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Jennifer L Hale-Gallardo,1 Consuelo M Kreider,2,3 Huanguang Jia,1 Gail Castaneda,2 I Magaly Freytes,1 Diane C Cowper Ripley,2 Zaccheus J Ahonle,3 Kimberly Findley,1 Sergio Romero1,2 1Department of Veterans Affairs, North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA; 2Department of Veterans Affairs, Veterans Rural Health Resource Center–Gainesville, Office of Rural Health, Gainesville, Florida, USA; 3Department of Occupational Therapy, University of Florida, Gainesville, Florida, USACorrespondence: Sergio RomeroVeterans Rural Health Resource Center – Gainesville, North Florida/South Georgia Veterans Health System, 1601 S.W. Archer Road, Gainesville, Florida 32608, USATel +1 352-264-3845Email Sergio.Romero@va.govPurpose: Telerehabilitation (TR) is increasingly being used to meet the rehabilitation needs of individuals living in rural areas. Nevertheless, reports on TR implementation for rural patients remain limited. As part of a broader evaluation, this study investigated barriers and facilitators to the implementation of a national TR program to meet the needs of rural Veterans Health Administration (VHA) patients.Methods: This study applied a qualitative approach to the RE-AIM framework to investigate barriers and facilitators impacting TR implementation. We conducted in-depth, semi-structured interviews with ten program managers and medical directors within the VHA at three time points during the first 18 months of implementation. Interviews were analyzed using thematic analysis.Results: Three themes were identified describing key cultural, infrastructural and logistical, and environmental barriers impacting the reach, adoption, and implementation of TR. Within the themes, facilitators for TR were also identified to include, allowing providers flexibility in implementing TR, mentorship and development of creative approaches to TR training, overcoming infrastructural and logistical TR barriers through championing, and continuous sharing of lessons learned in a community of practice.Discussion: This study explicates salient barriers and facilitators encountered during the first 18 months of implementation of a TR program within a national healthcare system in the United States. Implementing TR to meet the rehabilitation needs of Veterans in resource-limited rural environments requires creative approaches and flexibility, as well as perseverance and consistent championing in order to overcome cultural challenges. This, in combination with infrastructural challenges, such as lack of broadband, adds greater complexity to meeting the needs of rural patients. This study provides new and in-depth understanding of the processes by which TR is implemented in a large healthcare system and points to practical real-world lessons in implementing TR for rural patients.Keywords: telemedicine, health, culture, technology, evaluation, implementation science

Jennifer Harrison Elder,1 Consuelo Maun Kreider,2 Susan N Brasher,3 Margaret Ansell4 1Department of Family and Community Health Nursing Science, 2Department of Occupational Therapy, University of Florida, Gainesville, FL, 3Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, 4Health Science Center Libraries, University of Florida, Gainesville, FL, USA Abstract: Autism spectrum disorder (ASD) refers to a lifelong condition that usually appears in late infancy or early childhood, and is characterized by social and communication deficits that impede optimal functioning. Despite widespread research and greater public awareness, ASD has an unclear etiology and no known cure, making it difficult to acquire accurate and timely diagnoses. In addition, once an ASD diagnosis is made, parents find it challenging to navigate the healthcare system and determine which interventions are most effective and appropriate for their child. A growing body of evidence supports the value of early diagnosis and treatment with evidence-based interventions, which can significantly improve the quality of life of individuals with ASD as well as of their carers and families. Particularly noteworthy are early interventions that occur in natural surroundings and can be modified to address age-related goals throughout the lifespan. Therefore, the purpose of this review is to: 1) provide readers with a brief background related to ASD; 2) describe commonly used screening instruments and tools for early diagnosis; 3) describe early interventions that have empirical support; and 4) discuss how the parent–child and family relationships can be affected through this process. This information can provide professionals with information they can use to assist families who make critical and potentially life-changing decisions for children with ASD. Keywords: autism spectrum disorder, ASD, early diagnosis, early intervention, parent–child relationship

Jennifer Harrison Elder,1 Consuelo Maun Kreider,2 Nancy M Schaefer,3 Mary B de Laosa4 1Department of Family and Community Health Nursing Science, 2Department of Occupational Therapy, 3Health Science Center Library, 4Department of Psychology, University of Florida, Gainesville, FL, USA Background: The gluten-free, casein-free (GFCF) diet is heralded by strong anecdotal parental reports to greatly improve and even "cure" symptoms of autism spectrum disorders (ASDs). Yet, to date, little conclusive empirical evidence exists supporting its use. Objective: The purpose of this paper is to provide an overview of the state of the recent evidence regarding the use of GFCF diet for treatment of individuals with ASD. Methods: Five database providers (PubMed, Web of Knowledge, EBSCO, ProQuest, and WorldCat) were used to search 19 databases, yielding a total of 491 articles that were published through February 2015. Peer-reviewed articles published between January 2005 and February 2015 were included for review if study participants were identified as having ASD and if the study investigated the effects of the GFCF diet on ASD behaviors or the relationship between the diet and these behaviors. Results: Evaluation of search results yielded eleven reviews, seven group experimental studies including five randomized controlled trials, five case reports, and four group observational studies published during the last 10 years. These studies represent a marked increase in the number of reported studies as well as increased scientific rigor in investigation of GFCF diets in ASD. Conclusion: While strong empirical support for the GFCF diet in ASD is currently lacking, studies point to the need for identifying subsets of individuals (eg, those with documented gastrointestinal abnormalities) who may be the best responders to the GFCF diet. Identifying these subsets is critically needed to enhance rigor in this research area. Until rigorous research supporting the use of GFCF diet is reported, clinicians should continue to use caution and consider several factors when advising regarding implementation of the GFCF diet for individuals with ASD. Keywords: GFCF diet, autism spectrum disorders, review, gluten free, casein free, dietary intervention

Introduction: Adult-onset Still's disease is a rare systemic autoinflammatory disease. We present a case of a young man with a constellation of symptoms and myopericarditis as a complication of this disease., Case: A 36-year-old Hispanic man with no significant past medical history developed a quotidian fever pattern following an upper respiratory tract infection. He initially presented with chest pain concerning for myocardial infarction and underwent cardiac catheterization, which revealed non-obstructive coronary artery disease. He was found to have myopericarditis, significant neutrophilic leukocytosis, and hyperferritinemia. He improved on high-dose corticosteroids but developed steroid-induced psychosis, and 4 months from symptom onset, he finally received tocilizumab, which eventually induced remission without adverse reactions., Discussion: Adult-onset Still's disease should be considered in a patient with fevers of undetermined origin. Due to its multisystemic involvement, adult-onset Still's disease is often a diagnosis arrived at after an extensive cardiac, hematologic, malignant, and infectious workup. Imaging, laboratory testing, and bone marrow biopsy were necessary to rule out alternative etiologies of this patient's presentation. Steroids are the mainstay of treatment because they are easily affordable, although the high risk of adverse effects makes them less desirable. Interleukin-1 inhibitors (anakinra or canakinumab) and interleukin-6 inhibitor tocilizumab are the steroid-sparing biologic agents of choice but are cost-prohibitive., Conclusion: Adult-onset Still's disease should be considered in the differential diagnoses of fever of undetermined origin. Early identification and initiation of treatment are critical to faster recovery and prevention of progression to severe complications. Steroids remain the standard first-line therapy and should be followed by disease-modifying steroid sparing drugs. The social determinants of health may preclude their timely initiation and should alert providers of proactive ways to avoid further delays., (© 2024. The Author(s).)

Background: Workplace violence persists in health care with nurses reporting physical and verbal abuse from aggressive patients causing emotional stress and lost workdays. The Dynamic Appraisal of Situational Aggression-Inpatient Version (DASA-IV) was developed to measure risk for aggression in patients with behavioral health conditions in psychiatric and emergency department settings. The DASA-IV has not been validated with adult patients admitted to medical-surgical units., Objective: To determine whether DASA-IV scores are predictive of aggressive events in adults hospitalized on medical-surgical units., Methods: This multisite study used a case-control design. DASA-IV scores and acts of aggression were extracted from the medical record retrospectively to validate the appraisal's predictability. Receiver operating characteristic (ROC) and area under the curve (AUC) were used to correlate DASA-IV scores with aggressive events., Results: DASA-IV assessments (N=156 999; mean [SD] 10.1 [10.7]/patient; range 1-220) were collected from 13 611 patients. Patients were primarily White (86.1%) and female (51.7%). Aggression (n = 509 patients; 3.7%) was significantly associated with older age, male sex, smoking, illicit drug use, and high DASA-IV scores. AUC of the ROC analysis for the DASA-IV showed a 97% probability (95% confidence interval [CI] 0.964-0.977) that an aggressive patient would have a higher score on the DASA-IV than a nonaggressive patient. Binary logistic regression predicted that for every point increase in the DASA-IV, there was a 3.51 (95% CI 3.38-3.63) times increased risk for aggression ( B   =  1.255, SE = 0.18, Wald = 4766.6, P  < .001)., Conclusions: This study is the first to validate use of the DASA-IV in medical-surgical populations, demonstrating predictive ability for aggressive incidents. The DASA-IV can be used successfully in medical-surgical populations for early identification of potential aggression., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In 2019, the Food and Drug Administration introduced 11 pictorial warning labels (PWLs) for inclusion on cigarette packages, created in compliance with court recommendations and tailored to increase knowledge of smoking harms. Several highlighted lesser-known risks of smoking. No behavioral studies have yet evaluated how risk content in PWLs impacts viewing patterns, recall, and knowledge of smoking harms., Methods: Seventy adults who reported smoking cigarettes daily (62.9% male, 57.1% African American, mean age = 50.3, mean cigarettes per day = 14.4) completed a single-session laboratory study. They were randomized to view a set of four PWLs depicting either lesser-known or well-known risks of smoking while having eye movements recorded, then completed post-exposure recall and knowledge measures., Results: Participants exposed to PWLs depicting lesser-known smoking risks viewed the text of the warning sooner and for longer than the image (p's <0.05); those exposed to PWLs depicting well-known risks viewed the image longer than text (p <0.001). PWL condition did not affect recall of text or image (p's >0.1). Those viewing lesser-known (vs. well-known) risks had greater knowledge of smoking causing lesser-known risks of bladder cancer, blindness, bloody urine, cataracts, diabetes, and head and neck cancer (p's <0.001)., Conclusions: Individuals viewing PWLs depicting lesser-known (vs. well-known) smoking risks visually engaged with the PWL text more than image, had similarly high recall of PWL content, and had greater knowledge of lesser-known risks of smoking. Findings suggest including lesser-known risk information on PWLs improves overall knowledge of smoking health risks., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Our experience in Monmouth County with surgical resection of single brain metastases followed by whole brain radiotherapy confirms the findings of a recent prospective randomized controlled study of this problem and demonstrates that patients treated with surgical resection followed by whole brain radiation live longer and have a better quality of life than those patients treated with radiotherapy alone. Best results are attainable if there is no evidence of disease activity at the primary site or systemically at the time the brain metastasis is diagnosed.