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Objective: Veterans are at high risk for eating disorders (EDs), and specifically for atypical anorexia nervosa (atypical AN). The current study aimed to better understand this under-studied disorder and how it differs from weight loss without ED cognitive features., Method: Secondary analyses were conducted with data from a national study of Veterans (N = 882, 49.4% women). Participants were categorized into four mutually exclusive groups using the Eating Disorder Diagnostic Scale 5: probable atypical AN, a cognitive concerns group (Cog Only), a weight suppressed group (WS Only), and a no ED control group. Adjusted regression models were used to compare groups on measures of eating pathology and mental health. Three weight suppression thresholds (5%, 10%, and 15%) for probable atypical AN were also tested., Results: The sample was comprised of 12% probable atypical AN, 23.6% Cog Only, 16.3% WS Only, and 48.1% Control. The probable atypical AN group was most like the Cog Only group except for higher levels of dietary restraint. Atypical AN fared worse and was least like the Control group followed by the WS Only group. All weight suppression thresholds significantly predicted dietary restraint, with 5% being the best predictor., Discussion: Results found that probable atypical AN is a distinct clinical entity and that the exact weight suppression threshold associated with atypical AN is less important than having any weight suppression. Findings highlight the clinical significance of atypical AN and the importance of gaining a better understanding of how to address this clinical entity., Public Significance: Atypical anorexia nervosa is a relatively underexamined but highly prevalent eating disorder in the Veteran population. Results show that ED cognitive features are more closely linked to clinically significant eating pathology and poor mental health than weight suppression alone suggesting that negative thinking about weight gain and appearance, regardless of the presence or severity of weight loss, may signal the need for specialized intervention., (© 2023 Academy for Eating Disorders. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Background: Emergent large vessel occlusive (ELVO) stroke secondary to underlying carotid occlusive disease is frequently encountered in endovascular ischemic stroke therapy and trials. Up to 29% of all cerebral vascular accidents are attributed to severe carotid occlusive disease, and recent interventional trials have demonstrated this occurrence in 18.6-32.2% of ELVO stroke. We present a novel technique using the stent retriever guide wire to expedite angioplasty and/or stent placement for associated carotid occlusive disease during mechanical thrombectomy of ELVO stroke. This technique utilizes the "waiting time" during stent retriever integration within the thrombus as an opportunity to initiate revascularization of the cervical carotid, using the deployed stent retriever guidewire as an ad hoc rapid exchange wire while the stentriever serves as a potential surrogate distal embolic protection device. We present 23 cases using this novel endovascular approach, which we have called the single-cross technique , as the cervical lesion is only traversed once during therapy., Methods: A case series of 23 consecutive patients who underwent a novel endovascular technique for treating tandem ICA origin and intracranial occlusive lesions is presented. Endpoints measured were time to re-perfusion, rates of intracranial hemorrhage and clinical outcomes (mRS at 30 and 90 days)., Results: Average procedure time for revascularizing both the carotid and intracranial lesions was 52 min. A symptomatic ICH rate of 9% was observed. Seventy-four percent of patients had an mRS of 0-2 at follow-up., Conclusions: The single-cross technique appears to be a safe and effective option for treating tandem occlusive lesions in the setting of ELVO.

The mycobacterial outer membrane, or mycomembrane, is essential for the viability and virulence of Mycobacterium tuberculosis and related pathogens. The mycomembrane is a dynamic structure, whose chemical composition and biophysical properties can change during stress to give an advantage to the bacterium. However, the mechanisms that govern mycomembrane remodeling and their significance to mycobacterial pathogenesis are still not well characterized. Recent studies have shown that trehalose dimycolate (TDM), a major glycolipid of the mycomembrane, is broken down by the mycobacteria-specific enzyme TDM hydrolase (Tdmh) in response to nutrient deprivation, a process which appears to modulate the mycomembrane to increase nutrient acquisition, but at the expense of stress tolerance. Tdmh activity thus balances the growth of M. tuberculosis during infection in a manner that is contingent upon host immunity. Current methods to probe Tdmh activity are limited, impeding the development of inhibitors and the investigation of the role of Tdmh in bacterial growth and persistence. Here, we describe the synthesis and evaluation of FRET-TDM, which is a fluorescence-quenched analogue of TDM that is designed to fluoresce upon hydrolysis by Tdmh and potentially other trehalose ester-degrading hydrolases involved in mycomembrane remodeling. We found that FRET-TDM was efficiently activated in vitro by recombinant Tdmh, generating a 100-fold increase in fluorescence. FRET-TDM was also efficiently activated in the presence of whole cells of Mycobacterium smegmatis and M. tuberculosis , but the observed signal was predominantly Tdmh-independent, suggesting that physiological levels of Tdmh are low and that other mycobacterial enzymes also hydrolyze the probe. The latter notion was confirmed by employing a native protein gel-based fluorescence assay to profile FRET-TDM-activating enzymes from M. smegmatis lysates. On the other hand, FRET-TDM was capable of detecting the activity of Tdmh in cells when it was overexpressed. Together, our data demonstrate that FRET-TDM is a convenient and sensitive in vitro probe of Tdmh activity, which will be beneficial for Tdmh enzymatic characterization and inhibitor screening. In more complex samples, for example, live cells or cell lysates, FRET-TDM can serve as a tool to probe Tdmh activity at elevated enzyme levels, and it may facilitate the identification and characterization of related hydrolases that are involved in mycomembrane remodeling. Our study also provides insights as to how the structure of FRET-TDM or related fluorogenic probes can be optimized to achieve improved specificity and sensitivity for detecting mycobacteria., Competing Interests: The authors declare no competing financial interest.

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: The goal of this study was to investigate carotid plaque characteristics in symptomatic versus asymptomatic patients with the use of nonocclusive optical coherence tomography (OCT)., Background: The identification of asymptomatic patients with carotid disease who are at risk of stroke remains a challenge. There is an increasing awareness that plaque characteristics may best risk-stratify this population. We hypothesized that OCT, a new high-resolution (∼ 10 μm) imaging modality, might be useful for the identification of low-risk versus high-risk carotid plaque features and help us to understand the relationship between carotid diameter stenosis and plaque morphology to ischemic stroke., Methods: Fifty-three patients undergoing diagnostic carotid angiography were studied with OCT. Data analysis was carried out by imaging experts who were unaware of the clinical characteristics of the study population., Results: Plaque with American Heart Association type VI complicated features was more common in symptomatic than asymptomatic patients (74.1% vs. 36.4%, p = 0.02). This was largely driven by differences in the incidence of thin-cap fibroatheroma with rupture (40.7% vs. 13.6%, p = 0.056) and thrombus (67.7% vs. 36.4%, p = 0.034). Conversely, non-type VI plaques were more common in asymptomatic than symptomatic patients (63.6% vs. 25.9%, p = 0.02). No association between the degree of stenosis and plaque morphology was identified., Conclusions: This retrospective analysis of carotid OCT data supports the hypothesis that the evaluation of carotid plaque characteristics with this high-resolution imaging technique has the potential to alter the understanding and treatment of carotid artery disease., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

A 67-year-old man with medically refractory vertebrobasilar insufficiency and short segment occlusions of the intracranial vertebral arteries was treated with angioplasty and stent placement. Fifteen hours after the procedure the patient developed symptoms of posterior fossa ischemia and repeat angiography showed thrombus formation within the stent which was treated with thrombolytic and aggressive antiplatelet therapy. Angiography revealed lysis of the clot, but concerns regarding the mechanism of the thrombotic phenomenon prompted frequency-domain optical coherence tomography (FDOCT) assessment. FDOCT provided excellent visualization of the stent and vessel wall interactions, as well as excluding residual flow-limiting stenosis, obviating the need for further intervention. The potential utility of FDOCT in the evaluation of intracranial atherosclerotic disease and additional intracranial applications are discussed., (2014 BMJ Publishing Group Ltd.)

FD-OCT is a new imaging technique that allows unprecedented in vivo microlevel assessment of human carotid plaque morphologic patterns and stent-vessel interactions. Prior reports describing the use of this technique have used balloon occlusion of the target vessel or iodinated contrast media to facilitate imaging. We report, for the first time, in vivo FD-OCT imaging of human carotid arteries without the use of iodinated contrast material or balloon occlusion techniques.

Aneurysmal subarachnoid hemorrhage (SAH) accounts for a significant percentage of morbidity and mortality among patients admitted to neurosurgical centers throughout the world. Even for individuals surviving beyond the initial presentation and intervention for aneurysmal SAH, the occurrence of cerebral vasospasm has the potential to induce a second tier of complications that can be just as devastating as the inciting event. However, despite numerous studies and some initial advancements in management, therapeutic modalities are limited to help prevent or treat this complex entity. Historically, the mainstay of treatment for cerebral vasospasm has been a combination of hypervolemia, hemodilution, and hypertension. In addition, other systemic therapies such as oral nimodipine, statins, and intravenous magnesium, as well as intensive glucose control, appear to have some promise, although they are limited at times by adverse effects. To avoid these adverse consequences and perhaps gain some modicum of efficacy, attempts have been made to use endovascular techniques to physically dilate vessels or to administer drugs directly to the site of action and thus avoid many of the untoward effects of systemic pharmacotherapy. Controversy still remains over the success of intraarterial therapy, the drugs or techniques to be used, and the best timing of this therapy. Based on the currently available literature, it is impossible to assess the most effective intraarterial therapy. Randomized controlled trials that can control for baseline factors and technical expertise are needed to provide more conclusive data. Clinical pharmacists should be actively involved in assisting interventional radiologists and neurosurgeons in providing safe and appropriate pharmacotherapy in this promising but controversial arena of intraarterial drug delivery.

Among cavernomas of the central nervous system, spinal ones are rare. The true incidence of spinal cavernomas is unclear, but with widespread use of magnetic resonance imaging the number of cases is increasing. Furthermore, cavernomas represent only 5-12% of all vascular anomalies of the spinal cord, with a mere 3% reported to be intradural and intramedullary in location. Cervical spine intradural extramedullary cavernomas are very seldom seen, and only 4 cases have been reported in world literature previously. In this report, a unique case of an intradural extramedullary spinal cavernoma was surgically treated in a patient who presented only with an intramedullary hemorrhage.

Ophthalmological problems such as papilledema, loss of visual acuity, and oculomotor palsies are common in patients with shunt malfunctions. The authors report on three patients with shunts who presented with visual loss. In each case, the diagnosis of shunt malfunction was delayed because other classic signs and symptoms of intracranial hypertension were absent. All three patients underwent optic nerve sheath fenestration (ONSF) with resultant stabilization or improvement of visual symptoms before the shunt malfunction was recognized and treated. Consideration of these cases suggests a potential protective role of ONSF for patients with shunt malfunction.

The emergence of multidrug-resistant bacteria as the cause of ventriculoperitoneal shunt infections is a disconcerting phenomenon that often requires the use of alternative antimicrobials due to resistance against commonly used agents. The following is a case report describing the successful treatment of a ventriculoperitoneal shunt infection caused by a heteroresistant strain of Staphylococcus aureus with linezolid. Linezolid may have utility in treating pediatric CNS infections due to its tolerability, excellent blood-brain barrier penetration, and activity against multiple resistant Gram-positive organisms such as S. aureus, vancomycin-resistant Enterococcus faecium and Streptococcus pneumoniae., (Copyright (c) 2005 S. Karger AG, Basel.)

Background: The increasing presence of family medicine as a required clinical experience during medical school has created a need to provide quality experiences for a large number of students. Use of community private practices is one way to address this need. An important issue with this approach is standardization of clinical content among diverse teaching sites. This paper investigates whether students on required one-month family medicine clerkships occurring at university and private practice sites obtain comparable experiences., Methods: The experiences of 185 third-year medical students were compared in the following areas: patient volume, patient mix, and performance on end-of-clerkship oral and written examinations., Results: Of the 20 core problems seen most frequently by students, four were seen by significantly different numbers of university and private practice students overall; only two remained significantly different when analysis was restricted to the second half of the reporting period. Differences between the number of university and private practice students seeing the minimum targeted number of patients per session were nonsignificant (P = .895), as were differences between the two groups' oral and written examination scores (P = .507 and P = .595, respectively)., Conclusions: We found that clinical content of a required third-year clerkship could be successfully standardized, as measured by patient volume, mix, and student performance on examinations.

Change in the health care system is stimulating the interest of physicians policymakers, and third-party payers in practice management activities. New analytic techniques and management concepts enable interested parties to obtain more and better information about the overall results of practice. These new techniques and concepts offer physicians an opportunity to exert more influence on the direction and productivity of practice than in the past. This report reviews the development of three emerging fields and projects their impact on practice management. Outcomes management technology involves adjusting for the differences in patient biology between practices and describes outcomes of patient interventions in standard ways. Medical informatics involves the conversion of data into information that allows the physician manager to direct outcomes, quality, and costs. Quality management involves empowering employees and physicians to participate in improving the overall performance of the practice. The use of techniques for analysis and intervention is changing the definition of practice management beyond its conventional preoccupation with billing and accounts receivable. In fact, a new science of practice management is emerging that describes the interactions between the health care organization and the outcomes of services to patients. These tools empower physicians to direct the performance of the practice, to match services to patient needs, and to manage the costs of practice operations. Thus, the new methods and technologies of practice management have the potential to bring substantial benefits to patients, office staff, and physicians.

A prospective cohort study was designed to examine the independent effects of maternal smoking on infant birth weight adjusted for length of gestation. Obstetrical patients were enrolled from four university based family practice clinics; 772 mother-infant pairs were included in the final analyses. A multiple regression analysis found 53% of the variance in infant birth weight to be explained by length of gestation, race, pre-pregnancy weight, weight gain, gender of the infant, highest systolic blood pressure, and smoking. After adjusting for the effects of other independent variables, women who were self-reported smokers delivered infants who weighed 141.8 g less, on the average, than infants of nonsmoking mothers. Women who smoked fewer than 10, 10-19, or 20+ cigarettes per day delivered infants weighing 96 g, 183 g, and 200 g less, respectively, than infants born to nonsmokers, a clear dose-response effect among relatively low-risk obstetrical patients in a primary care setting. Multiple regression analysis within each smoking group found the effect of length of gestation upon infant birth weight to be markedly reduced among the heavy smokers; this indicates a strong association between heavy (one pack a day) smoking and infant birth weight adjusted for length of gestation.

A prospective cohort study was undertaken to evaluate the relationship of family functioning to infant birthweight adjusted for length of gestation. The mother's perception of family functioning was assessed at the initial prenatal visit using the Family Adaptability and Cohesion Evaluation Scales (FACES II). All obstetric patients at four family medicine clinics from April 1984 through April 1987 whose initial prenatal visits occurred by the 28th week of gestation were invited to participate; 95% chose to do so. Information was obtained on 833 mother-infant pairs. Listwise deletion on any one variable reduced the sample to 772 with no apparent bias in the dependent or predetermined variables. Twelve percent of the families were considered to be dysfunctional by scoring on the extremes of both the cohesion and adaptability continua of the self-report FACES II questionnaire. Infant birthweight was regressed on length of gestation and other known biomedical, anthropometric, risk-behavior, and sociodemographic determinants, as well as family functioning. Women who perceived their families as dysfunctional were delivered of infants who weighed on the average 126.4 g (95% CI 37.4, 215.4) less than infants born to women from functional families (P = .0055), after adjusting for other known determinants. Family functioning also was found to modify the effects of prepregnancy weight and infant sex on infant birthweight.

The number of faculty needed to teach in family practice residency programs has increased as student demand for training in the specialty has grown. Residency programs have recruited practicing family physicians or recent graduates of residency programs as physician faculty members. The multiple demands of faculty positions and difficult periods of orientation to effective faculty functioning have been significant obstacles to recruitment and retention of faculty. A statewide Family Practice Faculty Development Center has been formed and has received support from Texas medical school family practice departments and free-standing residency programs. The Faculty Development Center utilizes a multidisciplinary staff to offer a range of programs including fellowships, preceptorships, institutes, and workshops, and conducts research projects in the area of teaching family medicine in order to aid faculty in current and new residency programs in acquiring excellent teaching, research, and administrative skills.

In a randomized, double-blind placebo-controlled clinical trial, we evaluated the prophylactic effectiveness of rimantadine in children (ages 1 to 18 years) against infection with influenza A (H3N2) and associated illness and the prevention of transmission of infection to adult members of the child's family. One hundred ten volunteers from 29 families completed this study during a naturally occurring outbreak of influenza A (H3N2). Influenza infections, defined as a positive viral throat culture or a 4-fold increase in antibody titer, occurred in 31.0% of children in the placebo group and 7.4% in the rimantadine group (P = 0.026). Clinical illness with laboratory evidence of influenza infection occurred in 24.1% of children in the placebo group and none in the rimantadine group (P = 0.007). Rimantadine was well-tolerated by the children, with no significant difference in reported adverse effects between the placebo and rimantadine groups. A combined analysis by families of these data and those of our similarly designed 1984 study, revealed that families in whom the children were given rimantadine had a significantly lower rate of influenza A infection and influenza-like illness compared with the families in whom the children were given placebo (68.8% vs. 18.8%, P less than 0.001) and (56.3% vs. 12.5%, P less than 0.001), respectively. We conclude that rimantadine prophylaxis of children appears to be an effective method to prevent influenza A (either H1N1 or H3N2) infection and illness in children.

A prospective study was undertaken to evaluate the relationship of family functioning, family structure, and life events with pregnancy outcome. Family functioning was assessed utilizing the Family Adaptability and Cohesion Evaluation Scales (FACES) and the Family APGAR. One hundred twenty-five infants were delivered with a mean birth weight of 3,283 g and a mean gestational age of 281.2 days. Listwise deletion of missing data reduced the study sample to 102 mother-infant pairs with no bias in the dependent or predetermined variables in the subsample. Birth weight was regressed on medical, anthropometric, risk-behavior, sociodemographic, and life-events variables, which together explained 42 percent of the variance. Family functioning was found to contribute an additional 7 percent of the variance (adjusted R2 = 0.49). Family structure accounted for 4.5 percent of the variance in birth weight, and life events added 5 percent. As a complementary analysis, infant birth weight was regressed on the medical, anthropometric, sociodemographic, risk-behavior, and life-events variables, and the residuals from this equation were then regressed on the measures of family functioning. Again, abnormal family functioning proved to be a powerful and significant contributor to the explained variance.

The development and implementation of a weekend workshop format for faculty development in family medicine, which has met with some success in the state of Texas, is described. The topic selected for the workshop was one-on-one clinical teaching skills because of its applicability to all levels of involvement of family practice faculty. The weekend format was selected because of its cost efficiency and mobility, which allowed the center to take training to the physicians, and because of its previously demonstrated effectiveness as a format for faculty development in family medicine. A model for clinical teaching was developed to aid workshop participants' easy acquisition of the clinical teaching process through the use of positive transfer of learning from the medical problem solving process, a process well internalized by physicians through medical practice and training.

With recent studies suggesting that children are the main introducers of influenza infections into families, we conducted a placebo-controlled, double-blind, randomized trial to study the prophylactic effectiveness of rimantadine hydrochloride in children on the transmission of influenza A infections within families. One hundred forty-five volunteers from 35 families completed this study during a naturally occurring outbreak of influenza A (H1N1) infection. Influenza infections, defined as a positive viral throat culture or a fourfold increase in antibody titer, occurred in 31.7% of children in the placebo group and 2.9% of children in the rimantadine group. Clinical illness with laboratory evidence of influenza infection occurred in 17.0% of children in the placebo group and 0% of children in the rimantadine group. Rimantadine was well tolerated by the children, with no significant difference in reported side effects between the placebo and rimantadine groups. Influenza A infection occurred in 19.0% of adults whose children were receiving a placebo and 8.8% of adults whose children were receiving rimantadine. On the basis of our study, rimantadine prophylaxis of children appears to be an effective method to prevent influenza A infection in children. Additional studies are needed to demonstrate the effects of rimantadine prophylaxis of children on the incidence of influenza A infection in their parents.

A prospective cohort study was designed to study the effects of family functioning and stress on the incidence of influenza infection. Families from the clinic roster, containing two adults and at least one child between the ages of 1 and 18 years, were asked to participate. Baseline (pre-influenza) data included a serum determination for influenza A and B antibodies, family functioning as measured by the Family Adaptability and Cohesion Evaluation Scales (FACES) II and the Family APGAR, and parental stress as measured by the social readjustment rating scale (SRRS). During the study all family members of patients with upper respiratory tract infection symptoms or fever were seen, and throat swabs were obtained for viral culture. Approximately 2 weeks after the influenza epidemic ended (March 1984), sera for antibodies were again collected on all family members. Chi-square analysis showed that infection (defined as a fourfold titer rise or a positive viral throat culture) was significantly associated with both cohesion and adaptability as measured by FACES II. Neither the Family APGAR nor the SRRS was associated with influenza B infection. It was concluded that family functioning affects the frequency of influenza B infection within families. This finding raises the possibility that family dysfunction may lead to altered immune responses, which increases susceptibility to infection.