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Calcific aortic valve disease (CAVD) is increasingly prevalent worldwide with significant morbidity and mortality. Therapeutic options beyond surgical valve replacement are currently limited. In 2011, the National Heart Lung and Blood Institute assembled a working group on aortic stenosis. This group identified CAVD as an actively regulated disease process in need of further study. As a result, the Alliance of Investigators on CAVD was formed to coordinate and promote CAVD research, with the goals of identifying individuals at risk, developing new therapeutic approaches, and improving diagnostic methods. The group is composed of cardiologists, geneticists, imaging specialists, and basic science researchers. This report reviews the current status of CAVD research and treatment strategies with identification of areas in need of additional investigation for optimal management of this patient population.

Purpose: Head and neck surgery and radiation cause tissue fibrosis that leads to functional limitations and lymphedema. The objective of this study was to determine whether lymphedema therapy after surgery and radiation for head and neck cancer decreases neck circumference, increases cervical range of motion, and improves pain scores. Methods and materials: A retrospective review of all patients with squamous cell carcinoma of the oral cavity, oropharynx, or larynx who were treated with high-dose radiation therapy at a single center between 2011 and 2012 was performed. Patients received definitive or postoperative radiation for squamous cell carcinoma of the oral cavity, oropharynx, or larynx. Patients were referred to a single, certified, lymphedema therapist with specialty training in head and neck cancer after completion of radiation treatment and healing of acute toxicity (typically 1-3 months). Patients underwent at least 3 months of manual lymphatic decongestion and skilled fibrotic techniques. Circumferential neck measurements and cervical range of motion were measured clinically at 1, 3, 6, 9, and 12 months after completion of radiation therapy. Pain scores were also recorded. Results: Thirty-four consecutive patients were eligible and underwent a median of 6 months of lymphedema therapy (Range, 3-12 months). Clinically measured total neck circumference decreased in all patients with 1 month of treatment. Cervical rotation increased by 30.2% on the left and 27.9% on the right at 1 month and continued to improve up to 44.6% and 55.3%, respectively, at 12 months. Patients undergoing therapy had improved pain scores from 4.3 at baseline to 2.0 after 1 month. Conclusions: Lymphedema therapy is associated with objective improvements in range of motion, neck circumference, and pain scores in the majority of patients.

INTRODUCTION: While de qi, the acupuncture needling sensation, has been considered as an important component of acupuncture, little is known of the acupuncture patient's experience and beliefs about de qi in clinical settings. The aim of this study was to describe Chinese acupuncture patients' perceived sensations of, and beliefs about, acupuncture needling. METHODS: We developed a questionnaire and conducted a survey study at two time periods among 200 subjects at six outpatient acupuncture clinics in Beijing, China. RESULTS: Respondents were 55% female and had a mean age of 41 years. The most common types of needling sensations reported by subjects were the terms 'distended7rsquo; (94%), 'sore' (81%), 'electric' (81%) and 'numb' (78%). Eighty-nine percent of subjects reported that the needling sensation travelled away from the puncturing points or travelled among the needling points. Eighty-two percent of subjects believed that the needling sensation was very important for acupuncture treatment, and 68% further indicated that the stronger the needling sensation, the more effective the therapy. Eighty-one percent of subjects found the acupuncture process to be very comfortable and relaxing. CONCLUSION: Chinese acupuncture patients described the common characteristics of de qi and its migratory nature. The sensations were believed to be important in producing clinical efficacy by most patients. Measuring the sensations described as de qi in future prospective studies will help us understand the degree to which this phenomenon has an effect on the physiological outcome and clinical response to acupuncture. There appears to be a limit to the number of sensations that can be discriminated by each individual patient, and further development of the questionnaire is planned. [ABSTRACT FROM AUTHOR]

Don't let the plethora of cancer screening recommendations confuse you. There's more consensus than you might think. The real question is why so many women who need screening aren't getting it -- and why more physicians don't make the effort to recommend these lifesaving tests. [ABSTRACT FROM AUTHOR]

Purpose: S100A12 and fibroblast growth factor (FGF) 23 are biomarkers for cardiovascular mortality in patients with chronic kidney disease (CKD). The present study was designed to test the hypothesis that elevated serum levels of S100/calgranulin in mice with CKD would accelerate pathological cardiac remodeling, and to discover a potential link between S100A12 and FGF23.Methods: Human S100/calgranulin is expressed in C57BL6/J mice using a bacterial artificial chromosome containing the genes and regulatory elements for hS1008/9 and hS100A12 (hBAC-S100). hBAC-S100 mice were bred with mice lacking the receptor for advanced glycation endproducts (RAGE). CKD was induced in hBAC-S100 mice and wild type (WT) littermate mice by surgical ligation of the ureters. The heart and aorta were analyzed after 10 weeks of CKD.Results: S100A12 protein is expressed in myeloid cells and in serum of hBAC-S100 mice (25 ng/ml serum), and increased further in response to CKD. Moreover, serum IL-6 and IL-22 are elevated in hBAC-S100 mice at age 3 and 12 month. hBAC-S100 mice with CKD developed cardiac hypertrophy, diastolic dysfunction and ectopic cardiac calcification upon in-vivo echocardiography, heart weight, histology and gene expression of ANP, β-MHC, TGF-β, CTGF, and Col 1a1. Serum FGF23 was equally increased in WT/CKD and hBAC-S100/CKD compared to sham-operated animals. However, intra-cardiac expression of FGF23 mRNA (6 fold) and protein (2 fold) was increased only in hBAC-S100, and localized to the fibrous tissue of the aortic and mitral valve annulus. Importantly, IL-6, TNF-a, and LPS induced FGF23 mRNA and protein expression in cultured neonatal or adult cardiac fibroblasts while FGF23 mRNA was reduced by 90% in response to calcification-inducing medium (10mM glycerophosphate and 10nM dexamethasone). Recombinant S100A12 did not induce FGF23 mRNA. hBAC-S100 mice lacking RAGE, the receptor for S100/calgranulin, showed attenuation of systemic inflammation (IL-6, Il-22), attenuation of cardiac hypertrophy, diastolic dysfunction, cardiac FGF23 expression, and ectopic cardiac calcification when subjected to CKD, and the cardiac phenotype was similar to WT mice with CKD. Furthermore, aortic valve calcification develops spontaneously in 10-12-month old hBAC/S100 mice, suggesting that CKD accelerates this process, but is not required for S100/calgranulin-medicated aortic valve sclerosis.Conclusion: Myeloid-derived S100/calgranulin is sufficient to induce a sustained inflammatory state in vivo, which is associated with increased FGF23 expression in cardiac fibroblasts and cardiac remodeling in a RAGE dependent manner. [ABSTRACT FROM AUTHOR]

Purpose: Research suggests that expectancy may modulate the response to medical interventions, including acupuncture. However, the paucity of validated tools to measure expectancy limits rigorous evaluation. We sought to validate a previously developed Acupuncture Expectancy Scale (AES) as an instrument to measure patients' expected responses to acupuncture.Purpose: Participants were patients with stage I to III cancers seen in outpatient medical and radiation oncology clinics. They were drawn from three study cohorts that included 404 participants. We examined the reliability, validity, and responsiveness of the AES.Results: The scores on the AES had internal consistency (Cronbach's alpha coefficient) of 0.95 and test-retest reliability of 0.62 over 4 weeks without acupuncture treatment. Those who had previously used acupuncture had higher AES scores compared to those who were acupuncture naive (12.4 vs 9.5, P = .002). AES scores were higher in those who reported willingness to participate in an acupuncture trial compared to those who did not want to participate in an acupuncture trial (11.5 vs 8.1, P < .001). Patients who enrolled in a pilot trial of acupuncture had higher AES scores than the general outpatient population (13.0 vs 9.8, P = .02), and expectancy increased during the course of acupuncture treatment (13.0 to 16.5, P < .017).Conclusion: The AES is reliable and valid, and scores appear to increase during or after prior therapy. Incorporation of AES in clinical trials and outcome studies can evaluate the role of expectancy on acupuncture outcomes. [ABSTRACT FROM AUTHOR]

Objective: Our objective is to determine if the structure of Graduate Medical Education teaching clinics is associated with how well ophthalmology residents are prepared to meet the workload demands of independent clinical practice., Design: Resident preparedness to enter independent practice was measured by the Readiness Index. Part of the Department of Veterans Affairs' new Workload-based Resident Academic Performance measures (WRAP), resident readiness is computed from electronic health records for residents by clinic and service-date. The index compares resident productivity net of supervision and adjusted for care quality to the average productivity of non-supervising ophthalmologists. Readiness comprises a Workload component (ratio of resident gross productivity to the average productivity of non-supervising ophthalmologists) and Supervision component (ratio of resident net of supervision to gross productivity). Teaching clinic factors include resident postgraduate-year level, resident-to-physician staff ratios, patient care complexity, and program size. Covariates include time into the academic year, facility quality ranking and complexity rating, and attending physician productivity rate., Setting: Study setting is 109 ophthalmology outpatient clinics from the United States Department of Veterans Affairs and its 1,300 annual ophthalmology resident positions rotating on 84,600 ophthalmology clinic-days during academic years from July 1, 2015, through June 30, 2019., Participants: An average 2.6 residents at a second-year or higher saw 25.0 patients requiring 93.6 relative value units (RVUs) of workload., Results: Senior ophthalmology residents from clinics with higher resident-to-physician ratios had greater practice readiness than their counterparts primarily from having greater progressive autonomy from supervision. Residents from larger programs treating more complex patients had only slightly greater practice readiness than their counterparts primarily from having greater workload productivity., Conclusions: The readiness of ophthalmology residents to enter independent practice is associated with their academic level and resident-to-physician staff ratios, and to a lesser extent care complexity and program size., (Published by Elsevier Inc.)

Background: Patients with ascending thoracic aortic aneurysm are recommended to undergo routine imaging surveillance. Although maximal diameter is the primary metric of disease severity, recent American College of Cardiology/American Heart Association guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk. As diameter increases, it is assumed that aortic growth rate accelerates because of increased wall tension; however, this relationship is poorly studied. We aim to investigate the relationship between ascending thoracic aortic aneurysm diameter and growth rate using vascular deformation mapping, a validated technique for 3-dimensional growth mapping with submillimeter accuracy., Methods and Results: We retrospectively identified adult patients with ascending aortic dilation (≥4.0 cm) and serial gated computed tomography angiograms separated by ≥2 years, excluding confirmed heritable thoracic aortic disease. Ascending growth rate was defined as 90th percentile radial wall deformation by vascular deformation mapping. Maximal diameter measurements were derived from the baseline computed tomography angiogram, and aortic length and body size-adjusted indexes were calculated. Among 258 included patients (63.2% men; age of 63 years [interquartile range, 55-69 years]), mean±SD baseline diameter was 46.3±3.6 mm and median growth rate was 0.21 mm/year (interquartile range, 0.13-0.38 mm/year). No correlation was noted between growth rate and baseline diameter ( r =0.02, P =0.74) or other aortic size metrics. On multivariate analysis, age was independently predictive of growth rate (β=-0.007, P =0.021), alongside weight (β=0.003, P =0.016) and the presence of moderate or severe aortic valve insufficiency (β=0.146, P =0.049)., Conclusions: Maximal aortic diameter is not predictive of aortic growth rate, in this contemporary cohort of patients with sizes under current surgical thresholds (<55 mm).

Competing Interests: Dr Hofmann Bowman reports no conflicts. Dr Eagle is founder and principal investigator of IRAD, which receives research funding from W.L. Gore & Associates, and is a consultant for the Marfan Foundation.

Purpose: High-ranking educational leaders in academic medicine oversee multiple clinical programs. This requires them to prioritize dozens of emergent tasks and responsibilities daily, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Identifying their key responsibilities and frequently used skills and competencies may clarify the educational needs of senior educational leaders and facilitate targeted professional development to promote effective and efficient performance., Method: In August 2022 researchers interviewed 12 designated education officers (DEOs) from U.S. Department of Veterans Affairs (VA) Veterans Health Administration medical centers about their daily work and most challenging responsibilities. Content analysis of interview transcripts identified key responsibilities and activities identified by participants and prioritization of the perceived skills needed to complete them., Results: Participants emphasized 4 key areas of responsibility: fiscal, administrative, affiliate partnership, and educational duties. They identified 12 skills as baseline requirements for effective performance for which additional professional development would be useful and suggested that both new and more established educational leaders receive targeted professional development and mentoring to foster these capacities., Conclusions: The key skills participants identified by area of perceived responsibility are relevant to VA DEOs, designated institutional officers, and senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. Structured orientation programs and ongoing professional development for senior educational leaders could emphasize these areas of responsibility, potentially enriching DEOs' performance and reducing burnout., Competing Interests: Other disclosures: Neither the authors nor their family members have a financial interest in any commercial product, service, or organization providing financial support for this research. The authors report no actual or potential conflicts of interest in regard to this article., (Copyright © 2024 the Association of American Medical Colleges.)

Artificial intelligence (AI) is certainly going to have a large, potentially huge, impact on the practice of family medicine. The specialty is fortunate to have leading experts in the field to guide us along the way. One such team of forward thinkers provides insights into where AI can take the specialty. Another article reports on how well AI performed on the American Board of Family Medicine In-Training Examination. In addition to AI, we have 3 articles that investigate the intersection of social needs and the practice of medicine. Four clinical review articles cover nonalcoholic fatty liver disease, headache treatments, single maintenance and reliever therapy for asthma, and the use of cannabis in the setting of chronic pain. The clinical research articles cover point-of-care hemoglobin A1c testing, continuous glucose monitoring, and screening for HIV. Another group of articles examines the profession of family medicine, covering topics ranging from how women family physicians negotiate their first jobs to the words we use to define primary care., Competing Interests: Conflict of interest: The authors are editors of JABFM., (© Copyright by the American Board of Family Medicine.)

Vibrational spectroscopy enables critical insight into the structural and dynamic properties of molecules. Presently, the majority of theoretical approaches to spectroscopy employ wavefunction-based ab initio or density functional methods that rely on the harmonic approximation. This approximation breaks down for large molecules with strongly anharmonic bonds or for molecules with large internuclear separations. An alternative to these methods involves generating molecular anharmonic potential energy surfaces (potentials) and using them to extrapolate the vibrational frequencies. This study examines the efficacy of density functional theory (DFT) and the correlation consistent Composite Approach (ccCA) in generating anharmonic frequencies from potentials of small main group molecules. Vibrational self-consistent field Theory (VSCF) and post-VSCF methods were used to calculate the fundamental frequencies of these molecules from their potentials. Functional choice, basis set selection, and mode-coupling are also examined as factors in influencing accuracy. The absolute deviations for the calculated frequencies using potentials at the ccCA level of theory were lower than the potentials at the DFT level. With DFT resulting in bending modes that are better described than those of ccCA, a multilevel DFT:ccCA approach where DFT potentials are used for single vibrational mode potentials and ccCA is used for vibrational mode-mode couplings can be utilized for larger polyatomic systems. The frequencies obtained with this multilevel approach using VCIPSI-PT2 were closer to experimental frequencies than the scaled harmonic frequencies, indicating the success of utilizing post-VSCF methods to generate more accurate representations of computed infrared spectra., (© 2024 The Authors. Journal of Computational Chemistry published by Wiley Periodicals LLC.)

Introduction: Designated Education Officers (DEOs) at Veteran Health Administration (VHA) hospitals are senior educational leaders tasked with oversight of all clinical training at a particular facility. They prioritize dozens of tasks and responsibilities each day, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Clarifying priority competencies for the role can help executives recruit, appoint, and evaluate capable personnel and promote effective, efficient performance., Materials and Methods: Using a federally developed method of competency analysis, researchers consulted a panel of subject-matter experts to identify priority competencies for DEOs, using data from a 2013 study that operationalizes competencies for more than 200 federal jobs., Results: The research identified 25 primary competencies within 6 leadership domains. Five of the primary competencies cut across all leadership domains., Conclusions: Veteran Health Administration subject-matter experts in educational leadership say the identified competencies are urgently needed, critical for effective leadership, and valuable for distinguishing superior DEO performance. The competencies are relevant to VHA and perhaps other senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. In military training facilities, attending to these competencies can help Designated Institutional Officials responsible for graduate medical education become more credible partners to other hospital leaders and contribute to becoming a high reliability organization. Executives identifying, recruiting, and appointing VHA DEOs and Designated Institutional Officials at military training facilities should consider these competencies when assessing candidates., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Quite a lineup showcasing JABFM's emphasis on research and information for family medicine to improve patients' lives. Articles cover many topics: telemedicine, a clinical decision support tool, control of cardiovascular risk factors, opioid dose reduction, cancer survivorship care, patient engagement with case management/navigation, primary care physician capacity and usual source of care, marketing practices of Medicare Advantage programs, review articles (new diabetes medicine and treatment CHF with reduced ejection fraction), and more., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright 2024 by the American Board of Family Medicine.)

This issue highlights changes in medical care delivery since the start of the COVID-19 pandemic and features research to advance the delivery of primary care. Several articles report on the effectiveness of telehealth, including its use for hospital follow-up, medication abortion, management of diabetes, and as a potential tool for reducing health disparities. Other articles detail innovations in clinical practice, from the use of artificial intelligence and machine learning to a validated simple risk score that can support outpatient triage decisions for patients with COVID-19. Notably one article reports the impact of a voluntary program using scribes in a large health system on physician documentation behaviors and performance. One article addresses the wage gap between early-career female and male family physicians. Several articles report on inappropriate testing for common health problems; are you following recommendations for ordering Pulmonary Function Tests, mt-sDNA for colon cancer screening, and HIV testing?, Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright 2024 by the American Board of Family Medicine.)

This issue includes articles on the lingering impact of COVID-19, often negative but occasionally positive, on patients, treatment, practices, and health care personnel. Other articles inform on prevention, such as awareness of lung cancer screening among women undergoing screening mammography; failures on sports preparticipation physicals; advance care planning as prevention; and screening for social risk factors. Another article reports on patient experiences of legal recreational cannabis in Washington State. There is a review of perinatal depression recognition and treatment. Two articles separately identify the difficulties of the congressionally created Medicare Advantage & Pharmaceutical Benefit Managers., Competing Interests: Conflict of interest: The authors are editors of the JABFM., (© Copyright by the American Board of Family Medicine.)

Objective: Using health records from the Department of Veterans Affairs (VA), the largest healthcare training platform in the United States, we estimated independent associations between the intensity of attending supervision of surgical residents and 30-day postoperation patient outcomes., Background: Academic leaders do not agree on the level of autonomy from supervision to grant surgery residents to best prepare them to enter independent practice without risking patient outcomes., Methods: Secondary data came from a national, systematic 1:8 sample of n = 862,425 teaching encounters where residents were listed as primary surgeon at 122 VA medical centers from July 1, 2004, through September 30, 2019. Independent associations between whether attendings had scrubbed or not scrubbed on patient 30-day all-cause mortality, complications, and 30-day readmission were estimated using generalized linear-mixed models. Estimates were tested for any residual confounding biases, robustness to different regression models, stability over time, and validated using moderator and secondary factors analyses., Results: After accounting for potential confounding factors, residents supervised by scrubbed attendings in 733,997 nonemergency surgery encounters had fewer deaths within 30 days of the operation by 14.2% [0.3%, 29.9%], fewer case complications by 7.9% [2.0%, 14.0%], and fewer readmissions by 17.5% [11.2%, 24.2%] than had attendings not scrubbed. Over the 15 study years, scrubbed surgery attendings may have averted an estimated 13,700 deaths, 43,600 cases with complications, and 73,800 readmissions., Conclusions: VA policies on attending surgeon supervision have protected patient safety while allowing residents in selected teaching encounters to have limited autonomy from supervision., Competing Interests: The authors declare that they have nothing to disclose., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Concurrent cocaine and alcohol use is among the most frequent drug combination, and among the most dangerous in terms of deleterious outcomes. Cocaine increases extracellular monoamines by blocking dopamine (DA), norepinephrine (NE) and serotonin (5-HT) transporters (DAT, NET and SERT, respectively). Likewise, ethanol also increases extracellular monoamines, however evidence suggests that ethanol does so independently of DAT, NET and SERT. Organic cation transporter 3 (OCT3) is an emergent key player in the regulation of monoamine signaling. Using a battery of in vitro, in vivo electrochemical, and behavioral approaches, as well as wild-type and constitutive OCT3 knockout mice, we show that ethanol's actions to inhibit monoamine uptake are dependent on OCT3. These findings provide a novel mechanistic basis whereby ethanol enhances the neurochemical and behavioral effects of cocaine and encourage further research into OCT3 as a target for therapeutic intervention in the treatment of ethanol and ethanol/cocaine use disorders., (© 2023. The Author(s).)

Corneal wound healing is integral for resolution of corneal disease or for post-operative healing. However, corneal scarring that may occur secondary to this process can significantly impair vision. Tissue transglutaminase 2 (TGM2) inhibition has shown promising antifibrotic effects and thus holds promise to prevent or treat corneal scarring. The commercially available ocular solution for treatment of ocular manifestations of Cystinosis, Cystaran®, contains the TGM2 inhibitor cysteamine hydrochloride (CH). The purpose of this study is to assess the safety of CH on corneal epithelial and stromal wounds, its effects on corneal wound healing, and its efficacy against corneal scarring following wounding. Quantitative polymerase chain reaction (qPCR) and immunohistochemistry (IHC) were first used to quantify and localize TGM2 expression in the cornea. Subsequently, (i) the in vitro effects of CH at 0.163, 1.63, and 16.3 mM on corneal epithelial cell migration was assessed with an epithelial cell migration assay, and (ii) the in vivo effects of application of 1.63 mM CH on epithelial and stromal wounds was assessed in a rabbit model with ophthalmic examinations, inflammation scoring, color and fluorescein imaging, optical coherence tomography (OCT), and confocal biomicroscopy. Post-mortem assessment of corneal tissue post-stromal wounding included biomechanical characterization (atomic force microscopy (AFM)), histology (H&E staining), and determining incidence of myofibroblasts (immunostaining against α-SMA) in wounded corneal tissue. TGM2 expression was highest in corneal epithelial cells. Application of the TGM2 inhibitor CH did not affect in vitro epithelial cell migration at the two lower concentrations tested. At 16.3 mM, decreased cell migration was observed. In vivo application of CH at 57 mM was well tolerated and did not adversely affect wound healing. No difference in corneal scarring was found between CH treated and vehicle control eyes. This study shows that the TGM2 inhibitor CH, at the FDA-approved dose, is well tolerated in a rabbit model of corneal wound healing and does not adversely affect epithelial or stromal wound healing. This supports the safe use of this medication in Cystinosis patients with open corneal wounds. CH did not have an effect on corneal scarring in this study, suggesting that Cystaran® administration to patients with corneal wounds is unlikely to decrease corneal fibrosis., Competing Interests: Declaration of competing interest The authors have no conflicts to disclose., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

What is next for family medicine? After the long, rough road since the beginning of the COVID-19 pandemic, other topics are again receiving renewed attention. Family medicine researchers continue to consider issues important to our patients and practices. There is a collection of clinical research on children's health care. One article outlines practical actions to move medical academia past racism. The need for physician trust in patients is also often overlooked. Other articles address how to improve the practice of family medicine and a framework for thinking about legal and ethical issues in sports medicine. Three in-depth clinical reviews cover lumps and bumps of wrists and hands, spondylosis/spondylolistheses, and vitamin D association with specific disease entities., Competing Interests: Conflicts of interest: The authors are editors of the JABFM., (© Copyright by the American Board of Family Medicine.)

Background: Graduate medical education is centered in hospitals despite a care system where patients mostly receive their care in an outpatient setting. Such gaps may exist because of inadequate funding for residency positions in community and hospital-based clinics., Objective: Determine if physician residents' contribution to outpatient workload offsets their costs for supervision, salary, and fringe benefits as residents acquire skills to become independent practitioners., Research Design: VA's electronic patient records from 2005 through 2018 were analyzed using generalized linear mixed models to estimate resident and staff contributions to workload in relative value units., Measures: Resident participation rate is resident contributed workload net of supervision as a percent of total clinic workload. Productivity is per diem resident workload as a percent of per diem staff workload. Efficiency is per dollar resident workload as a percent of per dollar staff workload. Progressive independence is annual rate of change in resident productivity., Results: Average participation rates varied by specialty from 6% to 22%, with 11% (primary care) and 13% (psychiatry). Productivity rates ranged from 21% to 94%, with 57% (primary care) and 61% (psychiatry). Efficiency rates varied from 0.63 to 3.81, with 1.69 (primary care), 1.89 (psychiatry). Progressive independence rates varied from 2.7%/year (psychiatry) to 39.7%/year (specialty care)., Conclusions: Although residents rotating through most VA clinics generate revenue to cover their direct costs as they learn, some federal subsidies may be necessary to encourage hospital- and community-based clinics to accept residents from the less profitable primary care and mental health specialties., Competing Interests: The authors declare no conflict of interest.

Selective serotonin reuptake inhibitors (SSRIs) are less efficacious in treating depression in children than in adults. SSRIs block serotonin uptake via the high-affinity, low-capacity serotonin transporter. However, the low-affinity, high-capacity organic cation transporter 3 (OCT3) and plasma membrane monoamine transporter (PMAT) are emerging as important players in serotonin uptake. We hypothesized that OCT3 and/or PMAT are functionally upregulated in juveniles, thereby buffering SSRIs' ability to enhance serotonergic neurotransmission. Unlike in adult mice, we found the OCT/PMAT blocker, decynium-22, to have standalone antidepressant-like effects in juveniles. Using in vivo high-speed chronoamperometry, we found that juveniles clear serotonin from the CA3 region of the hippocampus ~2-fold faster than adult mice. Cell density did not differ between ages, suggesting that faster serotonin clearance in juveniles is unrelated to faster diffusion through the extracellular matrix. Western blot and immunohistochemistry showed that juvenile mice have modestly greater expression of PMAT than adults, whereas OCT3 expression in the CA3 region of the hippocampus was similar between ages. Together, these data suggest that faster serotonin clearance and antidepressant-like effects of decynium-22 in juvenile mice may be due to functionally upregulated PMAT. Faster serotonin clearance via PMAT in juveniles may contribute to reduced therapeutic efficacy of SSRIs in children relative to adults.

Background: The US Department of Veterans Affairs designated education officer (DEO) is a unique facility-based leadership role responsible for training of > 40 health professions in cooperation with affiliated academic institutions., Methods: We conducted mixed methods analyses of data from a DEO needs assessment. Quantitative analysis identified differences between DEOs who are physicians and DEOs who are other professions on role characteristics and self-perceived task effectiveness. Qualitative analysis using rapid analysis procedures was applied to open-ended responses on facilitators and barriers., Results: Responses were received from 127 DEOs (96% response rate). About 80% were physicians. There were no statistically significant differences between physician and other professional DEOs self-ratings for general tasks. For profession-specific tasks, physician DEOs were significantly less confident than other professional DEOs in working with associated health ( P < .001-.01) and nurse training programs ( P < .001-.03). DEOs identified multiple facilitators that assist their individual effectiveness (eg, training, mentorship, communication) and common barriers (eg, not enough staff)., Conclusions: Our findings are supportive of individuals from various health disciplines serving in the DEO role with responsibilities that span multiple health profession training programs. Future quantitative and qualitative work should include additional measures of individual and organizational characteristics, and actual measures of educational effectiveness., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article., (Copyright © 2022 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

Thoracic aortic aneurysm and dissection are complex diagnoses that require management by multidisciplinary providers using a variety of medical therapies, surgical interventions, and lifestyle modifications. Pharmacological agents, such as β-blockers (atenolol) and angiotensin II type 1 receptor blockers (losartan), have been mainstay treatments for several years, and research from the past decade has continued to evaluate these and other medication classes to further improve patient morbidity and mortality. Combination β- and renin-aldosterone-angiotensin blockade, statins, metformin, antioxidants, and vitamins have been evaluated as therapeutics in both thoracic and abdominal aortic aneurysms, as well as the effects of various antibiotics (ie, fluoroquinolones and tetracyclines) and benefits of lifestyle modifications (eg, diet and exercise) and enhanced patient-centered care and treatment adherence. In addition, as our understanding of the genetic, biochemical, and pathophysiological mechanisms behind these diseases expands, so do potential targets for future therapeutic research (eg, interleukins, matrix metalloproteases, and mast cells). This review incorporates the major meta-analyses, systematic and generalized reviews, and clinical trials published from 2010 through 2021 that focus on these topics in thoracic aortic aneurysms (and abdominal aneurysms when thoracic literature is scarce). Several key ongoing clinical trials, case studies, and in vivo/in vitro studies are also mentioned. Furthermore, we discuss current gaps in the literature and the abundance of clinical evidence for some interventions in abdominal aneurysms with few thoracic correlates, thus indicating a need for investigation of these subjects in the latter., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)