elicits psychoactive effects through modulation of dopaminergic neurons, thereby altering levels of dopamine in the brain. This case report highlights the complexity associated with medicinal cannabis and the health risks associated with its use. A 57-year-old male with Parkinson’s disease was experiencing worsening tremors and vivid hallucinations despite therapy optimization attempts. It was discovered that the patient took cannabis for chronic back pain, and a pharmacogenomics (PGx) test indicated the presence of variants for the COMT and HTR2A genes. These variants could increase dopamine levels and predispose patients to visual hallucinations. Once the cannabis was discontinued, the patient’s hallucinations began to slowly dissipate. Cannabis use continues to expand as it gains more acceptance legally and medicinally, but cannabis can affect the response to drugs. This patient case suggests that cannabis use in combination with dopamine-promoting drugs, especially in a patient with genetic variants, can increase the risk for vivid hallucinations. These conditions support the importance of considering herb–drug interactions and PGx data when performing a medication safety review.

Introduction Precision medicine customizes prevention, diagnosis, and treatment based on individual characteristics. Despite advancements, significant challenges remain in the widespread implementation of precision medicine across low- to middle-income countries (LMICs) such as Colombia. This review aims to identify and propose possible solutions to help close this gap.Areas covered Implementing precision medicine in LMICs requires addressing key barriers such as limited technology, inadequate healthcare training, ethical considerations, insufficient insurance coverage, public attitudes, high costs, and lack of political support.Expert opinion Precision medicine has the potential to revolutionize patient care and healthcare practices. By addressing these challenges and prioritizing strategic development areas, LMICs can fully embrace it, leading to significant improvements in healthcare outcomes for their diverse populations.

INTRODUCTION: Amiodarone reduces recurrent ventricular tachyarrhythmias (VTA) but may worsen cardiovascular outcomes in heart failure (HF) patients. Cardiac resynchronization therapy (CRT) may also be antiarrhythmic. When patients with prior sustained VTA are upgraded to CRT defibrillators (CRT-D) from conventional implantable cardioverter-defibrillators (ICDs), should concomitant amiodarone be continued or is CRT's antiarrhythmic potential sufficient? METHODS AND RESULTS: We identified 67 patients from a prospective CRT registry with spontaneous sustained VTA, New York Heart Association (NYHA) II-IV HF, and left bundle-branch block (LBBB) who were upgraded to CRT defibrillators from conventional ICDs. We compared changes in QRS duration and left ventricular ejection fraction (LVEF) pre- and post-CRT, time to death, transplant or ventricular assist device (VAD), and time to recurrent VTA therapies between 37 patients continuing amiodarone therapy and 30 amiodarone-naïve patients. Amiodarone-treated patients had worse renal function and a higher prevalence of prior VTA storm compared with amiodarone-naïve patients. After CRT, amiodarone-treated patients demonstrated less QRS narrowing (8 vs 20 ms; P = 0.021) and less LVEF improvement (-2.7 vs +5.2%; P = 0.006). Over 29 months, 31 (47%) patients died and 13 (20%) received transplant or VAD. Risk of death, transplant, or VAD was greater in amiodarone-treated than -naïve patients (corrected hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.12-4.11; P = 0.022). Appropriate CRT-D therapies occurred in 37 (55%) patients; amiodarone use was not associated time to first therapy (HR, 1.13; 95% CI, 0.59-2.16; P = 0.72). CONCLUSION: In patients with sustained VTA and LBBB upgraded from conventional ICDs to CRT defibrillators, concomitant amiodarone use is associated with less QRS narrowing, less LVEF improvement, greater risk of death, transplant, or VAD, and similar risk of recurrent VTA.