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PURPOSE: To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery. DATA SOURCES: A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home. CONCLUSIONS: Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services. IMPLICATIONS FOR PRACTICE: Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether race/ethnicity is an independent risk factor for peripheral arterial disease (PAD). PATIENTS AND METHODS: From September 2000 through August 2001, we screened patients (age > or = 55 years) for PAD within 4 primary care clinics located in the Houston, Tex, area. Variables that were bivariately associated with PAD (P< or = .05) were selected for entry into a multivariate logistic regression model to determine the independent risk factors for PAD. RESULTS: Among 403 patients (136 white, 136 African American, and 131 Latino patients, 81 of whom were Spanish speaking), the prevalence of PAD was 22.8% among African American patients, 13.7% among Latino patients, and 13.2% among white patients (P = .06). Within the multivariate model, adjusting for age, smoking status (odds ratio [OR], 2.58; 95% confidence interval [CI], 1.27-5.25), diabetes mellitus (OR, 2.98; 95% CI, 1.58-5.63), hypertension (OR, 2.58; 95% CI, 1.12-5.95), and education, African American and Latino patients were not more likely than white patients to have a diagnosis of PAD (OR 1.89, 95% CI 0.89-3.99 and OR 1.54, 95% CI 0.59-4.06, respectively). CONCLUSION: After adjusting for atherosclerotic risk factors and level of education, ethnicity was not an independent risk factor for PAD. When determining ethnic variation in outcomes among patients with PAD, efforts are needed to better understand the role of the primary care setting to reduce the burden of social inequality on health. [ABSTRACT FROM AUTHOR]

Study Objectives: Proinflammatory cytokines may contribute to disease progression in heart failure by virtue of the direct toxic effects that these molecules exert on the heart and the circulation. Accordingly, there is interest in developing therapeutic agents with anticytokine properties that might be used as adjunctive therapy to modulate proinflammatory cytokine levels in patients with heart failure. Previous experimental studies suggested that vesnarinone has potent anticytokine properties in vitro. Therefore, we examined the effects of vesnarinone on circulating levels of cytokines and cytokine receptors in a large-scale, multicenter, clinical trial of patients with moderate-to-advanced heart failure: the Vesnarinone Trial (VEST).Methods: Circulating levels of tumor necrosis factor (TNF)-alpha, soluble TNF-receptor type 1, soluble TNF-receptor type 2, as well as interleukin (IL)-6 and soluble IL-6 receptor (sIL-6R) were measured on plasma samples by enzyme-linked immunosorbent assay at baseline and at 24 weeks in patients who were receiving placebo (n = 352), 30 mg of vesnarinone (n = 367), and 60 mg of vesnarinone (n = 327).Results: Treatment with 30 mg and 60 mg of vesnarinone had no effect on circulating levels of cytokines or cytokine receptors in patients with advanced heart failure over a 24-week period.Conclusions: In contrast to the potent anticytokine effects observed with vesnarinone in experimental studies in vitro, the results of this clinical study suggest that vesnarinone does not have any measurable anticytokine effects in vivo in patients with moderate-to-advanced heart failure. [ABSTRACT FROM AUTHOR]

Question: In patients with osteoarthritis, does arthroscopic surgery of the knee relieve pain and improve function? Design: Randomized (allocation concealed), blinded (patients and outcome assessors), controlled trial with a 2-year follow-up. Setting: A Veterans Affairs medical center in Houston, Texas, USA. Patients: 180 patients who were ≤ 75 years of age (mean age, 52 years; 93% men), had osteoarthritis of the knee (defined by the American College of Rheumatology), reported at least moderate knee pain on average (≥4 on a visual analog scale that ranged from 0 to 10), and had had no arthroscopy of the knee during the previous 2 years. Exclusion criteria were a severity grade of ≥9 for osteoarthritis of the knee, severe deformity, and serious medical problems. 91% of the patients had complete follow-up. Intervention: Patients were randomly allocated to arthroscopic débridement (n = 59), arthroscopic lavage alone (n= 61), or a placebo procedure (n = 60). In the débridement group, the joint was lavaged with ≥ 10 L of fluid, rough articular cartilage was shaved (chondroplasty was performed), loose debris was removed, meniscal fragments were trimmed, and the remaining meniscus was smoothed to a stable rim. In the lavage group, the joint was lavaged with ≥10 L of fluid, and anything that could be flushed out through arthroscopic cannulae was removed. In the placebo group, a standard arthroscopic débridement procedure was simulated without insertion of the arthroscope. Main outcome measures: Pain in the study knee (as measured with the Knee-Specific Pain Scale, in which scores range from 0 to 100 [most severe]) at 24 months after the intervention was the primary outcome measure. Secondary outcome measures were arthritis pain in general (assessed with the Arthritis Impact-Measurement Scales 2 [AIMS2-P]), body pain (assessed with the 2-item pain subscale of the Medical Outcomes Study 36-item Short-Form General Health Survey... [ABSTRACT FROM AUTHOR]

Objectives: The basis for the associations among anger, hostility, aggressive behavior, and post-traumatic stress disorder (PTSD) remains unclear. We suggest classifying aggressive behavior may elucidate the associations among these factors. On the basis of diagnostic and neurobiological similarities between impulsive aggression (IA) and PTSD, we proposed that IA was the predominant form of aggression in PTSD and that anger and hostility would not significantly predict PTSD when IA was also included as a predictor.Methods: We used cross-sectional self-report data obtained from two samples of male veterans (N = 136).Results: Over 70% of veterans with PTSD reported IA compared to 29% of those without PTSD. IA, not anger, hostility, or premeditated aggression significantly predicted a diagnosis of PTSD.Conclusions: Associations between anger and PTSD may be unique to individuals with IA, and considering impulsive and premeditated aggressors separately may account for the heterogeneity found within samples of aggressive veterans with PTSD. [ABSTRACT FROM AUTHOR]

A review of high intensity, high dose mentalization-based inpatient psychiatric treatment indicated large effect-size reductions in symptoms of depression, anxiety, somatization, and improving emotion-regulation functioning (Allen et al., 2017). This study examined the impact of pathological personality traits has on baseline symptoms and functioning, as well as their impact on the longitudinal course in a large cohort of adult inpatient psychiatric sample ( N = 804). The Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012) was used to assess trait domains impact on longitudinal outcomes (anxiety, depression, somatic symptoms, and functional impairment) using hierarchical repeated measures modeling. Results indicate Negative Affectivity and Detachment were related to higher admission severity in all four outcome domains. Psychoticism was related to somatic symptoms, while Antagonism and Disinhibition were related to functional impairment. Paradoxically, when symptoms were plotted over 2-week intervals during hospitalization, patients with higher admission PID-5 trait scores exhibited greater improvement over time. The PID-5 appears to contribute to prediction of treatment outcome response above and beyond demographic and burden of illness. Importantly, the findings add to a growing body of literature indicating that impairments in personality traits do not preclude positive treatment response, particularly when treatments target pathological personality features. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: Diabetes distress is underrecognized and associated with poor outcomes. This study tested whether a 12-month collaborative, goal-setting, and behavioral telehealth intervention reduced diabetes distress levels. Methods: This is a secondary analysis of the Healthy Outcomes through Patient Empowerment (HOPE) study that included individuals (N = 225) with uncontrolled diabetes and depression living at least 20 miles from a Veteran's Affairs medical center. Participants were randomized to HOPE (intervention) or Enhanced Usual Care (EUC) with education. We evaluated diabetes distress levels as measured by the Problem Areas in Diabetes (PAID) Questionnaire and its four subscales (emotional, diabetes management, social, and treatment distress) at baseline, 6, and 12 months. Results: Between-group analysis revealed greater improvements in HOPE versus EUC for: 6-month PAID total score ( p  = 0.04), emotional ( p  = 0.03), and social ( p  = 0.04) subscales; 12-month PAID total score ( p  = 0.07) and emotional subscale ( p  = 0.07). Within-group comparisons showed larger effect sizes for HOPE compared with EUC: 12-month PAID total scores (0.82 vs. 0.54), 6-month emotional burden (0.54 vs. 0.31), and 6-month (0.32 vs. 0.08) and 12-month (0.41 vs. 0.12) social burdens. Repeated-measures analysis evaluating treatment group and time trended toward improvement in PAID overall for HOPE compared with EUC participants, but was not statistically significant ( β  = 6.96; SE = 4.35; p  = 0.13). Discussion: Clinically meaningful reductions in PAID overall and the emotional and social subscales were observed in HOPE compared with EUC participants. Conclusion: Further evaluation of diabetes telehealth interventions that include other facets related to diabetes distress, including treatment, diabetes management, social, and emotional burdens, is warranted. Clinical Trial Number. NCT01572389; Clinical Trial Registry. https://clinicaltrials.gov/ct2/show/NCT01572389.

Electromembrane extraction is a microextraction technique where charged analytes are extracted across a supported liquid membrane and selectively isolated from the sample based on an electrical field. Since the introduction in 2006, there has been continuously increasing interest in electromembrane extraction, and currently close to 50 new articles are published per year. Electromembrane extraction can be performed in different technical configurations, based on standard laboratory glass vials or 96-well plate systems, and applications are typically related to pharmaceutical, environmental, and food and beverages analysis. In addition to this, conceptual research has developed electromembrane extraction into different milli- and microfluidic formats. These are much more early-stage activities, but applications among others related to organ-on-chip systems and smartphone detection indicate unique perspectives. To stimulate more research in this direction, the current article reviews the scientific literature on electromembrane extraction in milli- and microfluidic formats. About 20 original research articles have been published on this subject so far, and these are discussed critically in the following. Based on this and the authors own experiences with the topic, we discuss perspectives, challenges, and future research., (© 2021 The Authors. Journal of Separation Science published by Wiley-VCH GmbH.)

Non-aqueous capillary electrophoresis (NACE) on microfluidic chips is still a comparatively little explored area, despite the inherent advantages of this technique and its application potential for, in particular, lipophilic compounds. A main reason is probably the fact that implementation of NACE on microchips largely precluded the use of polymeric substrate materials. Here, we report non-aqueous electrophoresis on a thiol-ene-based microfluidic chip coupled to mass spectrometry via an on-chip ESI interface. Microchips with an integrated ESI emitter were fabricated using a double-molding approach. The durability of thiol-ene, when exposed to different organic solvents, was investigated with respect to swelling and decomposition of the polymer. Thiol-ene exhibited good stability against organic solvents such as methanol, ethanol, N-methylformamide, and formamide, which allows for a wide range of background electrolyte compositions. The integrated ESI emitter provided a stable spray with RSD% of the ESI signal ≤8%. Separation efficiency of the developed microchip electrophoresis system in different non-aqueous buffer solutions was tested with a mixture of several drugs of abuse. Ethanol- and methanol-based buffers provided comparable high theoretical plate numbers (≈ 6.6 × 10 4 -1.6 × 10 5  m -1 ) with ethanol exhibiting the best separation efficiency. Direct coupling of non-aqueous electrophoresis to mass spectrometry allowed for fast analysis of hydrophobic compounds in the range of 0.1-5 μg mL -1 and 0.2-10 μg mL -1 and very good sensitivities (LOD ≈ 0.06-0.28 μg mL -1 ; LOQ ≈ 0.20-0.90 μg mL -1 ). The novel combination of non-aqueous CE on a microfluidic thiol-ene device and ESI-MS provides a mass-producible and highly versatile system for the analysis of, in particular, lipophilic compounds in a wide range of organic solvents. This offers promising potential for future applications in forensic, clinical, and environmental analysis. Graphical abstract.

The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.

A new and easy to construct sheathless capillary electrophoresis electro spray ionization mass spectrometry (CE-ESI-MS) interface was developed that offers several advantages compared to traditional liquid junction interfaces. The fabrication of the device only requires a CO 2 laser engraver that most groups working with microfluids have access to. It only takes a few seconds to create a CO 2 laser ablated opening in the bare-fused silica capillaries and the opening can be placed as close as a few mm from the spray tip. The capillary is punctured through a silicone tube such that the opening is directly placed inside this tube, which also serves as a liquid reservoir for the make-up liquid. Electrical contact required for both CE separation and ESI is established via the liquid in this reservoir which is in contact with the electrode of an external high voltage power supply. The developed CE-ESI-MS interface is capable of analysing both small molecules and biomolecules such as peptides in physisorbed PEG polymer brush coated capillaries. Proof-of-principle of the interface was demonstrated by analysing a tryptic digest of BSA. Further, a range of drugs of abuse were also investigated. The examined small molecules (pethidine, nortriptyline, methadone, haloperidol and loperamide) have a quantification limit (LOQ) of 150 ng/mL and a detection limit (LOD) of 40 ng/mL (except for loperamide: LOD = 80 ng/mL). Finally, we used our novel CE-MS interface for the analysis of the Aβ40 peptide. This is a member of the beta-Amyloid peptide family, involved in the development of Alzheimer's disease. A LOQ of 9 μg/mL was obtained for Aβ40, corresponding to 23 fmoles in a sample volume of 11 nL., (Copyright © 2020 Elsevier B.V. All rights reserved.)

One of the most attractive aspects of microfluidic chips is their capability of integrating several functional units into one single platform. In particular, enzymatic digestion and chemical separation are important steps in processing samples for many biochemical assays. This study presents the development and application of a free-flow electrophoresis microfluidic chip, and its upstream combination with an enzyme microreactor with immobilized pepsin in the same miniaturized platform. The whole microfluidic chip was fabricated by making use of thiol-ene click chemistry. As a proof of concept, different fluorescent dyes and labeled amino acids were continuously separated in the 2D electrophoretic channel. The protease pepsin was immobilized using a covalent linkage with ascorbic acid onto a high-surface monolithic support, also made of thiol-ene. To show the potential of the microfluidic chip for continuous sample preparation and analysis, an oligopeptide was enzymatically digested, and the resulting fragments were separated and collected in a single step (prior to mass spectrometric detection), without the need of further time-consuming liquid handling steps.

Background: To date, there have not been any epidemiologic studies that have evaluated the association between swimming over a lifetime and knee health., Objective: The study aimed to evaluate the relationship of a history of swimming with knee pain, radiographic knee OA (ROA), and symptomatic knee OA (SOA)., Design: Cross-sectional retrospective study., Setting: Four academic centers in the United States., Participants: Respondents to the historical physical activity survey within the Osteoarthritis Initiative with knee radiographs and symptom assessments., Methods: In this retrospective study nested within the Osteoarthritis Initiative, researchers performed logistic regression with the predictor being swimming over a lifetime and over particular age ranges., Main Outcome Measurements: Person-based definitions of frequent knee pain, ROA, and SOA., Results: A total of 2637 participants were included, with a mean age of 64.3 years (SD 8.9), body mass index of 28.4 kg/m 2 (SD 4.9), and 44.2% male. Over a lifetime, the adjusted prevalence measures for frequent knee pain, ROA, and SOA for any versus no history of swimming were 36.4% (33.4% - 39.5%) v. 39.9% (37.4% - 42.5%), 54.3% (51.0% - 57.6%) v. 61.1% (58.4% - 63.7%), and 21.9% (19.4% - 24.7%) v. 27.0% (24.7% - 29.4%) respectively., Conclusions: This is the first epidemiologic study to indicate that swimming is potentially beneficial toward knee health, particularly when performed earlier in life (before age 35). Future prospective studies are needed to confirm these findings and to better scrutinize the associations in older age groups., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Objectives: We sought to describe current outcomes of Multiple Organ Dysfunction Syndrome present on day 1 of PICU admission., Design: Retrospective observational cohort study., Setting: Virtual Pediatric Systems, LLC, database admissions, January 2014 and December 2015., Patients: We analyzed 194,017 consecutive PICU admissions, (age 1 mo to 18 yr) from the 2014-2015 Virtual Pediatric Systems database., Interventions: We identified day 1 Multiple Organ Dysfunction Syndrome by International Pediatric Sepsis Consensus Conference criteria with day 1 laboratory and vital sign values. Functional status was evaluated by Pediatric Overall Performance Category and Pediatric Cerebral Performance Category scores from PICU admission and discharge., Measurements and Main Results: Overall, PICU mortality was 2.1%. We identified day 1 Multiple Organ Dysfunction Syndrome in 14.4% of admissions. Patients with Multiple Organ Dysfunction Syndrome had higher mortality than those without Multiple Organ Dysfunction Syndrome (10.3% vs 0.7%; p < 0.0001), and a higher percentage of survivors had greater than or equal to 2 category worsening in Pediatric Cerebral Performance Category score (3.6% vs 0.5%; p < 0.0001) or Pediatric Overall Performance Category score (6.0% vs 1.8%; p < 0.0001). The odds of death with day 1 Multiple Organ Dysfunction Syndrome was 14.3 (95% CI, 13-15.7), while the odds of death or discharge with Pediatric Overall Performance Category/Pediatric Cerebral Performance Category score greater than or equal to 3 (poor functional outcome) was 6.7 (95% CI, 6-7.4). In a subset of 148,188 patients from hospitals where limitation of support decisions were recorded, 5.8% patients with Multiple Organ Dysfunction Syndrome had limitation of support decisions in place, compared with 0.8% of patients without Multiple Organ Dysfunction Syndrome (p < 0.0001). Of day 1 Multiple Organ Dysfunction Syndrome patients who died, 43.1% had limitation of support decisions in place, and 41.6% had withdrawal of life-sustaining therapies (p < 0.0001)., Conclusions: Multiple Organ Dysfunction Syndrome present on day 1 of admission continues to be a major source of morbidity and mortality in the PICU, but risk of poor neurologic outcome may be improved. Further research is needed to understand decisions regarding limitation of support and withdrawal of life-sustaining therapy decisions in patients admitted with day 1 Multiple Organ Dysfunction Syndrome.

In the present work, a new supported liquid membrane (SLM) has been developed for on-chip electromembrane extraction of acidic drugs combined with HPLC or CE, providing significantly higher stability than those reported up to date. The target analytes are five widely used non-steroidal anti-inflammatory drugs (NSAIDs): ibuprofen (IBU), diclofenac (DIC), naproxen (NAX), ketoprofen (KTP) and salicylic acid (SAL). Two different microchip devices were used, both consisted basically of two poly(methyl methacrylate) (PMMA) plates with individual channels for acceptor and sample solutions, respectively, and a 25 µm thick porous polypropylene membrane impregnated with the organic solvent in between. The SLM consisting of a mixture of 1-undecanol and 2-nitrophenyl octyl ether (NPOE) in a ratio 1:3 was found to be the most suitable liquid membrane for the extraction of these acidic drugs under dynamic conditions. It showed a long-term stability of at least 8 hours, a low system current around 20 µA, and recoveries over 94% for the target analytes. NPOE was included in the SLM to significantly decrease the extraction current compared to pure 1-undecanol, while the extraction properties was almost unaffected. Moreover, it has been successfully applied to the determination of the target analytes in human urine samples, providing high extraction efficiency., (© 2019 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Importance: Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care., Objective: To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression., Design, Setting, and Participants: In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat., Interventions: Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status., Main Outcomes and Measures: Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures., Results: Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01)., Conclusions and Relevance: Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care., Trial Registration: ClinicalTrials.gov identifier: NCT01572389.

Background: The authors conducted this study to determine whether septation of the first dorsal compartment is more prevalent in de Quervain tenosynovitis, and whether this contributes to failure of corticosteroid injection therapy., Methods: A retrospective review of 79 consecutive patients (85 wrists) with symptomatic de Quervain tenosynovitis treated with surgical release was performed. The number of corticosteroid injections performed preoperatively and the presence of first dorsal compartment septation determined intraoperatively were recorded. Correlation between the number of steroid injections and the presence of septation was evaluated. In addition, 48 matched cadaver upper extremities (96 wrists) that had not previously undergone surgery for de Quervain disease were evaluated for the presence of first dorsal compartment septation. The prevalence of septation was compared between matched wrists and against the surgically treated clinical cohort., Results: In the clinical cohort, 61.2 percent of wrists contained a septated first dorsal compartment. There was no correlation between the presence of a septated first dorsal compartment and the number of steroid injections before surgical release. In the cadaver portion of the study, 72.9 percent of wrists contained septa. There was no significant difference in the prevalence of septated first dorsal compartments between groups., Conclusions: In the present study, the majority of wrists contained a septated first dorsal compartment, with no difference in the prevalence of septa between surgically treated patients and a cadaver sample that had not undergone prior surgical release. Furthermore, there was no correlation between the presence of septa and the number of preoperative corticosteroid injections administered., Clinical Question/level of Evidence: Risk, III.

Objective: We evaluated the effect of brief cognitive behavioral therapy (bCBT) on suicidal ideation among medically ill veterans receiving mental health treatment in primary care., Methods: Secondary analysis was conducted on data collected during a multisite, patient-randomized trial investigating the impact of bCBT (n = 180) on depression and anxiety symptoms, relative to enhanced usual care (EUC; n = 122), in patients with congestive heart failure and/or chronic obstructive pulmonary disease. BCBT was delivered by primary care mental health providers over 4 months, with follow-up posttreatment assessments of suicidal ideation, measured by the Patient Health Questionnaire-9 (item 9) at 4, 8, and 12 months. Suicidal ideation was the primary outcome examined in the current analysis. Generalized estimating equations modeling suicidal ideation were used to compare the study arms., Results: Participants receiving bCBT were less likely to have high suicidal ideation than participants receiving EUC posttreatment and at 8-month follow-up after accounting for baseline suicidal ideation. Within-group comparisons suggest participants receiving bCBT were less likely to have high suicidal ideation at 4, 8, and 12 months when compared with baseline. High suicidal ideation for EUC participants did not differ at 4, or 8 months, but they were less likely to have high suicidal ideation at 12 months., Conclusion: bCBT in primary care reduces suicidal ideation and may help prevent future suicidal ideation., (Published by Elsevier Inc.)

Background: Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics., Methods: This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation., Discussion: This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics., Trial Registration: ClinicalTrials.gov registration number NCT02713217 . Registered on 18 March 2016.

Purpose: To evaluate the impact of suture caliber and looped configurations on the integrity of 4-strand modified Kessler zone II flexor tendon repairs during progressive cyclic loading., Methods: Seventy-two flexor digitorum profundus tendons from 18 fresh human cadaver hands were divided into 4 repair groups. Thirty-six matched tendons underwent repair using either a 4-0 looped or 4-0 single-stranded suture, and an additional 36 tendons underwent 3-0 looped or 3-0 single-stranded repairs. Repair strength was tested by progressive cyclic loading. The force generating 2-mm gap formation, ultimate failure, and the mechanism of failure were recorded for each test. The impact of looped versus single-stranded configurations and the effect of tendon cross-sectional area on repair integrity were analyzed for each suture caliber., Results: There was no statistically significant difference between groups regarding the force to 2-mm gap formation or ultimate failure, and all values exceeded the minimum threshold of 27 N required to withstand an early active range of motion rehabilitation protocol. The use of a 3-0 caliber suture resulted in a significantly higher proportion of repairs failing by suture pullout through the tendon substance, including 63.5% of looped and 38.9% of single-stranded core sutures. By comparison, this occurred in 11.1% of 4-0 looped and 0% of 4-0 single-stranded sutures. Larger tendon cross-sectional areas were associated with more robust repairs, particularly in the 3-0 looped group., Conclusions: In a human cadaver flexor tendon repair model, there was no significant difference in the mean force to failure between all 4 flexor tendon repair constructs under progressive cyclic loading. However, the 3-0 caliber suture failed more frequently by suture pullout, particularly with the use of a looped suture., Clinical Relevance: Four-strand flexor tendon repairs using a 3-0 caliber suture are more prone to early failure by suture pullout under progressive cyclic loading compared with a 4-0 caliber suture., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction It is estimated that 70% of patients with posttraumatic stress disorder (PTSD) have chronic insomnia. A recent meta-analysis examined cognitive-behavioural therapy for insomnia (CBT-I) in veterans with and without PTSD, and suggested that most studies had questionable methodology, but generally supported its effectiveness in this population. Further, while CBT-I via telehealth (i.e. using telecommunication and information technology to deliver health services) has shown effectiveness for primary insomnia, it has not been applied to PTSD-related insomnia. Methods Veterans with insomnia who were diagnosed with PTSD ( n = 12) or having significant subthreshold PTSD symptoms ( n = 6) on the Clinician Administered PTSD Scale were randomly assigned to receive CBT-I in-person ( n = 7) or by telephone ( n = 11), to pilot test the potential effectiveness, acceptability, and feasibility of administering CBT-I in rural veterans. A six-week CBT-I protocol was delivered, and the veteran's insomnia was assessed at post-treatment and follow-up. Results Given the small sample size, Cohen's d was used to detect group differences, finding large effect sizes favouring the in-person delivery, until three-months post-treatment when this difference diminished. Most veterans found the treatment acceptable, regardless of mode of delivery. Based on the results, a larger project is feasible. Feasibility for a larger project is favourable. Discussion In summary, our findings uphold and extend previous research. Specifically, current pilot data suggest that telephone-delivered CBT-I may be able to reduce trauma-related insomnia symptoms. Future trials are needed to assess the effectiveness of CBT-I delivered to rural veterans with posttraumatic insomnia.

Purpose: Both positive and negative ulnar variance have been implicated in a variety of wrist disorders. Surgery aims to correct the variance in these pathologic conditions. This necessitates accurate and reproducible measuring tools; however, the most accurate radiographic measurement technique remains unclear. The purposes of this study were to evaluate 3 methods for determining ulnar variance and to compare each with direct anatomic measurement in a cadaver model., Methods: We fixed 10 fresh above-elbow cadaver specimens in neutral rotation and obtained standardized fluoroscopic posteroanterior and lateral wrist images. A dorsal approach was performed and two independent investigators directly measured ulnar variance using digital calipers with the cartilage both intact and denuded. Ulnar variance was measured radiographically using the lateral, perpendicular, and central reference point methods. The reliability of each set of measurements (within a 1-mm cutoff) was assessed by the intraclass coefficient; agreement between radiographic and direct measurements was evaluated by the Bland-Altman method., Results: Each method of determining ulnar variance demonstrated near perfect agreement by the intraclass coefficient. The lateral radiograph method correlated highly with the directly measured ulnar variance with the cartilage denuded with an average measurement difference of 0.06 mm. No radiographic measurement technique demonstrated consistent agreement within 1 mm of the measured ulnar variance with the cartilage intact., Conclusions: Ulnar variance measured by the lateral wrist radiograph technique correlates highly with the directly measured osseous ulnar variance. The remaining measurement techniques did not correlate reliably to within 1 mm of the directly measured ulnar variance with 95% confidence. No method was able to account accurately for the articular cartilage thicknesses at the lunate facet of the radius or the distal ulnar head, which we found to vary in an unpredictable manner. Whereas the lateral radiograph has been shown to allow for more reliable standardization of wrist position compared with the posteroanterior view, this study also highlights the inherent limitations of using static radiographic images in evaluating ulnar variance., Clinical Relevance: The results of the current study demonstrate the utility of the lateral wrist radiograph for assessing bony ulnar variance., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Higher levels of moderate to vigorous physical activity improve all-cause mortality and cardiovascular events. However, the effect of running, a moderate to vigorous activity, in those with knee osteoarthritis (OA), a common arthritis that occurs with aging, a high-risk group for mortality and cardiovascular events, is unclear. Therefore, we aimed to evaluate the association of self-selected running on OA symptom and structure progression in people with knee OA. This nested cohort study within the Osteoarthritis Initiative (OAI) (2004-2014) included those at least 50 years old with OA in at least one knee. Runners were defined using a self-administered questionnaire at the 96-month visit. At baseline and 48-months, symptoms were assessed and radiographs were scored for Kellgren-Lawrence (KL) grade (2-4) and medial Joint Space Narrowing (JSN) score (0-3). We evaluated the association of self-selected running with outcomes: KL worsening, medial JSN worsening, new knee pain, and improved knee pain over 48 months, adjusting for baseline age, sex, body mass index (BMI), KL score, contralateral KL score, contralateral knee pain, and injury. If data were not available at the 48-month visit, then they were imputed from the 36-month visit. One thousand two hundred three participants had a mean age of 63.2 (7.9) years, BMI of 29.5 (4.6) kg/m 2 , 45.3% male, and 11.5% runners. Data from 8% of participants required imputation. Adjusted odds ratios for KL grade worsening and new frequent knee pain were 0.9 (0.6-1.3) and 0.9 (0.6-1.6) respectively. Adjusted odds ratio for frequent knee pain resolution was 1.7 (1.0-2.8). Among individuals 50 years old and older with knee OA, self-selected running is associated with improved knee pain and not with worsening knee pain or radiographically defined structural progression. Therefore, self-selected running, which is likely influenced by knee symptoms and may result in lower intensity and shorter duration sessions of exercise, need not be discouraged in people with knee OA.

Objective: This study examined predictors of treatment outcome in a randomized controlled trial of brief cognitive-behavioral therapy (bCBT) for patients with a cardiopulmonary condition and comorbid, clinically significant symptoms of depression and/or anxiety., Method: Only those who completed outcome assessments in the bCBT arm were studied (n = 132), to provide information about predictors of change in psychological symptoms. Multivariable linear regressions were conducted with baseline depression and anxiety symptoms, functional limitations, coping, self-efficacy, number of treatment sessions attended, and working alliance as potential predictors of change from pre- to postintervention on the dependent variables, depression [Patient Health Questionniare-9] and anxiety [Beck Anxiety Inventory])., Results: Significant predictors of improvement in depression and anxiety included baseline mental health symptoms, physical health functional impairment, and self-efficacy. Coping, working alliance, and number of sessions attended were not associated with change in depression or anxiety., Conclusion: Patients with greater physical functioning limitations and lower self-efficacy may experience less change in depression and anxiety during brief CBT. Future research should examine how to boost treatment effectiveness for patients with these characteristics. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

This paper reports for the first time nanoliter-scale electromembrane extraction (nanoliter-scale EME) in a microfluidic device. Six basic drug substances (model analytes) were extracted from 70 μL samples of human whole blood, plasma, or urine through a supported liquid membrane (SLM) of 2-nitrophenyl octyl ether (NPOE) and into 6 nL of 10 mM formic acid as an acceptor solution. A DC potential of 15 V was applied across the SLM and served as the driving force for the extraction. The cathode was located in the acceptor solution. Because of the small area of the SLM (0.06 mm 2 ), the system provided soft extraction with recoveries <1% for the 70 μL samples. Because of the large sample-to-acceptor-volume ratio, analytes were enriched in the acceptor solution. The enrichment capacity was 6-7-fold per minute, and after 60 min of operation, most of the model analytes were enriched by a factor of approximately 400. Because of the SLM and the direction of the applied electrical field, substantial sample cleanup was obtained. The chips were based on thiol-ene polymers, and the soft-lithography-fabrication procedure and the materials were selected in such a way that future mass production should be feasible. The chip-to-chip variability was within 23% RSD (and less than 10% in most cases) with respect to extraction recovery. Our findings have verified that nanoliter-scale EME is highly feasible and provides reliable data, and for future studies, the concept should be tested for applicability in connection with in vitro microphysiological systems, organ-on-a-chip systems, and point-of-care diagnostics. These are potential areas where the combination of soft extraction and high enrichment from limited sample volumes is required for reliable analytical measurements.

Background: Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects., Purpose: To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness., Methods: Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition., Results: Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning., Conclusions: Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients.

Evaluation of drug precipitation is important in order to address challenges regarding low and variable bioavailability of poorly water-soluble drugs, to assess potential risk of patient safety with infusion therapy, and to explore injectable in situ suspension-forming drug delivery systems. Generally, drug precipitation is assessed in vitro through solution concentration analysis methods. Dual-wavelength UV-vis imaging is a novel imaging technique that may provide an opportunity for simultaneously monitoring changes in both solution and solid phases during precipitation. In the present study, a multimodal approach integrating UV-vis imaging, light microscopy, and Raman spectroscopy was developed for characterization of piroxicam supersaturation, precipitation, and dissolution in a flow-through setup. A solution of piroxicam dissolved in 1-methyl-2-pyrrolidinone was injected into a flowing aqueous environment (pH 7.4), causing piroxicam to precipitate. Imaging at 405 and 280 nm monitored piroxicam concentration distributions during precipitation and revealed different supersaturation levels dependent on the initial concentration of the piroxicam solution. The combination with imaging at 525 nm, light microscopy, and Raman spectroscopy measurements demonstrated concentration-dependent precipitation and the formation, growth, and dissolution of individual particles. Results emphasize the importance of the specific hydrodynamic conditions on the piroxicam precipitation. The approach used may facilitate comprehensive understanding of drug precipitation and dissolution processes and may be developed further into a basic tool for formulation screening and development.

This study sought to identify salient factors associated with the Problem Areas in Diabetes Scale to facilitate improved assessment and treatment of diabetes-related burden. Exploratory factor analysis assessed the factor structure of the Problem Areas in Diabetes Scale among 224 Veterans with uncontrolled type 2 diabetes and depressive symptoms. A four-factor solution of emotional, diabetes management, treatment, and social support burden subscales was extracted. These factors represent clinically relevant components of diabetes burden that include but go beyond symptoms of depression. The Problem Areas in Diabetes subscales may expand assessments for depression and improve medical and behavioral health interventions for patients with diabetes.

Many patients with diabetes have poorly controlled blood sugar levels and remain at risk for serious diabetes complications, despite access to effective diabetes treatments and services. Using the transactional model of stress and coping framework, the study investigated the contributions of affect (Positive and Negative Affect Schedule) and coping (maladaptive and adaptive coping from the Brief Cope) on diabetes self-management behaviors, namely diet and exercise. One hundred seventy-eight rural adults with uncontrolled diabetes and moderate depressive symptoms completed the measures. Multiple regression analyses demonstrated that positive affect and negative affect were significantly associated with diet and exercise, even after adjusting for diabetes severity, illness intrusiveness, and diabetes knowledge. However, two path analyses clarified that adaptive coping mediated the relationships between affect (positive and negative) and self-management behaviors (diet and exercise). Comprehensive diabetes treatments that include self-management support can assist patients in recognition and use of adaptive emotion-focused coping skills.