A Self-Help Crisis Outreach Effort for At-Risk Primary Care Patients: A Pilot Study of Veterans During the COVID-19 Pandemic

Stressful events can exacerbate symptoms of psychiatric disorders among primary care patients, putting them at increased risk for suicide. In a pilot study that ran from August to December of 2020, researchers evaluated the acceptability and implementation of Managing Emotions in Disaster and Crisis (MEDIC), a self-help intervention designed to assist at-risk primary care patients. A total of 108 at-risk veterans completed baseline and 6-week assessments. Results were promising, with high patient acceptability and engagement along with improvement in all measures of mental illness symptoms from baseline to posttreatment. Self-help interventions like MEDIC may offer a low-burden way for primary care providers to support more patients.

Piplartine eliminates CD34 + AML stem/progenitor cells by inducing oxidative stress and suppressing NF-κB signalling

Acute myeloid leukaemia (AML) is a haematological malignancy characterised by the accumulation of transformed myeloid progenitors in the bone marrow. Piplartine (PL), also known as piperlongumine, is a pro-oxidant small molecule extracted from peppers that has demonstrated antineoplastic potential in solid tumours and other haematological malignancies. In this work, we explored the potential of PL to treat AML through the use of a combination of cellular and molecular analyses of primary and cultured leukaemia cells in vitro and in vivo. We showed that PL exhibits in vitro cytotoxicity against AML cells, including CD34+ leukaemia-propagating cells, but not healthy haematopoietic progenitors, suggesting anti-leukaemia selectivity. Mechanistically, PL treatment increased reactive oxygen species (ROS) levels and induced ROS-mediated apoptosis in AML cells, which could be prevented by treatment with the antioxidant scavenger N-acetyl-cysteine and the pancaspase inhibitor Z-VAD(OMe)-FMK. PL treatment reduced NFKB1 gene transcription and the level of NF-κB p65 (pS536), which was depleted from the nucleus of AML cells, indicating suppression of NF-κB p65 signalling. Significantly, PL suppressed AML development in a mouse xenograft model, and its combination with current AML treatments (cytarabine, daunorubicin and azacytidine) had synergistic effects, indicating translational therapeutic potential. Taken together, these data position PL as a novel anti-AML candidate drug that can target leukaemia stem/progenitors and is amenable to combinatorial therapeutic strategies.

Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study

BACKGROUND

Individuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers' role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings.

METHODS

We conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper.

RESULTS

Sixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers' roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out.

CONCLUSIONS

Feedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers' unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

PET imaging of TREM1 identifies CNS-infiltrating myeloid cells in a mouse model of multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system (CNS) that causes substantial morbidity and diminished quality of life. Evidence highlights the central role of myeloid lineage cells in the initiation and progression of MS. However, existing imaging strategies for detecting myeloid cells in the CNS cannot distinguish between beneficial and harmful immune responses. Thus, imaging strategies that specifically identify myeloid cells and their activation states are critical for MS disease staging and monitoring of therapeutic responses. We hypothesized that positron emission tomography (PET) imaging of triggering receptor expressed on myeloid cells 1 (TREM1) could be used to monitor deleterious innate immune responses and disease progression in the experimental autoimmune encephalomyelitis (EAE) mouse model of MS. We first validated TREM1 as a specific marker of proinflammatory, CNS-infiltrating, peripheral myeloid cells in mice with EAE. We show that the ⁶⁴Cu-radiolabeled TREM1 antibody-based PET tracer monitored active disease with 14- to 17-fold higher sensitivity than translocator protein 18 kDa (TSPO)-PET imaging, the established approach for detecting neuroinflammation in vivo. We illustrate the therapeutic potential of attenuating TREM1 signaling both genetically and pharmacologically in the EAE mice and show that TREM1-PET imaging detected responses to an FDA-approved MS therapy with siponimod (BAF312) in these animals. Last, we observed TREM1⁺ cells in clinical brain biopsy samples from two treatment-naïve patients with MS but not in healthy control brain tissue. Thus, TREM1-PET imaging has potential for aiding in the diagnosis of MS and monitoring of therapeutic responses to drug treatment.

Implementing evidence-based telephone coaching for health behavior program enrollment: A quality improvement project

INTRODUCTION

This program evaluation describes the use of implementation facilitation to support uptake of a telephone-based engagement coaching intervention, ACTIVATE, using paraprofessional staff, to support health behavior program enrollment.

METHOD

The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework guided the formative evaluation. A mixed-methods approach was used to integrate qualitative (i.e., rapid analysis approach) and quantitative (i.e., descriptive statistics, chi-square test of independence, logistic regression) analyses for each outcome.

RESULTS

Most patients (95%; 319 of 335) were offered ACTIVATE, and 82 patients completed ACTIVATE. Delivery with paraprofessional staff was feasible with adaptations for translation from research to a clinical setting, which are described. External facilitation (a form of implementation facilitation) was associated with higher reach.

DISCUSSION

Delivery of telephone-based coaching by paraprofessional staff to support health behavior program enrollment was feasible. External facilitation was important to the translation of ACTIVATE from research to clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Effects of Acute and Repeated Administration of Ketamine on Memory, Behavior, and Plasma Corticosterone Levels in Female Mice

Ketamine is an anesthetic drug that has recently been approved for the treatment of treatment-resistant depression. Females are diagnosed with Major Depressive Disorder at higher rates than males, yet most of the pre-clinical research on ketamine has been conducted in male subjects. Additionally, the literature on the acute and long-term behavioral and cognitive effects of ketamine shows conflicting results. It is important to examine the acute and long-term cognitive and behavioral effects of ketamine exposure at lower sub-anesthetic doses, as the recreational use of the drug at higher doses is associated with cognitive and memory impairments. The current study examined the effects of acute and repeated ketamine exposure on anxiety-like behavior, novel object recognition memory, depression-like behavior, and plasma corticosterone levels in 20 adult female C57BL/6J mice. Mice were exposed acutely or repeatedly for 10 consecutive days to saline or 15 mg/kg ketamine and behavior was measured in the open field test, novel object recognition test, and the Porsolt forced swim test. Plasma corticosterone levels were measured following behavioral testing. Acute ketamine exposure decreased locomotor activity and increased anxiety-like behavior in the open field test compared to controls, while repeated ketamine exposure impaired memory in the novel object recognition test. There were no effects of acute or repeated ketamine exposure on depression-like behavior in the Porsolt forced swim test or on plasma corticosterone levels. These findings suggest that a subanesthetic dose of ketamine alters behavior and cognition in female mice and the effects are dependent on the duration of exposure.

Variation within the visually evoked neurovascular coupling response of the posterior cerebral artery is not influenced by age or sex

Neurovascular coupling (NVC) is the temporal and spatial coordination between local neuronal activity and regional cerebral blood flow. The literature is unsettled on whether age and/or sex affect NVC, which may relate to differences in methodology and the quantification of NVC in small sample-sized studies. The aim of this study was to 1) determine the relative and combined contribution of age and sex to the variation observed across several distinct NVC metrics (n = 125, 21–66 yr; 41 males) and 2) present an approach for the comprehensive systematic assessment of the NVC response using transcranial Doppler ultrasound. NVC was measured as the relative change from baseline (absolute and percent change) assessing peak, mean, and total area under the curve (tAUC) of cerebral blood velocity through the posterior cerebral artery (PCAv) during intermittent photic stimulation. In addition, the NVC waveform was compartmentalized into distinct regions, acute (0–9 s), mid (10–19 s), and late (20–30 s), following the onset of photic stimulation. Hierarchical multiple regression modeling was used to determine the extent of variation within each NVC metric attributable to demographic differences in age and sex. After controlling for differences in baseline PCAv, the R² data suggest that 1.6%, 6.1%, 1.1%, 3.4%, 2.5%, and 4.2% of the variance observed within mean, peak, tAUC, acute, mid, and late response magnitude is attributable to the combination of age and sex. Our study reveals that variability in NVC response magnitude is independent of age and sex in healthy human participants, aged 21–66 yr.

NEW & NOTEWORTHY We assessed the variability within the neurovascular coupling response attributable to age and sex (n = 125, 21–66 yr; 41 male). Based on the assessment of posterior cerebral artery responses to visual stimulation, 0%–6% of the variance observed within several metrics of NVC response magnitude are attributable to the combination of age and sex. Therefore, observed differences between age groups and/or sexes are likely a result of other physiological factors.

Practical and Emotional Peer Support Tailored for Life's Challenges: Personalized Support for Progress Randomized Clinical Pilot Trial in a Veterans Health Administration Women's Clinic

INTRODUCTION

Women Veterans experience a broad range of stressors (e.g., family, relationship, and financial) and high rates of mental health and physical health conditions, all of which contribute to high levels of stress. Personalized Support for Progress (PSP), an evidence-based intervention, is well suited to support women Veterans with high stress as it involves a card-sort task to prioritize concerns as well as pragmatic and emotional support to develop and implement a personalized plan addressing those concerns. Our aims were to explore the population and context for delivery and evaluate the feasibility, acceptability, and utility of PSP delivered by a peer specialist to complement existing services in a Veterans Health Administration (VHA) Women's Wellness Center.

MATERIALS AND METHODS

This randomized controlled pilot trial compared treatment as usual plus PSP to treatment as usual and used the a priori Go/No-Go criteria to establish success for each outcome. We interviewed staff regarding the population and delivery context at a VHA Women's Wellness Center and analyzed interviews using a rapid qualitative approach. For the rapid qualitative analysis, we created templated summaries of each interview to identify key concepts within each a priori theme, reviewed each theme's content across all interviews, and finally reviewed key concepts across themes. We evaluated feasibility using recruitment and retention rates; acceptability via Veteran satisfaction, working relationship with the peer, and staff satisfaction; and utility based on the proportion of Veterans who experienced a large change in outcomes (e.g., stress, mental health symptoms, and quality of life). The Syracuse VA Human Subjects Institutional Review Board approved all procedures.

RESULTS

Staff interviews highlight that women Veterans have numerous unmet social needs and concerns common among women which increase the complexity of their care; call for a supportive, consistent, trusting relationship with someone on their health care team; and require many resources (e.g., staff such as social workers, services such as legal support, and physical items such as diapers) to support their needs (some of which are available within VHA but may need support for staffing or access, and some of which are unavailable). Feasibility outcomes suggest a need to modify PSP and research methods to enhance intervention and assessment retention before the larger trial; the recruitment rate was acceptable by the end of the trial. Veteran acceptability of PSP was high. Veteran outcomes demonstrate promise for utility to improve stress, mental health symptoms, and quality of life for women Veterans.

CONCLUSIONS

Given the high acceptability and promising outcomes for utility, changes to the design to enhance the feasibility outcomes which failed to meet the a priori Go/No-Go criteria are warranted. These outcomes support future trials of PSP within VHA Women's Wellness Centers.

Shock wave formation from head-on collision of two subsonic vortex rings

Vortex ring collisions have attracted intense interest in both water and air studies (Baird in Proc R Soc Lond Ser Math Phys Sci 409:59–65, 1987, Poudel et al. in Phys Fluids 33:096105, 2021, Lim and Nickels in Nature 357:225, 1992, New et al. in Exp Fluids 57:109, 2016, Suzuki et al. in Geophys Res Lett 34, 2007, Yan et al. in J Fluids Eng 140:054502, 2018, New et al. in J Fluid Mech 899, 2020, Cheng et al. in Phys Fluids 31:067107, 2019, Hernández and Reyes in 29:103604, 2017, Mishra et al. in Phys Rev Fluids, 2021, Zednikova et al. in Chem Eng Technol 42:843–850, 2019, Kwon et al. in Nature 600:64–69, 2021). These toroidal structures spin around a central axis and travel in the original direction of impulse while spinning around the core until inertial forces become predominant causing the vortex flow to spontaneously decay to turbulence (Vortex Rings, https://projects.iq.harvard.edu/smrlab/vortex-rings). Previous studies have shown the collision of subsonic vortex rings resulting in reconnected vortex rings, but the production of a shock wave from the collision has not been demonstrated visibly (Lim and Nickels in Nature 357:225, 1992, Cheng et al. in Phys Fluids 31:067107, 2019). Here we present the formation of a shock wave due to the collision of explosively formed subsonic vortex rings. As the vortex rings travel at Mach 0.66 toward the collision point, they begin to trap high pressure air between them. Upon collision, high pressure air was imploded and released radially away from the axis of the collision, generating a visible shock wave traveling through and away from the colliding vortices at Mach 1.22. Our results demonstrate a pressure gradient with high pressure release creating a shock wave. We anticipate our study to be a starting point for more explosively formed vortex collisions. For example, explosives with different velocities of detonation could be tested to produce vortex rings of varying velocities.

Characteristics of Patients With Complex Limb Pain Evaluated Through an Interdisciplinary Approach Utilizing Magnetic Resonance Neurography

Patients with persistent complex limb pain represent a substantial diagnostic challenge. Physical exam, and tests such as nerve conduction, are often normal even though the patient suffers from severe pain. In 2015, we initiated a team-based approach to evaluate such patients. The approach included physicians from several specialties (Anesthesiology/Pain Medicine, Radiology, Plastic Surgery, Neurosurgery) combined with the use of advanced imaging with Magnetic Resonance Neurography (MRN). This preliminary case series discusses MRN findings identified in patients with previously difficult-to-diagnose peripheral limb pain and describes how this combination of approaches influenced our diagnosis and treatment plans. We extracted demographics, patient characteristics, presenting features, diagnostic tests performed, treatments provided, referral diagnosis and the diagnosis after interdisciplinary team evaluation from patient charts. We evaluated MRN and electrodiagnostic studies (EDX) ability to identify injured nerves. We compared abnormal findings from these diagnostics to patient reported outcome after ultrasound-guided nerve block. A total of 58 patients, 17 males and 41 females, were identified. The majority of patients presented with lower extremity pain (75%) and had prior surgery (43%). The most commonly identified abnormality on MRN was nerve signal alteration on fluid sensitive sequences, followed by caliber change and impingement. Comparing the outcome of diagnostic nerve blocks with abnormal nerve findings on MRN or EDX, we found that MRN had a sensitivity of 67% and specificity of 100% while for EDX it was 45 and 0%, respectively. After interdisciplinary discussion and imaging review, a more specific diagnosis was produced in 78% of evaluated cases opening up additional treatment pathways such as nerve-targeted surgery, which was performed in 36% cases. This descriptive case series demonstrates that a majority of patients evaluated by our team for complex limb pain were women with lower extremity pain resulting from surgery. In addition, an interdisciplinary team evaluation and the use of the moderately sensitive but highly specific MRN imaging modality resulted in a change in diagnosis for a majority of patients with complex limb pain. Future studies investigating patient outcomes after diagnosis change are currently underway based on the findings of this preliminary study.

Leveraging Integrated Primary Care to Address Patients' and Families' Unmet Social Needs: Aligning Practice with National Academy of Sciences, Engineering and Medicine Recommendations

Primary care is well-poised to address unmet social needs that affect health. Integrated primary care is increasingly common and can be leveraged to facilitate identification of practice and clinician-level modifiable characteristics and assist practices to address unmet social needs for patients and families. A recent National Academies of Sciences, Engineering, and Medicine (NASEM)'s consensus report identified 5 critical system-level activities to facilitate the integration of addressing social needs into health care: awareness (ask patients), adjustment (flexible intervention delivery), assistance (intervention to address the social need), alignment (link with community resources), and advocacy (policy change). This article outlines how integrated primary care characteristics, such as routine screening, functional workflows, interprofessional team communication, and patient-centered practices, exemplify the NASEM report's activities and offer robust biopsychosocial tools for addressing social needs. We provide a case to illustrate how these strategies might be used in practice.

Expanding access to psychosocial research studies during the COVID-19 pandemic through virtual modalities

The COVID-19 pandemic has caused psychosocial researchers and clinicians to quickly shift from standard in-person practices to remote modalities. Despite calls to maintain current virtual care modalities due to the potential to improve access to health care, we are not yet aware of any scholarly works which explicitly describe specific modifications made in response to the restrictions to face-to-face care, resulting access, and implications for the field. This commentary describes how modifications to transition both clinical and research processes to fully virtual modalities in 2 ongoing integrated primary care clinical trials during the COVID-19 pandemic increased access. Given the feasibility of implementing these modifications and the success demonstrated by increased enrollment, we advocate for continued use of virtual modalities for both clinical work and research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Temperature alone is insufficient to understand hibernation energetics

Energy conservation has long been a focal point in hibernation research. A long-standing assumption is that ambient temperature (Ta) largely defines the rate of energy expenditure because of well-known relationships between Ta, metabolic rate and frequency of arousal from torpor. Body condition and humidity also affect energy expenditure but are usually considered secondary factors. We held tricolored bats (Perimyotis subflavus) in captivity under multiple environmental conditions to directly compare the importance of Ta, fat mass and humidity for hibernation energy expenditure. Fat mass was the best predictor of female mass loss, followed by Ta and humidity. However, males had less fat and adopted a more energetically conservative hibernation strategy. Our results demonstrate that understanding the evolution of behavior, physiology and ecology of hibernation requires disentangling the relative contributions of multiple drivers of hibernation energetics, and that Ta is not always the most important factor driving energy expenditure.

The Cost of Cancer: The Association of Financial and Cancer-Related Stress on Maladaptive Coping Styles in Families with a Cancer Diagnosis

According to the American Cancer Society (2020), it is estimated that 1.8 million new cancer diagnoses will occur in 2019 in the United States. Due to the frequency of cancer diagnoses and the increasing costs of treatment, financial stress is common among cancer patients. Guided by the Family Systems Illness Model (FSI), a cross-sectional study of individuals and family members where there was an active cancer diagnosis (n = 53) was conducted. The study utilized structural equation modeling to examine the impact of cancer stress and financial stress on maladaptive family coping mechanisms, and in turn, their effect on family communication and satisfaction. Findings indicate individuals with higher financial stress reported greater cancer stress. In turn, individuals with higher cancer stress, reported higher rigidity in their family coping which was associated with less family satisfaction. Additionally, as individuals reported greater family disengagement and chaos, lower levels of family communication and satisfaction were found. These findings provide evidence to the complex stresses experienced by cancer patients and their families. Therapeutic implications of how emotionally focused therapy may support these families dealing with a cancer diagnosis are discussed.

Engagement, experience, and satisfaction with peer-delivered whole health coaching for veterans with PTSD: A mixed methods process evaluation

To describe the process of peer-delivered Whole Health Coaching, a primary care-based intervention in which peers provide patients with individualized support to set and work toward wellness goals. Fifteen primary care Veterans with PTSD participated in peer-delivered Whole Health Coaching during a multiple baseline design study. This is a planned mixed methods concurrent equal status analysis of the process of peer-delivered Whole Health Coaching including patient engagement, patient experience, fidelity to the coaching and peer roles, and patient satisfaction. Data sources were feedback interviews, electronic medical record reviews, self-report assessments, and observer fidelity ratings of session recordings. Qualitative data were used to expand the interpretation of quantitative descriptive data. A rapid assessment approach was used for qualitative analysis. Retention in peer-delivered Whole Health Coaching was 11 of 15 participants, and factors facilitating engagement were peers as providers and flexibility in scheduling/modality of sessions. Peers demonstrated high fidelity to coaching skills, Whole Health Coaching phases and stages, and the peer role. Participants expressed high satisfaction and perceived peer-delivered Whole Health Coaching as helpful with making progress on individualized wellness goals. Results build on the literature describing the expansion of peer services into primary care and implementation of interventions such as wellness coaching. This initial small study suggests that peers can deliver high-quality wellness coaching, and this description of the process can guide the integration of peers doing wellness coaching in similar clinical settings and for future research trials. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Problem recognition and treatment beliefs relate to mental health utilization among veteran primary care patients

Mental health concerns are prevalent among primary care patients, but many do not utilize services for these conditions. This study aims to conduct a comprehensive assessment of barriers and facilitators to mental health care utilization among veteran primary care patients with common mental health concerns. We hypothesized that beliefs and knowledge about mental illness and mental health care would be more strongly associated with recent mental health care utilization than stigma, help-seeking behaviors, or logistical barriers. Veterans (n = 116) enrolled in primary care with current symptoms of depression (58%), posttraumatic stress disorder (37%), and/or hazardous alcohol use (50%) who either recently used mental health services (47%) or had no recent mental health treatment utilization (53%) completed a telephone-based screening, medical records review, and mail survey of 10 measures of barriers and facilitators to mental health treatment utilization. Recognition of problems as a cause for concern, odds ratio = 5.95, 95% confidence interval [2.36, 15.01], and beliefs about psychotherapy, odds ratio = 2.53, 95% confidence interval [1.39, 4.60], emerged as stronger correlates of recent mental health care utilization than stigma, self-efficacy, and external barriers to treatment. Results suggest the use of specific theories, measures, and interventions that focus on patient recognition of problems and beliefs about treatment over those that focus on other treatment barriers and facilitators. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Bronchoalveolar lavage fluid IMMY Sona Aspergillus lateral-flow assay for the diagnosis of invasive pulmonary aspergillosis: a prospective, real life evaluation

Prompt and reliable diagnosis of invasive pulmonary aspergillosis (IPA) is essential for early initiation of antifungal therapy. We evaluated bronchoalveolar lavage (BAL) fluid IMMY Sona Aspergillus lateral-flow assay (IMMY LFA) in 92 individuals with suspected pulmonary infection. Sensitivity and specificity (vs. host factor but no IPA) of BAL IMMY LFA for diagnosis of IPA in individuals with any European Organisation for Research and Treatment of Cancer-defied "host factor" were 67% and 85%, respectively. Performance appeared better in individuals with renal transplantation (100%, 100%), compared to those with hematological malignancy and/or allogenic stem cell transplantation (70%, 78%). We found BAL IMMY LFA to be a convenient and useful addition to our diagnostic armory for IPA.

LAY ABSTRACT

We evaluated a new test for diagnosing invasive pulmonary aspergillosis from bronchoscopy samples. We tested 92 people and found that it was 67% sensitive and 85% specific (compared to diagnosis according to a set of internationally recognised criteria). We found this test convenient and useful.

PTPN11 Gain-of-Function Mutations Affect the Developing Human Brain, Memory, and Attention

The Ras-MAPK pathway has an established role in neural development and synaptic signaling. Mutations in this pathway are associated with a collection of neurodevelopmental syndromes, Rasopathies; among these, Noonan syndrome (NS) is the most common (1:2000). Prior research has focused on identifying genetic mutations and cellular mechanisms of the disorder, however, effects of NS on the human brain remain unknown. Here, imaging and cognitive data were collected from 12 children with PTPN11-related NS, ages 4.0-11.0 years (8.98 ± 2.33) and 12 age- and sex-matched typically developing controls (8.79 ± 2.17). We observe reduced gray matter volume in bilateral corpus striatum (Cohen's d = -1.0:-1.3), reduced surface area in temporal regions (d = -1.8:-2.2), increased cortical thickness in frontal regions (d = 1.2-1.3), and reduced cortical thickness in limbic regions (d = -1.6), including limbic structures integral to the circuitry of the hippocampus. Further, we find high levels of inattention, hyperactivity, and memory deficits in children with NS. Taken together, these results identify effects of NS on specific brain regions associated with ADHD and learning in children. While our research lays the groundwork for elucidating the neural and behavioral mechanisms of NS, it also adds an essential tier to understanding the Ras-MAPK pathway's role in human brain development.

Using routine blood parameters to anticipate clinical outcomes in invasive aspergillosis

OBJECTIVE

In invasive aspergillosis (IA), monitoring response to antifungal treatment is challenging. We aimed to explore if routine blood parameters help to anticipate outcomes following IA.

METHODS

Post hoc secondary analysis of two multicenter randomized trials was performed. The Global Comparative Aspergillosis Study (GCA, n = 123) and the Combination Antifungal Study (CAS, n = 251) constituted the discovery and validation cohorts respectively. The outcome measures were response to treatment and survival to 12 weeks. Interval platelet, galactomannan index (GMI) and C-reactive protein (CRP) levels prior and during antifungal treatment were analysed using logistic regression, Kaplan-Meier survival and receiver operating characteristic (ROC) analyses.

RESULTS

The 12-week survival was 70.7% and 63.7% for the GCA and CAS cohorts respectively. In the GCA cohort, every 10 × 10⁹/L platelet count increase at week 2 and 4 improved 12-week survival odds by 6-18% (odds ratio (OR) 1.06-1.18, 95% confidence interval (CI) 1.02-1.33). Survival odds also improved 13% with every 10 mg/dL CRP drop at week 1 and 2 (OR 0.87, 95% CI 0.78-0.97). In the CAS cohort, week 2 platelet count was also associated with 12-week survival with 10% improved odds for every 10 × 10⁹/L platelet increase (OR, 1.10, 95% CI 1.04-1.15). A GMI drop of 0.1 unit was additionally found to increase the odds of treatment response by 3% at the baseline of week 0 (OR 0.97, 95% CI 0.95-0.99). Week 2 platelet and CRP levels performed better than GMI on ROC analyses for survival (area under ROC curve 0.76, 0.87 and 0.67 respectively). A baseline platelet count higher than 30 × 10⁹/L clearly identified patients with >75% survival probability.

CONCLUSIONS

Higher serial platelets were associated with overall survival while GMI trends were linked to IA treatment response. Routine and simple laboratory indices may aid follow-up of response in IA patients.

Defining the things we can change to improve access to mental health care

Access and utilization of mental health care are critical components of ensuring public health. In this conceptual article, we define modifiable factors affecting mental health care utilization with the goal of providing a pragmatic framework for providers and clinics to increase access to mental health care. Five shared constructs emerged from a review of prominent health behavior theories: (a) mental illness beliefs, knowledge, and recognition; (b) mental health treatment beliefs and knowledge; (c) stigma including perceived norms, public stigma, and self-stigma; (d) help-seeking behaviors including knowledge, motivation, self-efficacy, and skills; and (e) external barriers and facilitators such as cues, logistics, and social support. We explore how these constructs influence mental health care utilization including interpretation and perception of mental health symptoms, acceptability and awareness of treatment options, and skills and ability to find, schedule, and attend mental health care. Finally, we make recommendations on how this broader framework can be used by primary care clinician innovators to implement interventions to reduce disparities and improve access to mental health care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A pilot study comparing peer supported web-based CBT to self-managed web CBT for primary care veterans with PTSD and hazardous alcohol use

OBJECTIVE

Many combat veterans struggle with posttraumatic stress disorder (PTSD) and hazardous alcohol use and are hesitant to engage in behavioral health services. Combining peer support with an eHealth intervention may overcome many barriers to care. This pilot study investigated the feasibility of adding peer support to a web-based cognitive behavior therapy (CBT) targeting PTSD symptoms and hazardous drinking, called Thinking Forward.

METHOD

Thirty primary care patients with PTSD and hazardous alcohol use were randomized to receive Thinking Forward with or without peer support. Participants were assessed at pretreatment, posttreatment, and 24-week follow-up. Feasibility was analyzed with descriptive statistics. Preliminary outcomes were analyzed with multilevel modeling and effect sizes are presented.

RESULTS

Peer support specialists can be feasibly trained to support the Thinking Forward intervention with good fidelity. Both participants and peers reported good satisfaction with the protocol; although peers discussed a mismatch between the philosophies of peer support and diagnostically focused CBT. All participants experienced significant improvements in PTSD, quality of life, resiliency, and coping from pre- to posttreatment, with no differences between conditions. Pretreatment patient activation predicted outcomes regardless of whether participants received peer support.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Peer support interventions to facilitate eHealth programs should strive to be consistent with the person-centered, recovery orientation of peer support, explicitly focus on patient activation, and consider characteristics of the patients, such as their level of problem recognition and willingness to engage in traditional behavioral health modalities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Peripheral TREM1 responses to brain and intestinal immunogens amplify stroke severity

Stroke is a multiphasic process in which initial cerebral ischemia is followed by secondary injury from immune responses to ischemic brain components. Here we demonstrate that peripheral CD11b+CD45+ myeloid cells magnify stroke injury via activation of triggering receptor expressed on myeloid cells 1 (TREM1), an amplifier of proinflammatory innate immune responses. TREM1 was induced within hours after stroke peripherally in CD11b+CD45+ cells trafficking to ischemic brain. TREM1 inhibition genetically or pharmacologically improved outcome via protective antioxidant and anti-inflammatory mechanisms. Positron electron tomography imaging using radiolabeled antibody recognizing TREM1 revealed elevated TREM1 expression in spleen and, unexpectedly, in intestine. In the lamina propria, noradrenergic-dependent increases in gut permeability induced TREM1 on inflammatory Ly6C+MHCII+ macrophages, further increasing epithelial permeability and facilitating bacterial translocation across the gut barrier. Thus, following stroke, peripheral TREM1 induction amplifies proinflammatory responses to both brain-derived and intestinal-derived immunogenic components. Critically, targeting this specific innate immune pathway reduces cerebral injury.

Professional development in evidence-based practice: course survey results to inform administrative decision making

Objective

To understand librarians’ evidence-based practice (EBP) professional development needs and assist library administrators with professional development decisions in their own institutions, the study team surveyed past participants of an EBP online course. This study aimed to (1) understand what course content participants found valuable, (2) discover how participants applied their course learning to their work, and (3) identify which aspects of EBP would be beneficial for future continuing education.

Methods

The study team distributed an eighteen-question survey to past participants of the course (2011–2017). The survey covered nontraditional demographic information, course evaluations, course content applications to participants’ work, additional EBP training, and EBP topics for future CE opportunities. The study team analyzed the results using descriptive statistics.

Results

Twenty-nine percent of course participants, representing different library environments, responded to the survey. Eighty-five percent of respondents indicated that they had prior EBP training. The most valuable topics were searching the literature (62%) and developing a problem, intervention, comparison, outcome (PICO) question (59%). Critical appraisal was highly rated for further professional development. Fifty-three percent indicated change in their work efforts after participating in the course. Ninety-seven percent noted interest in further EBP continuing education.

Conclusions

Survey respondents found value in both familiar and unfamiliar EBP topics, which supported the idea of using professional development for learning new concepts and reinforcing existing knowledge and skills. When given the opportunity to engage in these activities, librarians can experience new or expanded EBP work roles and responsibilities. Additionally, the results provide library administrators insights into the benefit of EBP professional development.

Wellness in Sickness and Health (The W.I.S.H. Project): Advance Care Planning Preferences and Experiences Among Elderly Latino Patients

OBJECTIVE

To assess advance care planning (ACP) preferences, experiences, and comfort in discussing end-of-life (EOL) care among elderly Latinos.

METHODS

Patients aged 60 and older from the Los Angeles County and University of Southern California (LAC+USC) Medical Center Geriatrics Clinic (n = 41) participated in this intervention. Trained staff conducted ACP counseling with participants in their preferred language, which included: (a) pre-counseling survey about demographics and EOL care attitudes, (b) discussion of ACP and optional completion of an advance directive (AD), and (c) post-session survey.

RESULTS

Patients were primarily Spanish speaking with an average of 2.7 chronic medical conditions. Most had not previously documented (95%) or discussed (76%) EOL wishes. Most were unaware they had control over their EOL treatment (61%), but valued learning about EOL options (83%). Post-counseling, 85% reported comfort discussing EOL goals compared to 66% pre-session, and 88% elected to complete an AD. Nearly half of patients reported a desire to discuss EOL wishes sooner.

CONCLUSIONS

Elderly Latino patients are interested in ACP, given individualized, culturally competent counseling in their preferred language.

CLINICAL IMPLICATIONS

Patients should be offered the opportunity to discuss and document EOL wishes at all primary care appointments, regardless of health status. Counseling should be completed in the patient's preferred language, using culturally competent materials, and with family members present if this is the patient's preference. Cultural-competency training for providers could enhance the impact of EOL discussions and improve ACP completion rates for Latino patients.

Correlates and predictors of mental health care utilization for veterans with PTSD: A systematic review

OBJECTIVE

Treatment utilization among veterans with posttraumatic stress disorder (PTSD) is low. Understanding correlates and predictors of mental health care for veterans with PTSD is critical to facilitating treatment utilization. However, given the size of the literature base and disparate findings, it is difficult to interpret available research. Correlates and predictors of mental health care for veterans with PTSD published between 2012 and 2016 were examined to (a) define the scope of recent literature and (b) summarize predictive evidence.

METHOD

This 2-phase systematic review conducted scientific database searches. Phase 1 defined the scope of recent literature (n = 51) and tabulated types of correlates, outcomes, and sources of bias. Phase 2 summarized results from prospective studies (n = 17) evaluating mental health care utilization (PROSPERO ID No. CRD42017082686).

RESULTS

Demographics-social network characteristics (61%) and evaluated need (61%) were the most common correlates of mental health utilization. Facilitators with the strongest evidence for predicting utilization (both initiation and retention) were characteristics of the episode of care (e.g., mental health in primary care) and greater PTSD symptom severity. Study biases favoring Department of Veterans Affairs (VA) enrollees (92%) and excluding outside VA care outcomes (86%) limit generalizability of results.

CONCLUSIONS

Efforts focused on providing mental health in primary care, interventions to address mental health beliefs, and outreach to racial-ethnic minority veterans and those with mild to moderate PTSD could increase mental health care utilization. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Emergence of Candida auris in Russia

This paper reports the emergence of Candida auris infections in an intensive care unit at a hospital in Moscow. Forty-nine cases were diagnosed in 2016-2017, and the risk factors and antifungal susceptibilities are described. The 30-day all-cause mortality for 19 bloodstream infections in patients who did not receive appropriate antifungal therapy was 42.1%. Phylogenetic analysis of the internal transcribed spacer and D1-D2 regions and K143R substitution in the ERG11 gene indicated that the studied C. auris strains were of South Asian origin. This first reported series of C. auris infections in Russia demonstrates the rapid dissemination of this species, and the need for international surveillance and control measures.

Functional concerns and treatment priorities among veterans receiving VHA Primary Care Behavioral Health services

INTRODUCTION

The Primary Care-Mental Health Integration program is a component of the Veterans Health Administration's patient-centered medical home, which emphasizes comprehensive, patient-centered care. One model of primary care-mental health integration, known as Primary Care Behavioral Health (PCBH), positions trained behavioral health providers as members of the primary care team. Whereas patient perspectives are essential to effective patient-centered care, little empirical information exists regarding patients' goals and priorities for addressing their biopsychosocial concerns in PCBH.

METHOD

A regional mail survey of Veterans Health Administration patients was used. We collected data from 281 veterans (27% response rate) who received PCBH services in a northeastern region.

RESULTS

Respondents identified difficulty with sleep (80%), low energy/amotivation (78%), and managing stress (72%) as the most prevalent individual concerns, although the majority endorsed concerns in multiple domains of functioning. Overwhelmingly, patients who endorsed any biopsychosocial problem area reported that they did (53-93%) or would like to (56-81%) address that concern with a behavioral health provider. Respondents most frequently identified anger as a top priority for future care, followed by stress management, energy/motivation, and sleep disturbance. Whereas sample means signaled neutral or better quality of life in most individual domains, total Quality of Life Inventory scores suggested very low (32%) to average (30%) overall quality-of -life ratings for most participants.

DISCUSSION

In addition to symptom-focused PCBH assessments, providers should gather biopsychosocial data to identify and monitor functional and quality-of -life concerns and evaluate patient preferences in addressing these concerns over the course of clinical care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A library mobile device deployment to enhance the medical student experience in a rural longitudinal integrated clerkship

Objective

Investigators implemented the Rural Information Connection (RIC) project, a library-initiated deployment of iPad Mini 3s for third-year medical students who were enrolled in a seven-month rural longitudinal integrated clerkship (LIC) rotation. The research aims were to determine if devices preloaded with high-quality mobile health apps enhanced the experience and increased access to and awareness of mobile health information resources for the enrolled project participants.

Methods

Nine participants enrolled in this mixed methods research project. Pre- and post-survey and structured learning journals (SLJs) were used for data collection on device and app use. Descriptive statistics and thematic coding analysis included data from seven pre-surveys, nine post-surveys, and sixty-four SLJ prompts. The validated Technology Acceptance Model instrument was also incorporated to gauge the devices’ integration into the participants’ workflow.

Results

The investigation indicated that the iPad Mini 3 and resources were utilized and integrated at varying levels in the participants’ workflow. Reported use of health information apps suggests a preference for broad-based information sources rather than specific or specialized information resources. Participants performed several tasks on the device, including seeking background information, educating patients, and managing rotation schedules. Participant reflections indicated positive experiences utilizing the device and health information resources, which enhanced their rural LIC rotations.

Conclusions

The research analysis demonstrates the information-seeking behavior of medical students immersed in a rural environment and indicates an acceptance of mobile technology into the workflow of participants in this project. Mobile device deployments offer great opportunities for librarians to design innovative programming in medical education.

Perceived barriers and facilitators to implementation of peer support in Veterans Health Administration Primary Care-Mental Health Integration settings

Peer support is increasingly recognized as consistent with the goals of integrated primary care and is being implemented in primary care settings as a patient-centered approach that increases patient activation and access to care. Within the Veterans Health Administration (VHA), peer support specialists (PSSs) have traditionally worked in specialty mental health settings and only recently started working in Primary Care-Mental Health Integration (PC-MHI) settings. Prior research has identified implementation challenges, such as role confusion, when integrating peer support into new settings. In this qualitative descriptive study, we conducted semistructured interviews on perceived barriers and facilitators to implementing peer support in PC-MHI with 25 key stakeholders (7 PSSs, 6 PSS supervisors, 6 PC-MHI providers, and 6 primary care providers). We used conventional content analysis to code responses within four a priori implementation categories: barriers, initial facilitators, long-term facilitators, and leadership support. Perceived barriers included poor program functioning, inadequate administrative support, role confusion, and negative stakeholder attitudes. Key perceived facilitators of initializing and maintaining peer support were similar; administrative support was emphasized followed by program functioning and team cohesion. Stakeholder buy-in and access/visibility were perceived to facilitate initial implementation, whereas evidence of success was believed to facilitate maintenance. Stakeholder buy-in and administrative support were considered key elements of leadership support. Results were consistent with prior research from specialty mental health settings, but identified unique considerations for PC-MHI settings, particularly clarifying the PSS role based on local PC-MHI needs, obtaining buy-in, and facilitating integration of PSSs into the primary care team. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

11C-DPA-713 Versus 18F-GE-180: A Preclinical Comparison of Translocator Protein 18 kDa PET Tracers to Visualize Acute and Chronic Neuroinflammation in a Mouse Model of Ischemic Stroke

Neuroinflammation plays a key role in neuronal injury after ischemic stroke. PET imaging of translocator protein 18 kDa (TSPO) permits longitudinal, noninvasive visualization of neuroinflammation in both preclinical and clinical settings. Many TSPO tracers have been developed, however, it is unclear which tracer is the most sensitive and accurate for monitoring the in vivo spatiotemporal dynamics of neuroinflammation across applications. Hence, there is a need for head-to-head comparisons of promising TSPO PET tracers across different disease states. Accordingly, the aim of this study was to directly compare 2 promising second-generation TSPO tracers, ¹¹C-DPA-713 and ¹⁸F-GE-180, for the first time at acute and chronic time points after ischemic stroke. Methods: After distal middle cerebral artery occlusion or sham surgery, mice underwent consecutive PET/CT imaging with ¹¹C-DPA-713 and ¹⁸F-GE-180 at 2, 6, and 28 d after stroke. T2-weighted MR images were acquired to enable delineation of ipsilateral (infarct) and contralateral brain regions of interest (ROIs). PET/CT images were analyzed by calculating percentage injected dose per gram in MR-guided ROIs. SUV ratios were determined using the contralateral thalamus (SUV_Th) as a pseudoreference region. Ex vivo autoradiography and immunohistochemistry were performed to verify in vivo findings. Results: Significantly increased tracer uptake was observed in the ipsilateral compared with contralateral ROI (SUV_Th, 50-60 min summed data) at acute and chronic time points using ¹¹C-DPA-713 and ¹⁸F-GE-180. Ex vivo autoradiography confirmed in vivo findings demonstrating increased TSPO tracer uptake in infarcted versus contralateral brain tissue. Importantly, a significant correlation was identified between microglial/macrophage activation (cluster of differentiation 68 immunostaining) and ¹¹C-DPA-713- PET signal, which was not evident with ¹⁸F-GE-180. No significant correlations were observed between TSPO PET and activated astrocytes (glial fibrillary acidic protein immunostaining). Conclusion: ¹¹C-DPA-713 and ¹⁸F-GE-180 PET enable detection of neuroinflammation at acute and chronic time points after cerebral ischemia in mice. ¹¹C-DPA-713 PET reflects the extent of microglial activation in infarcted distal middle cerebral artery occlusion mouse brain tissue more accurately than ¹⁸F-GE-180 and appears to be slightly more sensitive. These results highlight the potential of ¹¹C-DPA-713 for tracking microglial activation in vivo after stroke and warrant further investigation in both preclinical and clinical settings.

Abstract 3031: Positron emission tomography imaging of activated T cells by targeting OX40 reveals spatiotemporal immune dynamics and predicts response to in situ tumor vaccination

Clinical success of cancer immunotherapies has renewed interest in imaging the behavior of immune cells. Due to the spatiotemporally varying signatures of immune response, it has been difficult to monitor and predict patient outcomes using traditional clinical tests. ImmunoPET, defined herein as positron emission tomography utilizing radiolabeled antibodies, has the potential to enable noninvasive, sensitive and longitudinal interrogation of immune cell subset and state. Cell states including activation, anergy, and exhaustion may be more prognostic of disease outcome than the presence of tumor-infiltrating immune cells alone. In particular, T cell activation is thought to be critical to treatment success across many classes of cancer immunotherapy. In this work, we present the first radionuclide imaging of OX40, a novel and specific biomarker of activated antigen-specific T cells. Activation dependent and T cell restricted expression of OX40 was validated in vitro via flow cytometric analysis. Cell uptake studies with radiolabeled 64Cu-DOTA-AbOX40 demonstrated ~11 fold [p < .0001] higher uptake in dyna-bead activated T cells compared to resting. The tracer showed negligible nonspecific uptake in OX40 blocked or OX40-/- T cells and low background levels across a panel of 5 cancer cell lines tested. In vivo, ImmunoPET imaging revealed new insights into response following in situ tumor vaccination with CpG, an adjuvant immunotherapy currently in clinical trials. Balb-C mice bearing dual A20 lymphoma tumors were administered low dose CPG directly in the left tumor (n=7-10), while vehicle control mice received PBS (n=7-10). Early after vaccination, imaging revealed increased OX40 radiotracer uptake in the CPG treated tumor (TT) [~37%; p<0.05] confirmed by immunofluorescent staining. ViSNE, a visualization technique for high-dimensional cytometry data, classified OX40+ single cells in a cluster associated with a nonregulatory, activated CD4 T cell phenotype. CPG treatment led to local expansion of this unique OX40 cell population [~63%; p<0.05]. By late time points, a full systemic response emerged as evidenced by increased Luminex cytokine measurements in the plasma of CPG-treated mice. Unsupervised hierarchical clustering based on radiotracer or cytokine measurements correctly assigned mice into CPG-treated or vehicle cohorts, with few exceptions. More remarkably, a generalized linear regression model indicated early PET signal (mean %ID/g) in the local tumor environment to be highly predictive of response outcomes at late timepoints [r2=0.746]. OX40 ImmunoPET provides a readily translatable approach for monitoring activated T cells with high sensitivity and specificity. In this instance, integration of molecular imaging and computational immunology enabled systems-level interrogation of vaccine response.

Citation Format: Aaron T. Mayer, Israt S. Alam, Idit Sagiv-Barfi, Kezheng Wang, Ophir Vermesh, Debra K. Czerwinski, Emily M. Johnson, Michelle L. James, Ronald Levy, Sanjiv S. Gambhir. Positron emission tomography imaging of activated T cells by targeting OX40 reveals spatiotemporal immune dynamics and predicts response to in situ tumor vaccination [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3031.

Patient outcomes associated with primary care behavioral health services: A systematic review

OBJECTIVE

This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction.

METHOD

Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principle summary measures of odd ratios or Cohen's d effect sizes were reported.

RESULTS

Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high.

CONCLUSIONS

The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.

PET Imaging of Neuroinflammation Using [11C]DPA-713 in a Mouse Model of Ischemic Stroke

Neuroinflammation is central to the pathological cascade following ischemic stroke. Non-invasive molecular imaging methods have the potential to provide critical insights into the temporal dynamics and role of certain neuroimmune interactions in stroke. Specifically, Positron Emission Tomography (PET) imaging of translocator protein 18 kDa (TSPO), a marker of activated microglia and peripheral myeloid-lineage cells, provides a means to detect and track neuroinflammation in vivo. Here, we present a method to accurately quantify neuroinflammation using [¹¹C]N,N-Diethyl-2-[2-(4-methoxyphenyl)-5,7-dimethylpyrazolo[1,5-a]pyrimidin-3-yl]acetamide ([¹¹C]DPA-713), a promising second generation TSPO-PET radiotracer, in distal middle cerebral artery occlusion (dMCAO) compared to sham-operated mice. MRI was performed 2 days post-dMCAO surgery to confirm stroke and define the infarct location and volume. PET/Computed Tomography (CT) imaging was carried out 6 days post-dMCAO to capture the peak increase in TSPO levels following stroke. Quantitation of PET images was conducted to assess the uptake of [¹¹C]DPA-713 in the brain and spleen of dMCAO and sham mice to assess central and peripheral levels of inflammation. In vivo [¹¹C]DPA-713 brain uptake was confirmed using ex vivo autoradiography.

Imaging activated T cells predicts response to cancer vaccines

In situ cancer vaccines are under active clinical investigation, given their reported ability to eradicate both local and disseminated malignancies. Intratumoral vaccine administration is thought to activate a T cell-mediated immune response, which begins in the treated tumor and cascades systemically. In this study, we describe a PET tracer (64Cu-DOTA-AbOX40) that enabled noninvasive and longitudinal imaging of OX40, a cell-surface marker of T cell activation. We report the spatiotemporal dynamics of T cell activation following in situ vaccination with CpG oligodeoxynucleotide in a dual tumor-bearing mouse model. We demonstrate that OX40 imaging was able to predict tumor responses on day 9 after treatment on the basis of tumor tracer uptake on day 2, with greater accuracy than both anatomical and blood-based measurements. These studies provide key insights into global T cell activation following local CpG treatment and indicate that 64Cu-DOTA-AbOX40 is a promising candidate for monitoring clinical cancer immunotherapy strategies.

Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app

Posttraumatic stress disorder (PTSD) is common and undertreated among Veterans Affairs (VA) primary care patients. A brief primary care intervention combining clinician support with a self-management mobile app (Clinician-Supported PTSD Coach, CS-PTSD Coach) may improve patient outcomes. This study developed and refined an intervention to provide clinician support to facilitate use of the PTSD Coach app and gathered VA provider and patient qualitative and quantitative feedback on CS-PTSD Coach to investigate preliminary acceptability and implementation barriers/facilitators. VA primary care providers and mental health leadership (N = 9) completed a survey and interview regarding implementation barriers and facilitators structured according to the Consolidated Framework for Implementation Research (CFIR). Clinicians who delivered CS-PTSD Coach (N = 3) and patients (N = 9) who received it provided feedback on the intervention and implementation process. CS-PTSD Coach has high provider and patient acceptability. Important implementation factors included that CS-PTSD Coach be compatible with the clinics' current practices, have low complexity to implement, be perceived to address patient needs, and have strong support from leadership. Diverse factors related to CS-PTSD Coach delivery facilitate implementation, provide an opportunity to problem-solve barriers, and improve integration of the intervention into primary care.

Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

Predictors of Mental Health Care Utilization in Veterans With Post-Traumatic Stress Disorder Symptoms and Hazardous Drinking

OBJECTIVES

Describe outpatient mental health service use in a sample of recent combat Veterans with post-traumatic stress disorder (PTSD) symptoms and hazardous alcohol use and investigate predictors of mental health care utilization.

METHODS

In this prospective study, 126 Veterans with full or subthreshold PTSD and hazardous alcohol use completed a baseline assessment and reported mental health service use through a 12-month follow-up period. Logistic regressions were used to identify factors predicting mental health care utilization.

RESULTS

Veterans who were employed were 63% less likely to use outpatient mental health care in the 12 months following baseline. Additionally, for each 1-point increase in negative mental health care beliefs, participants were 70% less likely to use outpatient mental health care. For each 1-point worsening in social support and leisure functioning, participants were 2.2 times more likely to use outpatient mental health care.

CONCLUSIONS

The current study indicates that negative mental health beliefs are barriers to mental health care while unemployment and poor social support/leisure functioning are predictors of mental health care utilization for recent combat Veterans with PTSD symptoms and hazardous alcohol use. Patient and system level interventions for these factors are discussed to guide efforts to improve mental health care among this high-need population.

Imaging B Cells in a Mouse Model of Multiple Sclerosis Using 64Cu-Rituximab PET

B lymphocytes are a key pathologic feature of multiple sclerosis (MS) and are becoming an important therapeutic target for this condition. Currently, there is no approved technique to noninvasively visualize B cells in the central nervous system (CNS) to monitor MS disease progression and response to therapies. Here, we evaluated ⁶⁴Cu-rituximab, a radiolabeled antibody specifically targeting the human B cell marker CD20, for its ability to image B cells in a mouse model of MS using PET. Methods: To model CNS infiltration by B cells, experimental autoimmune encephalomyelitis (EAE) was induced in transgenic mice that express human CD20 on B cells. EAE mice were given subcutaneous injections of myelin oligodendrocyte glycoprotein fragment_1-125 emulsified in complete Freund adjuvant. Control mice received complete Freund adjuvant alone. PET imaging of EAE and control mice was performed 1, 4, and 19 h after ⁶⁴Cu-rituximab administration. Mice were perfused and sacrificed after the final PET scan, and radioactivity in dissected tissues was measured with a γ-counter. CNS tissues from these mice were immunostained to quantify B cells or were further analyzed via digital autoradiography. Results: Lumbar spinal cord PET signal was significantly higher in EAE mice than in controls at all evaluated time points (e.g., 1 h after injection: 5.44 ± 0.37 vs. 3.33 ± 0.20 percentage injected dose [%ID]/g, P < 0.05). ⁶⁴Cu-rituximab PET signal in brain regions ranged between 1.74 ± 0.11 and 2.93 ± 0.15 %ID/g for EAE mice, compared with 1.25 ± 0.08 and 2.24 ± 0.11 %ID/g for controls (P < 0.05 for all regions except striatum and thalamus at 1 h after injection). Similarly, ex vivo biodistribution results revealed notably higher ⁶⁴Cu-rituximab uptake in the brain and spinal cord of huCD20tg EAE, and B220 immunostaining verified that increased ⁶⁴Cu-rituximab uptake in CNS tissues corresponded with elevated B cells. Conclusion: B cells can be detected in the CNS of EAE mice using ⁶⁴Cu-rituximab PET. Results from these studies warrant further investigation of ⁶⁴Cu-rituximab in EAE models and consideration of use in MS patients to evaluate its potential for detecting and monitoring B cells in the progression and treatment of this disease. These results represent an initial step toward generating a platform to evaluate B cell-targeted therapeutics en route to the clinic.

NExT: creating an interdisciplinary alliance to diminish informational barriers for public health nursing

BACKGROUND

Public health nurses (PHNs) are challenged in obtaining opportunities to learn evidence-based practice (EBP). An interdisciplinary alliance was created between health sciences librarians and nurse educators to create a continuing education (CE) opportunity.

OBJECTIVE

To measure the effectiveness of CE training for PHNs on the knowledge gained about the EBP process and information resources.

METHODS

Ten in-person CE workshops were offered to 69 attendees in rural and urban areas. A pre-test/post-test survey was administered immediately before and after the training that asked participants to rate their perceived knowledge and comfort levels with EBP concepts and resources.

RESULTS

Ninety-seven per cent of participants reported the training was a good use of their time. Based on a 5-point Likert scale self-assessment, participants developed new skills (m = 4.06, SD = 0.968) and were able to find evidence-based literature (m = 4.16, SD = 0.980). Participants reported increasing their understanding of EBP concepts and familiarity of information resources. All data were statistically significant at P < 0.001 (95% CI).

DISCUSSION

With the interdisciplinary collaboration capitalising on the instructors' disciplinary skill sets, the team was able to create a new effective EBP education intervention for PHNs.

CONCLUSION

Public health nurses were able to increase knowledge of EBP concepts and information resources to utilise in practice or grant development.

Natural Course of Co-Occurring PTSD and Alcohol Use Disorder Among Recent Combat Veterans

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) commonly co-occur in veterans, yet little is known about the longitudinal course of PTSD and drinking in comorbid populations. This study assessed the natural course of daily alcohol consumption and weekly changes in PTSD symptoms in 112 recent combat veterans over the course of 11 months. Latent class growth mixture modeling was used to classify individuals into distinct classes with similar PTSD symptom and alcohol use growth trajectories. We then investigated theorized predictors of class membership including sociodemographics; pre-, peri-, and postdeployment factors; coping; symptom severity; and number of mental health/substance use appointments attended. Results revealed that most participants had severe and nonremitting PTSD. Trajectories for alcohol use included gradual and drastic declines, and chronic low-level drinking. The use of behavioral health services (odds ratio = 2.47) and fewer current stressors (odds ratio = 0.42) predicted AUD remission. Because little variation was observed in the PTSD course, our study did not observe coordinated fluctuations of PTSD symptoms and heavy drinking. Our findings suggest that treatment impacts the course of AUD and that recent combat veterans who do not seek PTSD treatment may have chronic and severe PTSD symptoms.

The Extinction and Return of Fear of Public Speaking

Prior studies indicate extinguished fear often partially returns when participants are later tested outside the extinction context. Cues carried from the extinction context to the test context sometimes reduce return of fear, but it is unclear whether such extinction cues (ECs) reduce return of fear of public speaking. Here we assessed return of fear of public speaking, and whether either of two types of ECs can attenuate it. Participants gave speeches of increasing difficulty during an exposure practice session and were tested 2 days later in a different context. Testing occurred in the presence of physical ECs, after mentally rehearsing the exposure session, or without either reminder. Practice reduced fear of public speaking, but fear partially returned at test. Neither physical nor mental ECs reduced partial return of fear of public speaking. The return of extinguished fear of public speaking, although small, was reliable, but not appreciably sensitive to presence of ECs.