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OBJECTIVE External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI). METHODS The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018. RESULTS A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003). CONCLUSIONS The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Background Although ablative techniques are the standard of care for the treatment of fine lines and wrinkles, microneedling offers a minimally invasive alternative. Objectives The purpose of this study was to assess the efficacy of microneedling on facial and neck fine lines and wrinkles. Methods Thirty-five subjects between 44 and 65 years old with Fitzpatrick skin types I to IV received 4 monthly microneedling treatments over the face and neck. Subjects returned 1 and 3 months posttreatment. At every visit, high-resolution ultrasonography and optical coherence tomography were performed, and transepidermal water loss and skin elasticity were measured. Microbiopsies (0.33 mm) were collected pretreatment, before the fourth treatment and 3 months posttreatment. Results Thirty-two subjects (30 females, 2 males) completed all 7 visits. Facial dermal and epidermal density increased 101.86% and 19.28%, respectively, from baseline at 3 months posttreatment. Facial elasticity increased 28.2% from baseline at 3 months posttreatment. Facial attenuation coefficient increased 15.65% and 17.33% at 1 and 3 months posttreatment, respectively. At study completion, blood flow at a depth of 300 µm decreased 25.8% in the face and 42.3% in the neck. Relative collagen type III and elastin gene expression was statistically higher 3 months posttreatment. However, total elastin protein levels were unchanged from baseline values. Dermal muscle formation was observed in 58% of biopsies extracted 3 months posttreatment compared with 15.3% at baseline. Conclusions The results illustrate the effects of microneedling treatments. Noninvasive measurements and biopsy data showed changes in skin architecture and collagen/elastin gene expression, suggesting skin rejuvenation, with new extracellular matrix production and muscle formation. Level of Evidence: 3

Background Despite the proven efficacy of liposuction, there is a population of patients who prefer non-surgical alternatives. Laser hyperthermia-induced lipolysis has emerged as one non-invasive alternative to liposuction. Objectives The authors sought to evaluate the safety and efficacy of a 1060-nm (±10 nm) diode laser for non-invasive fat reduction of the abdomen. Methods This single-arm, 2-center study enrolled 30 patients. Patients received a 25-minute 1060-nm diode laser treatment on their abdomen. Ultrasound adipose measurements, body weight, and circumference were taken at baseline and at 6- and 12-week follow-up visits. Blinded evaluators identified “before” and “after” photos of each patient. A patient satisfaction questionnaire was completed by each patient at study exit. Results A total 29 patients completed all treatment and follow-up visits. Ultrasound images showed an adipose reduction of 8.55% at 12 weeks post-treatment (P Conclusions These results indicate that a single treatment with a 1060-nm (±10 nm) diode laser, per the treatment protocol, is safe and effective in reducing unwanted fat in the abdomen as objectively measured employing ultrasound. The treatment was well-tolerated among all patients, with minimal discomfort reported and high patient satisfaction. Level of Evidence: 4

There is a pressing need for strategies to slow or treat the progression of functional decline in people living with HIV. This paper explores a novel rehabilitation robotics approach to measuring cognitive and motor impairment in adults living with HIV, including a subset with stroke. We conducted a cross-sectional study with 21 subjects exhibiting varying levels of cognitive and motor impairment. We developed three robot-based tasks trajectory tracking, N-back, and spatial span – to assess if metrics derived from these tasks were sensitive to differences in subjects with varying levels of executive function and upper limb motor impairments. We also examined if these metrics could estimate clinical cognitive and motor scores. The results showed that the average sequence length on the robot-based spatial span task was the most sensitive to differences between subjects’ cognitive and motor impairment levels. We observed strong correlations between robot-based measures and clinical cognitive and motor assessments relevant to the HIV population, such as the Color Trails 1 (rho = 0.83), Color Trails 2 (rho = 0.71), Digit Symbol – Coding (rho = 0.81), Montreal Cognitive Assessment – Executive Function subscore (rho = 0.70), and Box and Block Test (rho = 0.74). Importantly, our results highlight that gross motor impairment may be overlooked in the assessment of HIV-related disability. This study shows that rehabilitation robotics can be expanded to new populations beyond stroke, namely to people living with HIV and those with cognitive impairments.

Background Skin scarring can occur after punch biopsies, prohibiting their routine utilization, especially in the central face. Objectives This paper describes a scarless, 0.33-mm-diameter skin microbiopsy for molecular analysis of skin. Methods This is was single-center, randomized, prospective study with 15 patients receiving no biopsy or biopsy on the left or right nasolabial fold. Six blinded raters assessed participant photos at baseline, 1 month, and 3 months post biopsy to evaluate for a visualized scar. Patient and Observer Scar Assessment Scale was completed. Additionally, biopsies from various skin regions of body along with arm skin after treatment with a single Erbium-YAG laser were processed for molecular analysis. Results No patients exhibited scar formation based on evaluation of photographs and patient feedback. There was no mark at the biopsy site 7 days post-procedure. Optical coherence tomography showed a complete closing of the biopsy-punch wound 48 hours post-biopsy. One month post-biopsy, photography reviewers were unable to identify a scar, on average, 90% of the time at 3-month follow-up. Microbiopsies from various anatomical regions were successfully extracted for histology, electron microscopy, and gene expression analysis. Selected skin rejuvenation markers in the biopsies from Erbium-YAG–treated forearm skin resulted in significant gene upregulation in extracellular matrix molecules at 1 month posttreatment compared with untreated skin. Conclusions A core microbiopsy of 0.33 mm can be extracted reproducibly for histological, ultrastructural, and gene expression analysis without scarring. This allows repeated sampling for assessment of skin treatments and diseases, including aesthetics and wound-healing progress.

Background and objective Patient-reported outcomes and blinded observer rating scales are subjective and unreliable but are extensively utilized to evaluate cosmetic office-based treatments, including ablative lasers. This study aims to assess the practicality of using non-invasive and minimally invasive methods for objective skin assessment following a skin rejuvenation treatment. Study design/materials and methods Twelve patients received a single 1,470/2,940 nm laser treatment for facial rejuvenation. Assessments were performed before treatment, and 7 days, 3 weeks, and 3 months post-treatment. Images were taken with the VISIA Skin Analysis System to measure wrinkles, textures, pores, ultraviolet (UV) spots, brown spots, red areas, and porphyrins. Other non-invasive skin measurements-high-resolution ultrasonography, optical coherence tomography, transepidermal water loss and BTC 2000-were used to measure epidermal/dermal thickness, blood flow, surface roughness, wrinkle depth, attenuation coefficient, elasticity, laxity, and viscoelasticity. Microbiopsies (0.33 mm in diameter or the equivalent of a 23-gauge needle) were collected for histology and gene expression of tissue rejuvenation. Results Significant improvement in facial skin aesthetics after laser treatment was recorded in UV spots, brown spots and pores after 3 weeks and in UV spots and brown spots after 3 months. The dermal attenuation coefficient decreased significantly at 3 weeks, while blood flow 0.5 to 0.7 mm below the skin surface increased significantly between 5 days and 3 weeks following treatment. Epidermal hyaluronic acid expression assessed by immunostaining and expression of inflammatory genes were elevated at 7 days post-treatment compared with untreated or 3 months post-treatment. There were no statistically significant changes in collagen or elastin-related genes between groups at the studied parameters. Conclusion Non-invasive devices can be effectively used to provide objective measurements of skin structure, pigmentation, blood flow, and elasticity to assess the efficacy of facial skin rejuvenation treatments. Furthermore, microbiopsies can objectively evaluate facial skin rejuvenation without scarring. Using non-invasive skin imaging, a single treatment with the 1,470/2,940 nm laser was observed to be effective in improving skin appearance after 3 months, namely in reducing UV spots and brown spots, without significant changes in the tissue at the molecular level, as assessed by microbiopsy. Lasers Surg. © 2020 Wiley Periodicals, Inc.

Introduction There is ample evidence that overnight sleep and daytime naps benefit memory retention, compared to comparable amounts of active wakefulness. Yet recent evidence also suggests that a period of post-training rest (eg, quiet wakefulness with eyes closed) provides a similar memory benefit compared to wake. However, the relative benefits of sleep vs quiet waking rest on memory remain poorly understood. Here, we assessed the extent to which sleep provides a unique memory benefit, above and beyond that conferred by quiet waking rest. Methods In a sample of healthy undergraduate students (N=83), we tested the effect of 30 mins of post-learning sleep, rest, or active wake on concept learning (dot pattern classification) and declarative memory (word pair associates) across a 4-hr daytime training-retest interval. Results and conclusions Contrary to our hypotheses, we found no differences in performance between the three conditions for either task. The findings are interpreted with reference to methodological considerations including the length of the experimental interval, the nature of the tasks used, and challenges inherent in creating experimental conditions that can be executed by participants.

Assessments of non-surgical office-based aesthetic treatments' efficacy including lasers are mostly based on subjective evaluation of clinical photography. Accumulating evidence suggest that non-invasive skin imaging such as optical coherence tomography (OCT) can be effectively used to assess not only the skin surface but also the underlying epidermis and dermis, providing objective and clinically relevant data. In this review, we highlight the potential of OCT imaging for the aesthetic medicine field along with OCT measurement parameters and their clinical relevance to healthy and pathological skin conditions. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

BACKGROUND: Adherence to clinical practice guidelines for alcohol and drug screening, brief intervention, and referral to treatment (SBIRT) is often inadequate. Mobile apps developed as clinical translation tools could improve the delivery of high fidelity SBIRT. METHODS: This study tested the effectiveness of an SBIRT mobile app conceptually aligned with the Theory of Planned Behavior (TPB) to support SBIRT delivery by health care trainees (nursing, social work, internal medicine, psychiatry, and psychology) working in clinical settings (N=101). Bivariate analyses examined the rate of SBIRT delivery between trainees assigned to the experimental (app) and control (no app) study conditions; as well as the relationship between TPB-based constructs, intention to deliver SBIRT, and screening rates. RESULTS: No significant differences were identified between the study conditions in SBIRT delivery. Significant correlations were found between intent to screen and TPB variables including attitudes/behavioral beliefs concerning substance use treatment (r=.49, p=.01); confidence in clinical skills (r=.36, p=.01); subjective norms (r=.54, p=.01) and perceived behavioral control over appointment time constraints (r=.42, p=.01). Also significant were correlations between percent of patients screened and confidence (r=.24, p=.05); subjective norms (r=.22, p=.05) and perceived behavioral control (r=.28, p=.01). CONCLUSIONS: The negative results of the study condition comparisons indicate the need for further investigation of strategies to optimize mobile app utilization, engagement, and effectiveness as a clinical translation tool. Findings of significant correlations between substance use screening rates and both norms and confidence support the potential value of the TPB model in explaining behavior of health care learners in SBIRT delivery.

The purpose of this paper is to describe the curriculum and self-reported outcomes on measures of interdisciplinary leadership skills for work within the field of developmental disabilities from trainees in one interprofessional training program. The paper highlights one program’s curriculum and strategy for capturing self-report survey measures from trainees in cohorts from 2014–2018 (n = 86) on two surveys (Interdisciplinary Attitudes and Skills and Leadership Self-Evaluation Form) and three time points across the training year: before training (T1), mid-year (T2), and after training (T3). Data from 86 trainees are reported including demographics (nearly 80% white, 92% female), non-descriptive statistics due to non-normative samples, and tertiles demonstrating changes between time points. Significant differences between medians are reported between T1-T3 specifically related to utilizing interdisciplinary skills and gains in leadership competencies. Specific utilization of skills was reported to be ‘Greatly’ attributable to the LEND program related to sharing ideas and asking for help across disciplines. Trainees’ self-report from before training to after training indicates an increase in competence and utilization of interdisciplinary skills to be expected from participation in the curriculum. Self-report measures are

Sleep following learning facilitates the consolidation of memories. This effect has often been attributed to sleep-specific factors, such as the presence of sleep spindles or slow waves in the electroencephalogram (EEG). However, recent studies suggest that simply resting quietly while awake could confer a similar memory benefit. In the current study, we examined the effects of sleep, quiet rest, and active wakefulness on the consolidation of declarative and procedural memory. We hypothesized that sleep and eyes-closed quiet rest would both benefit memory compared with a period of active wakefulness. After completing a declarative and a procedural memory task, participants began a 30-min retention period with PSG (polysomnographic) monitoring, in which they either slept (n = 24), quietly rested with their eyes closed (n = 22), or completed a distractor task (n = 29). Following the retention period, participants were again tested on their memory for the two learning tasks. As hypothesized, sleep and quiet rest both led to better performance on the declarative and procedural memory tasks than did the distractor task. Moreover, the performance advantages conferred by rest were indistinguishable from those of sleep. These data suggest that neurobiology specific to sleep might not be necessary to induce the consolidation of memory, at least across very short retention intervals. Instead, offline memory consolidation may function opportunistically, occurring during either sleep or stimulus-free rest, provided a favorable neurobiological milieu and sufficient reduction of new encoding.

Background:\ud Seizures triggered by eating (STE) behavior are very rare in humans and have not been documented previously in dogs.\ud \ud Objectives:\ud To document the occurrence of STE in dogs and describe their clinical features.\ud \ud Animals:\ud Ten client‐owned dogs with STE diagnosed at 5 European referral centers.\ud \ud Methods:\ud A call for suspected cases of STE was made online. This call was followed by a retrospective review of medical records, combined with a questionnaire to be completed by both the owner and the board‐certified neurologist who made the diagnosis. Cases were included if >50% of the seizures that occurred were related to eating and if a minimum diagnostic evaluation for seizures had been performed.\ud \ud Results:\ud Four cases only had STE and 6 cases had both STE and spontaneous seizures. Four of the dogs were retrievers. The most common seizure type was focal epileptic seizures evolving to become generalized. Nine dogs were diagnosed with idiopathic epilepsy. One dog had a presumptive diagnosis of glioma involving the margins of the parietal, temporal, and frontal cortex (the perisylvian region), an area known to have a key role in eating‐associated epilepsy in people. Treatment strategies included a combination of pharmacological management and eating habit changes.\ud \ud Conclusions and Clinical Importance:\ud We have identified a form of reflex epilepsy in dogs, with STE behavior. Further studies are warranted to improve the characterization and management of STE.

Post-training sleep benefits both declarative and procedural memory consolidation. However, recent research suggests that eyes-closed waking rest may provide a similar benefit. Brokaw et al. (2016), for example, recently demonstrated that verbal declarative memory improved more following a 15 min period of waking rest, in comparison to 15 min of active wake. Here, we used the same procedures to test whether procedural memory similarly benefits from waking rest. Participants were trained on the Motor Sequence Task (MST), followed by a 15 min retention interval during which they either rested with their eyes closed or completed a distractor task. Rest significantly enhanced MST performance, mirroring the effect observed in Brokaw et al. (2016) and demonstrating that waking rest benefits the early stages of procedural memory. An additional group of participants tested 4 h later displayed no effect of rest. Overall, these results suggest that the early MST performance "boost" described in prior studies may depend on post-learning state.

Exercise provides a wide range of health-promoting benefits, but support is limited for clinical programs that use exercise as a means of health promotion. This stands in contrast to restorative or rehabilitative exercise, which is considered an essential medical service. We propose that there is a place for ongoing, structured wellness and health promotion programs, with exercise as the primary therapeutic focus. Such programs have long-lasting health benefits, are easily implementable, and are associated with high levels of participant satisfaction. We describe the dissemination and implementation of a long-standing exercise and health promotion program, Gerofit, for which significant gains in physical function that have been maintained over 5 years of follow-up, improvements in well-being, and a 10-year 25% survival benefit among program adherents have been documented. The program has been replicated at 6 Veterans Affairs Medical Centers. The pooled characteristics of enrolled participants (n = 691) demonstrate substantial baseline functional impairment (usual gait speed 1.05 ± 0.3 m/s, 8-foot up and go 8.7 ± 6.7 seconds, 30-second chair stands 10.7 ± 5.1, 6-minute walk distance 404.31 ± 141.9 m), highlighting the need for such programs. Change scores over baseline for 3, 6, and 12 months of follow-up are clinically and statistically significant (P < .05 all measures) and replicate findings from the parent program. Patient satisfaction ratings of high ranged from 88% to 94%. We describe the implementation process and present 1-year outcomes. We suggest that such programs be considered essential elements of healthcare systems.

An 11-year-old intact male Green iguana (Iguana iguana) was referred for treatment of a probable iridophoroma based on previous cytopathology. A periocular mass was present near the right medial canthus. Computed tomography did not show any sign of metastasis. Clinicopathologic abnormalities included lymphopenia and hyperproteinemia. Cytologic and histologic evaluations of the mass were consistent with iridophoroma. Complete surgical excision of the mass was not possible without removal of the orbit due to local tissue involvement. Recovery and suture removal were unremarkable. Adjunctive radiation therapy was recommended, but not performed. A year later, the surgical site had healed well. To our knowledge, this is the first reported chromatophoroma cytopathology in a Green iguana. Chromatophoromas should be included in the differential diagnoses of pigmented skin tumors in reptiles. Early surgical excision is useful to limit local tissue destruction and metastatic potential.

Across a broad spectrum of memory tasks, retention is superior following a night of sleep compared to a day of wake. However, this result alone does not clarify whether sleep merely slows the forgetting that would otherwise occur as a result of information processing during wakefulness, or whether sleep actually consolidates memories, protecting them from subsequent retroactive interference. Two influential studies (Ellenbogen, et al., 2006, 2009) suggested that sleep protects memories against the subsequent retroactive interference that occurs when participants learn new yet overlapping information (interference learning). In these studies, interference was much less detrimental to memory following a night of sleep compared to a day of wakefulness, a finding that provided strong evidence that sleep supports this important aspect of memory consolidation. In the current well-powered replication study, we repeated the protocol of Ellenbogen, et al. (2009) and, additionally, we examined the impact of intrinsic motivation on performance in sleep and wake participants. We were unable to replicate the finding that sleep protects memories against retroactive interference, with the detrimental effects of interference learning being essentially the same in wake and sleep participants. We also found that while intrinsic motivation benefitted task acquisition it was not a modulator of sleep-wake differences in memory processing. These finding of this replication study draw into question the claim that sleep protects memories against the effects of retroactive interference, and moreover, they highlight the importance of replicating key findings in the study of sleep’s impact on memory processing before drawing strong conclusions that drive the direction of future research.

The slow waves (SW) of non-rapid eye movement (NREM) sleep reflect neocortical components of network activity during sleep-dependent information processing; their disruption may therefore impair memory consolidation. Here, we quantify sleep-dependent consolidation of motor sequence memory, alongside sleep EEG-derived SW properties and synchronisation, and SW–spindle coupling in 21 patients suffering from schizophrenia and 19 healthy volunteers. Impaired memory consolidation in patients culminated in an overnight improvement in motor sequence task performance of only 1.6%, compared with 15% in controls. During sleep after learning, SW amplitudes and densities were comparable in healthy controls and patients. However, healthy controls showed a significant 45% increase in frontal-to-occipital SW coherence during sleep after motor learning in comparison with a baseline night (baseline: 0.22 ± 0.05, learning: 0.32 ± 0.05); patient EEG failed to show this increase (baseline: 0.22 ± 0.04, learning: 0.19 ± 0.04). The experience-dependent nesting of spindles in SW was similarly disrupted in patients: frontal-to-occipital SW–spindle phase-amplitude coupling (PAC) significantly increased after learning in healthy controls (modulation index baseline: 0.17 ± 0.02, learning: 0.22 ± 0.02) but not in patients (baseline: 0.13 ± 0.02, learning: 0.14 ± 0.02). Partial least-squares regression modelling of coherence and PAC data from all electrode pairs confirmed distributed SW coherence and SW–spindle coordination as superior predictors of overnight memory consolidation in healthy controls but not in patients. Quantifying the full repertoire of NREM EEG oscillations and their long-range covariance therefore presents learning-dependent changes in distributed SW and spindle coordination as fingerprints of impaired cognition in schizophrenia.

Background External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. Objective The aim of this retrospective single-center large sample was to assess the rate and factors predictive of infection. Methods We performed a retrospective review of patients who underwent EVD placement between January 2012 and January 2018. Results A total of 714 patients were included in the study. The infection rate was 3.6% (26/714). In 45% of the cases, the indication for ventriculostomy placement was for acute subarachnoid hemorrhage (aSAH) or intracerebral hemorrhage (ICH). Of the factors that were an independently significant predictor of ventriculostomy-associated infection (VAI) was the placement of a second EVD; the likelihood was eight times higher than if only a single EVD was placed (OR: 7.95, 95% CI: 1.01–62.9, p 1060, p Conclusion Our study shows that the rate of VAI was 3.6%. Only three variables were significant independent predictors of VAI; these were the replacement of the EVD, routine CSF aspiration, and intrathecal drug delivery. Disclosures A. Sweid: None. S. Tjoumakaris: None. C. Wamsley: None. E. Mann: None. C. Neely: None. J. Head: None. M. Gooch: None. N. Herial: None. T. Alexander: None. S. Missios: None. N. Chalouhi: None. R. Rosenwasser: None. P. Jabbour: None.

Introduction Slow wave sleep (SWS) is thought to especially benefit declarative memory (i.e., memory for facts and events). As such, recent studies have used various methods to experimentally increase the amount of slow wave sleep that participants obtain, with the goal of assessing how SWS affects declarative memory consolidation. Studies dating back decades have reported that exercising before sleep may increase time spent in SWS. Thus, the aim of the current project was to determine whether exercising after learning verbal information enhances slow wave sleep during a subsequent nap and/or enhances memory for verbal information. Methods Participants who exercised regularly were recruited to attend two 2.5hr laboratory sessions. During each session, they trained on a paired associates learning task and then completed either a 20min cardiovascular exercise routine or a 20min stretching routine. Following a 1hr nap opportunity, participants were tested on their memory. PSG was recorded during the nap, and scored following AASM criteria. Participants were excluded from analysis if they failed to sleep for at least 10 min. Following exclusions, n=30 participants were included in analysis. Results Contrary to our hypotheses, there was no significant difference between the exercise and stretching conditions for minutes spent in slow wave sleep (p=.16), % time spent in slow wave sleep (p=.22), or raw improvement in paired associated performance (p=.23). The amount of SWS obtained during the nap did not correlate with performance in either condition (SWS min vs. memory in exercise condition: r28=.10, p=.60; sleep condition: r28=-.06, p=.74). Exercise did not affect time spent in any other sleep stage, nor did it affect total sleep time. Conclusion Contrary to our hypotheses and the results of prior research, we were unable to detect a significant effect of exercise on slow wave sleep. Also contrary to our hypotheses, exercise did not affect memory retention across the nap interval. These null results could indicate that there is no effect of exercise on nap sleep and/or associated memory retention. However, it could also be that we lacked sufficient power to detect effects that were smaller than expected. Support (if any)

The COVID-19 global pandemic has stretched the capacities of public health institutions and health systems around the world, opening the door to a range of technologically-driven solutions. In this article, we seek to historicize the expanding role of digital health technologies and examine the political-economic context from which they have emerged. Drawing on critical insights from science and technology studies, we maintain that the rise of digital health technologies has been catalyzed by broad shifts in global health governance that have expanded the role of market forces in public health and a unique set of political and economic crises that have accelerated the adoption of digital technologies—often under the guise of appeals to technological innovation to address “unprecedented” crises. These interrelated historical trends, we contend, are critical for understanding current state responses to the pandemic and possibilities for more equitable and democratic applications of technology in public health.

Background: Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves. Aim: To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve. Methods: Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed. Results: While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression. Conclusion: Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

REVIEW QUESTION/OBJECTIVE The objective is to identify the effect of peak inspiratory pressure on the development of postoperative pulmonary complications.More specifically, the objective is to identify the effect of maintaining intraoperative peak inspiratory pressure less than or equal to 30 cmH2O compared with peak inspiratory pressure greater than 30 cmH2O on the incidence of postoperative atelectasis, pneumonia and acute respiratory distress syndrome in mechanically ventilated adult surgical patients.

Background: Screening, brief intervention, and referral to treatment (SBIRT) improves identification and intervention for patients at risk for developing an alcohol use disorder (AUD). Residency curriculum is designed to teach SBIRT skills, but resources are needed to promote skill implementation. The electronic health record (EHR) can facilitate implementation through integration of decision-support tools. The authors developed electronic tools to facilitate documentation of alcohol assessment and brief intervention and to reinforce skills from an SBIRT curriculum. This prospective cohort study assessed primary care internal medicine residents’ use of SBIRT skills and EHR tools in practice using chart-stimulated recall (CSR). Methods: Postgraduate year 2 and 3 residents received a 5-hour SBIRT curriculum with skills practice and instruction on SBIRT electronic tools. Participants were then given a list of their patients seen in a 1-year period who were drinking at/above the recommended limit. Trainees selected 3 patients to review with a faculty member in a CSR. Faculty used a 24-item chart checklist to assess application of SBIRT skills and electronic tool use and met with residents to complete a CSR interview. CSR interview notes were analyzed qualitatively to understand application of SBIRT skills and EHR tool use. Results: Eighteen of 20 residents participated in the CSR, and 5 faculty reviewed 46 patient charts. Residents documented alcohol use (84.2% of charts) and assessment of quantity/frequency of use (71.0%) but were less likely to document assessment for an AUD (34%), an appropriate plan (50.0%), or follow-up (55%). Few residents used EHR tools. Residents reported barriers in addressing alcohol use, including lack of knowledge, patient barriers, and time constraints. Conclusions: More intensive training in SBIRT with opportunities for practice and feedback may be necessary for residents to consistently apply SBIRT skills in practice. EHR tools need to be better integrated into the clinic workflow in order to be useful.

Introduction Past research has demonstrated that sleep benefits the consolidation of memories. However, more recent studies have suggested that quiet rest could have similar benefits for memory. Here, we examined the effect of a brief period of sleep, quiet rest, or active wakefulness on declarative and procedural memory. We hypothesized that sleep and quiet rest would equally benefit memory, compared to a period of active wakefulness. Methods After completing a declarative (Icelandic-English word pairs) and procedural memory task (the Motor Sequence Task (MST)), participants began a 30-min retention period with PSG monitoring, in which they either slept (n=24), quietly rested with their eyes closed (n=22), or completed a distractor task (n=28). Following the retention period, participants were tested on the same memory tasks they completed earlier. Results Percent improvement on the MST from the end of training to the end of the test session differed by condition, F(2, 73)=4.21, p=.019. Sleep and quiet rest led to nearly identical improvement (p=.95), with improvement in both of these conditions being significantly greater than in active wake (sleep vs. active wake: p=.01; quiet rest vs. active wake: p=.02). Similarly, retention of the Icelandic-English word pairs differed by condition (F(2, 73)=5.68, p=.005), with sleep and quiet rest demonstrating nearly identical memory change over time (p=.81), and retention in both of these conditions being significantly higher than in active wake (sleep vs. active wake: p=.007; quiet rest vs. active wake: p=.004). Conclusion These data suggest that sleep and quiet rest can exert an equivalent effect on memory consolidation for both declarative and procedural memory, at least across very brief retention durations. Therefore, neurobiology specific to sleep might not be necessary to induce offline improvement in memory across short intervals. Support This research was supported by National Institutes of Health Award R15MH107891.

Balance is a common mobility limitation following stroke, but determination of the most effective balance-related plan of care can be difficult due to multiple balance impairments that vary between individuals. The Brief-BESTest is a validated outcome measure for balance based on six systems of postural control. It may also be a useful tool to guide clinicians in their balance plan of care design.The objective of this study was to determine the feasibility of a quantitative balance plan of care for patients with subacute stroke, using a novel algorithm that utilizes the scoring design of the Brief-BESTest. The authors hypothesized that this plan of care could create targeted balance interventions among this population.Eligible patients with subacute stroke at an inpatient rehab facility completed the Brief-BESTest within 1 week of admission. The subjects participated in specific interventions based on test section scores during their rehab stay.Five subjects completed testing and participated in targeted balance interventions, addressing three to five systems of postural control. Subjects demonstrated improved Brief-BESTest overall scores by 2, 1, 7, 4, and 6 points from admission to discharge. Improvements in section scores were primarily seen in the systems of postural control identified by the algorithm. All subjects improved in Functional Independence Measure (FIM™)Our observational study found this method of assessment and intervention to be feasible in the subacute stroke population and was associated with improved balance scores and improved functional mobility. Further study is warranted to determine effectiveness and efficiency.

The stream of human consciousness persists during sleep, albeit in altered form. Disconnected from external input, the mind and brain remain active, at times creating the bizarre sequences of thought and imagery that comprise "dreaming." Yet despite substantial effort toward understanding this unique state of consciousness, no reliable neurophysiological indicator of dreaming has been discovered. Here, we identified electroencephalographic (EEG) correlates of dreaming using a within-subjects design to characterize the EEG preceding awakenings from sleep onset, REM (rapid eye movement) sleep, and N2 (NREM Stage 2) sleep from which participants were asked to report their mental experience. During the transition into sleep, compared to periods during which participants reported thinking, emergence of dream imagery was associated with increased absolute power below 7 Hz. During later N2, dreaming conversely occurred during periods of decreased relative power below 1 Hz, accompanied by an increase in relative power above 4 Hz. No EEG predictors of dreaming were identified during REM. These observations suggest an inverted-U relationship between dreaming and the prevalence of low-frequency EEG rhythms, such that dreaming first emerges in concert with EEG slowing during the sleep-wake transition, but then disappears as high-amplitude slow oscillations come to dominate the recording during later N2 sleep.

Objective To evaluate the efficacy of synovial fluid culture in obtaining the causative organism from dogs with suspected septic arthritis. Methods In this retrospective evaluation, synovial fluid cytology and microbiology submissions from dogs with suspected septic arthritis from March 2007 to August 2011 were reviewed. Synovial fluid cytology consistent with joint sepsis was identified. Cultures of synovial fluid from dogs with clinical histories and abnormalities consistent with septic arthritis were used to evaluate the efficacy of bacterial isolation. Results In total, 36 dogs met the inclusion criteria. Initial aerobic cultures of joint fluid yielded bacterial growth in 44% of these dogs. All anaerobic cultures were negative. In 19% of the dogs with positive cultures, antibiotics had been administered prior to arthrocentesis compared with 10% of dogs with negative cultures. There was no association between culture efficacy and the administration of antimicrobial treatment prior to synovial fluid culture or recent surgery involving the affected joint (P = 0.637 and P = 0.106, respectively). Conclusion Culture of synovial fluid from dogs with suspected septic arthritis has a low yield, necessitating a more effective means of identifying bacteria from suspected septic joints in dogs.

Offline reactivation of task-related neural activity has been demonstrated in animals but is difficult to directly observe in humans. We sought to identify potential electroencephalographic (EEG) markers of offline memory processing in human subjects by identifying a set of characteristic EEG topographies (“microstates”) that occurred as subjects learned to navigate a virtual maze. We hypothesized that these task-related microstates would appear during post-task periods of rest and sleep. In agreement with this hypothesis, we found that one task-related microstate was increased in post-training rest and sleep compared to baseline rest, selectively for subjects who actively learned the maze, and not in subjects performing a non-learning control task. Source modeling showed that this microstate was produced by activity in temporal and parietal networks, which are known to be involved in spatial navigation. For subjects who napped after training, the increase in this task-related microstate predicted the magnitude of subsequent change in performance. Our findings demonstrate that task-related EEG patterns re-emerge during post-training rest and sleep.

Background: Translation of knowledge and skills from classroom settings to clinical practice is a major challenge in healthcare training, especially for behavioral interventions. For example, screening, brief intervention, and referral to treatment (SBIRT) is a highly-promoted approach to identifying and treating individuals at risk for alcohol or drug problems, yet effective, routine use of SBIRT has lagged. Objective: The objective of this paper is to describe the development, pilot testing, and trial protocol of a mobile app based on the theory of planned behavior (TPB) to promote SBIRT skill translation and application. Methods: Intended for use after classroom training occurs, the mobile app has three primary functions designed to increase behavioral intent to deliver SBIRT: (1) review skills (ie, address knowledge and beliefs about SBIRT), (2) apply skills with patients (ie, build confidence and perceived behavioral control), and (3) report performance data (ie, increase accountability and social norms and/or influence). The app includes depression and anxiety screening tools due to high comorbidity with substance use. A randomized controlled trial (RCT) is in progress among health and social service learners (N=200) recruited from 3 universities and 6 different training programs in nursing, social work, internal medicine, psychiatry, and psychology. Participants are randomized to SBIRT classroom instruction alone or classroom instruction plus app access prior to beginning their field placement rotations. TPB-based data are collected via Qualtrics or via the mobile app pre-post and SBIRT utilization, weekly for 10 weeks. Key outcomes include the frequency of and self-reported confidence in delivery of SBIRT. Results: Beta testing with advanced practice nursing students (N=22) indicated that the app and its associated assessment tools were acceptable and useful. The system usability scale (SUS) mean was 65.8 (n=19), which indicated that the SBIRT app was acceptable but could benefit from improvement. Indeed, modifications were implemented prior to starting the trial. Enrollment of trial participants began in September 2016. Results are expected by December 2017. Conclusions: This report describes the process of TPB-based app development and testing, and the protocol for a RCT to determine the effectiveness of the app in enhancing skill translation. If effective, this approach could improve SBIRT implementation, fidelity, and clinical outcomes. [JMIR Res Protoc 2017;6(4):e55]

Background: Haptic TheraDrive is a low-cost robotic system that uses off-the-shelf computer gaming wheels with force feedback for post-stroke upper extremity rehabilitation. Preliminary results have shown that the Haptic TheraDrive system is not capable of delivering effective therapy to low-functioning patients. A new low-cost, high-force haptic robot with a single degree of freedom has been developed to address this concern. The purpose of this case is to determine the impact on motor performance and function with use of a custom force-feedback device, Haptic TheraDrive, to complete games for rehabilitation in a low-to-moderate functioning stroke survivor with hemiplegia. Methods: A case study design was used with a 52-year old male 22 months post stroke. His Fugl-Meyer Assessment of the Upper Extremity of 37/66 indicated a low-to-moderate functioning upper extremity. The subject participated in Haptic TheraDrive robot use for computer gaming of movement timing, velocity and accuracy for 3 x/a week for one month (10 sessions) - approximately 60 minutes per session. An adaptive controller monitored the subject's performance to ensure that the exercises were difficult but doable. Results: After session 10 the subject demonstrated improvements in: Fugl-Meyer Arm Motor Scale (8 points), coordination speed (59%), grip strength (18%) and Box and Block Test (122%). Gains at one month follow up included: Fugl-Meyer Arm Motor Scale (11 points, a minimally clinically important difference), coordination speed (63%), and grip strength (39%). Since completion of the training long terms gains included: Fugl-Meyer Arm Motor Scale (3 points), coordination speed (9%) and grip strength (18%). Conclusion: TheraDrive provides an adaptive controller using force-feedback to deliver individualized and effective therapy for a single low-to-moderate functioning stroke survivor with hemiplegia. The long-term goal of this project is to develop an inexpensive high-force haptic rehabilitation robot that can safely be used by patients at home.

Background Previous reports suggest an association between Bartonella infection and effusions in dogs and human beings. Objectives The aims of this study were to determine the prevalence of Bartonella infection in canine effusions and to investigate historic and clinical parameters predictive of Bartonella in dogs with effusions. Methods Canine cavitary effusions submitted for analysis and, if available, paired EDTA blood, were screened for Bartonella infection using the Bartonella α-proteobacteria growth medium enrichment culture/PCR diagnostic platform (Bartonella enrichment PCR or ePCR) at Galaxy Diagnostics, Inc. Results Bartonella henselaeDNA was PCR-amplified and sequenced from 15% (12/80) of sampled dogs. Enrichment culture prior to PCR testing was required for Bartonella detection in 92% (11/12) of cases. Twenty percent (4/20), 13% (8/60), and 0% (0/4) of dogs with pleural, peritoneal, and pericardial effusions, respectively, tested positive. Bartonella henselae was detected most frequently in the fall, and young and middle-aged dogs appeared to be overrepresented. Golden Retrievers and Yorkshire/Silky Terriers each comprised 25% of infected dogs (odds ratio 3.4 for Golden Retrievers). There was a weak association with hemorrhagic effusions. Fifty percent of Bartonella-positive dogs had hemorrhage as a component of their effusion compared to 37% of PCR-negative dogs (odds ratio 1.7). Conclusions Viable B henselae organisms occur in pleural and peritoneal effusions of dogs; the clinical relevance of which remains unclear and may represent opportunistic infection. Associations found in this study included seasonal variation, age, breed, and site of effusion.

Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue neoplasm with metastatic potential and needs to be recognized as such, because it can be mistaken for other types of sarcoma due to its unremarkable appearance. This 49-year-old man presented with an approximately 5-cm mass on the anteromedial aspect of his left thigh that slowly increased over 10 years. Clinical symptoms were limited to local discomfort and intermittent distal numbness. Due to the location, imaging findings, and lack of serious symptoms, the initial differential diagnosis favored a schwannoma. An initial biopsy revealed histopathological findings consistent with a perineurioma, although with atypical features. The patient elected to have the mass excised, and the tumor, which arose from a branch of the saphenous nerve, could be separated well from the surrounding soft tissue. Histopathological investigation of the mass displayed characteristic features of a fibromyxoid sarcoma, which was confirmed by subsequent fluorescence in situ hybridization analysis. Due to concerns about infiltration beyond the margins, radical reexcision was advocated and performed, resulting in definite clear surgical margins. At follow-up, the patient had regained full strength with no residual neurological symptoms or any new deficits. He has since been healthy and disease free for a total of 4 years in follow-up. This case documents, to the authors' knowledge, the first observation of an LGFMS associated with a peripheral nerve. It also supports the use of fluorescence in situ hybridization analysis as an essential diagnostic method in establishing the diagnosis of LGFMS.

STUDY OBJECTIVES We investigated a generally unappreciated feature of the sleep disorder narcolepsy, in which patients mistake the memory of a dream for a real experience and form sustained delusions about significant events. DESIGN We interviewed patients with narcolepsy and healthy controls to establish the prevalence of this complaint and identify its predictors. SETTING Academic medical centers in Boston, Massachusetts and Leiden, The Netherlands. PARTICIPANTS Patients (n = 46) with a diagnosis of narcolepsy with cataplexy, and age-matched healthy healthy controls (n = 41). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS "Dream delusions" were surprisingly common in narcolepsy and were often striking in their severity. As opposed to fleeting hypnagogic and hypnopompic hallucinations of the sleep/wake transition, dream delusions were false memories induced by the experience of a vivid dream, which led to false beliefs that could persist for days or weeks. CONCLUSIONS The delusional confusion of dreamed events with reality is a prominent feature of narcolepsy, and suggests the possibility of source memory deficits in this disorder that have not yet been fully characterized.

STUDY OBJECTIVES Several studies have now demonstrated that spatial information is processed during sleep, and that posttraining sleep is beneficial for human navigation. However, it remains unclear whether the effects of sleep are primarily due to consolidation of cognitive maps, or alternatively, whether sleep might also affect nonhippocampal aspects of navigation (e.g., speed of motion) involved in moving through a virtual environment. DESIGN Participants were trained on a virtual maze navigation task (VMT) and then given a memory test following either a day of wakefulness or a night of sleep. Subjects reported to the laboratory for training at either 10:00am or 10:00pm, depending on randomly assigned condition, and were tested 11 h later. Overnight subjects slept in the laboratory with polysomnography. SETTING A hospital-based academic sleep laboratory. PATIENTS OR PARTICIPANTS Thirty healthy college student volunteers. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Point-by-point position data were collected from the VMT. Analysis of the movement data revealed a sleep-dependent improvement in maze completion time (P < 0.001) due to improved spatial understanding of the maze layout, which led to a shortening of path from start to finish (P = 0.01) rather than faster exploration speed through the maze (P = 0.7). CONCLUSIONS We found that overnight sleep benefitted performance, not because subjects moved faster through the maze, but because they were more accurate in navigating to the goal. These findings suggest that sleep enhances participants' knowledge of the spatial layout of the maze, contributing to the consolidation of hippocampus-dependent spatial information. CITATION Nguyen ND; Tucker MA; Stickgold R; Wamsley EJ. Overnight sleep enhances hippocampus-dependent aspects of spatial memory. SLEEP 2013;36(7):1051-1057.

Background: Screening, brief intervention, and referral to treatment (SBIRT) is a practical means to address substance misuse in primary care. Important barriers to implementing SBIRT include adequacy of training and provider confidence as well as logistical hurdles and time constraints. A faculty development initiative aimed at increasing SBIRT knowledge and treatment of substance use disorders (SUDs) should lead to increased use of SBIRT by faculty and the residents they teach. This study examined how a faculty development program to promote SBIRT influenced faculty practice and resident teaching. Methods: This was a cross-sectional study of faculty exposed to multiple SBIRT educational interventions over a 5-year period in an academic faculty-resident general medicine practice. Participants completed a brief online survey followed by a semistructured interview. Quantitative responses were examined descriptively. Qualitative questions were reviewed to identify key themes. Results: Fifteen of 29 faculty (52%) completed the survey and 13 (45%) completed the interviews regarding faculty development interventions. Faculty thought that SBIRT was an important skill and had confidence in screening for substance use disorders, although confidence in making treatment referrals and prescribing pharmacotherapy were rated lower. Many faculty reported screening more frequently for SUDs after attending faculty development sessions. However, several reported that the training did not improve their SBIRT teaching to residents during clinic precepting sessions. To improve uptake of SBIRT, a majority of faculty recommended electronic health record (EHR) alerts. Conclusions: SBIRT is a highly valued set of skills, and training may enhance rates of screening for substance misuse. However, participants did not report a substantial change in SBIRT teaching as a result of faculty development. In the future, small, targeted faculty development sessions, potentially involving strategies for using the electronic health record (EHR), may be an effective way to enhance primary care SBIRT skills.

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Although not included in the classic tetrad of symptoms, nocturnal dream experience shows a number of abnormalities in narcolepsy patients. While some of these are benign, others rise to the level of a significant complaint that can impair a patients’ daily functioning. For example, patients with narcolepsy are prone to suffer from nightmares, have uncomfortably intense dream experience, and, perhaps most pathologically, are often troubled by a confusion in which dreamed events are mistaken for reality. While all of these experiences occur in the general population, their incidence and severity is pronounced in narcolepsy. Some of these dream-related experiences may be traced to well-described sleep abnormalities in narcolepsy, including fragmented nighttime sleep and fragmented, early-onset REM periods. Understanding the unique qualities of dreaming in narcolepsy provides a more complete picture of the symptom profile and may additionally offer insight into disruptions of underlying sleep neurophysiology.

Serum from 21 healthy, captive Asian elephants (Elephas maximus) was evaluated by measured and calculated osmolality. Serum osmolality results for this population of Asian elephants had a median of 261 mOsm/kg and an interquartile interval of 258-269 mOsm/kg when measured by freezing point osmometry and a median of 264 mOsm/kg and an interquartile interval of 257-269 mOsm/kg when measured by vapor pressure osmometry. These values are significantly lower than values reported in other mammalian species and have important diagnostic and therapeutic implications. Calculated osmolality produced unreliable results and needs further study to determine an appropriate formula and its clinical application in this species. A 16-hr water deprivation test in 16 Asian elephants induced a small, subclinical, but statistically significant increase in measured serum osmolality. Serum osmolality, blood urea nitrogen, and total protein by refractometer were sensitive indicators of hydration status. Serum osmolality measurement by freezing point or vapor pressure osmometry is a useful adjunct to routine clinical tests in the diagnostic evaluation of elephants.

In December 2009, the American Society for Veterinary Clinical Pathology (ASVCP) Quality Assurance and Laboratory Standards committee published the updated and peer-reviewed ASVCP Quality Assurance Guidelines on the Society's website. These guidelines are intended for use by veterinary diagnostic laboratories and veterinary research laboratories that are not covered by the US Food and Drug Administration Good Laboratory Practice standards (Code of Federal Regulations Title 21, Chapter 58). The guidelines have been divided into 3 reports: (1) general analytical factors for veterinary laboratory performance and comparisons; (2) hematology, hemostasis, and crossmatching; and (3) clinical chemistry, cytology, and urinalysis. This particular report is one of 3 reports and documents recommendations for control of preanalytical, analytical, and postanalytical factors related to urinalysis, cytology, and clinical chemistry in veterinary laboratories and is adapted from sections 1.1 and 2.2 (clinical chemistry), 1.3 and 2.5 (urinalysis), 1.4 and 2.6 (cytology), and 3 (postanalytical factors important in veterinary clinical pathology) of these guidelines. These guidelines are not intended to be all-inclusive; rather, they provide minimal guidelines for quality assurance and quality control for veterinary laboratory testing and a basis for laboratories to assess their current practices, determine areas for improvement, and guide continuing professional development and education efforts.

Objective: To examine the effect of body mass index (BMI) on the impact of a health promotion intervention on health services use and expenditures among Medicare beneficiaries with disabilities. Method: We analyzed data from 452 Medicare beneficiaries who participated in a Medicare demonstration. The intervention included the following components: patient education, health promotion coaching, medication management, and physician care management. We performed the analysis by using generalized linear models (GLM) to examine the impact of BMI and the intervention on total health care expenditures. Results: The intervention was cost neutral over the 2-year study period. Participants in the intervention group used less home health aide services ( p = .03) and had fewer nursing home days ( p = .05). The intervention appeared to have smaller effects on expenditures as BMI level increased. Discussion: The findings suggest that a health promotion intervention may achieve better beneficiary outcomes without an increase in resource use in this Medicare population.

A 14-year-old female spayed Golden Retriever was presented to the University of Florida's Veterinary Medical Center with history of lymphoplasmacytic gastroenteritis, intermittent vomiting, watery diarrhea, and weight loss for over a year. CBC, biochemical profile, and urinalysis were within reference intervals. Abdominal ultrasonographic examination revealed mesenteric and jejunal lymphadenopathy and hyperechoic hepatic nodules. Cytologic examination of the enlarged lymph nodes revealed loosely cohesive cells with moderate nuclear pleomorphism and rare punctate eosinophilic cytoplasmic granules. The cytologic interpretation was metastatic neuroendocrine neoplasia. On surgical exploration, a mass was detected in the right lobe of the pancreas. Histologic evaluation determined the mass to be an islet cell tumor. Approximately 98% of cells were positive by immunolabeling for pancreatic polypeptide (PP), and only rare cells were positive for insulin or somatostatin. All cells were negative for glucagon, gastrin, vasoactive intestinal polypeptide, protein gene product 9.5, synaptophysin, and chromogranins A and B. Pancreatic tumors that primarily produce PP are rare in dogs, and this is the first report of both the cytologic and histologic features of an islet cell tumor predominantly secreting PP. Clinical signs for these tumors are typically absent or nonspecific; signs may include watery diarrhea, as noted in this dog, although the diarrhea may have resulted from lymphoplasmacytic gastroenteritis. Additional case studies are needed to further characterize the cytomorphologic features and clinical presentation of PP-secreting islet cell tumor, or polypeptidoma, in dogs.

The purpose of this study is to evaluate the effect of a primary care affiliated disease management-health promotion nurse intervention on paid personal assistance (PA) use and expenditures among Medicare beneficiaries with disabilities. We analyzed data on 570 community-dwelling Medicare beneficiaries aged 65 years and older who participated in the Medicare Primary and Consumer-Directed Care Demonstration, a randomized controlled trial. We estimated a two-part model to test the effect of the nurse intervention on PA use and expenditures during the 2 years after study entry. Adjusting for covariates, average annual PA expenditures were $1,464 (29%) lower per person in the intervention group as compared to the control group. The findings of this study will help policy makers and practitioners understand the potential benefit of primary care affiliated nurse home visiting interventions on PA expenditures.