Updates to the Annual P Loss Estimator (APLE) model.

The Annual P Loss Estimator (APLE) is a spreadsheet-based model developed for predicting annual field-scale P loss in surface runoff and changes in soil test P. This empirically based model was designed for use by those without significant modeling experience. However, a significant limitation with the model is that it does not calculate runoff. Moreover, APLE is deterministic and thus predicts a single value for a given set of inputs, thereby ignoring any uncertainties associated with model inputs. Here, we describe modifications to APLE that allow users to estimate runoff using the Curve Number method. Using Monte Carlo simulations, the updated version of APLE also provides users the ability to account for model input uncertainties in estimating model prediction errors. We provide examples of using the revised version of APLE (ver. 3.0) for calculating P loss from two fields in Mississippi over a 4-yr period and calculating the change in Mehlich-3 P concentrations over a 9-yr period at three locations in Maryland following cessation of P application. Both examples demonstrate that incorporating estimates of uncertainties in both measured data and model predictions provides modelers with a more realistic understanding of the model's performance.

Deprescribing Interventions by Palliative Care Clinical Pharmacists Surrounding Goals of Care Discussions.

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Progress in Cancer Control in Maryland: 1985-2015.

PURPOSE: Maryland historically had a high cancer burden, which prompted the implementation of aggressive cancer control strategies. We examined the status of cancer in Maryland and work under the current and previous editions of the MD Comprehensive Cancer Control Plan. METHODS: We examined the prevalence of cancer mortality, cancer incidence, and cancer-related behaviors in Maryland and the United States from 1985 to 2015 using publicly available data in the US Cancer Control PLANET, CDC WONDER, and Behavioral Risk Factor Surveillance System portals. We estimated the average annual cancer deaths avoided by triangulation. RESULTS: In 1983-1987, Maryland had the highest age-adjusted cancer mortality rate of all 50 states, second only to Washington, District of Columbia. Today (2011-2015), Maryland's age-adjusted cancer mortality rate ranks 31st. Overall cancer mortality rates have declined 1.9% annually from 1990 to 2015, avoiding nearly 60 000 deaths over 3 decades. While the prevalence of healthy cancer-related behaviors in Maryland was qualitatively similar or higher than that of the United States in 2015, Maryland's 5-year (2011-2015) cancer incidence rate was significantly greater than that of the United States. CONCLUSIONS: Maryland's 30-year cancer mortality declines have outpaced other states. However, a reduction in mortality while incidence rates remain high indicates a need for enhanced focus on primary prevention.

The effect of a mobile integrated health program on health care cost and utilization.

OBJECTIVE: To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. DATA SOURCES: Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. STUDY DESIGN: We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. DATA COLLECTION: Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. PRINCIPAL FINDINGS: The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio = 1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio = 1.78, 95% CI = [1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. CONCLUSIONS: We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

Meeting Proceedings for SCI 2020: Launching a Decade of Disruption in Spinal Cord Injury Research.

The spinal cord injury (SCI) research community has experienced great advances in discovery research, technology development, and promising clinical interventions in the past decade. To build upon these advances and maximize the benefit to persons with SCI, the National Institutes of Health (NIH) hosted a conference February 12-13, 2019 titled "SCI 2020: Launching a Decade of Disruption in Spinal Cord Injury Research." The purpose of the conference was to bring together a broad range of stakeholders, including researchers, clinicians and healthcare professionals, persons with SCI, industry partners, regulators, and funding agency representatives to break down existing communication silos. Invited speakers were asked to summarize the state of the science, assess areas of technological and community readiness, and build collaborations that could change the trajectory of research and clinical options for people with SCI. In this report, we summarize the state of the science in each of five key domains and identify the gaps in the scientific literature that need to be addressed to move the field forward.

The relation between mindfulness and perceived partner responsiveness during couples' vulnerability discussions.

Intimacy develops when a person discloses vulnerability and perceives their partner's response as supportive. However, a published experimental study found that individuals report their partners as less supportive in response to disclosures of specific examples of vulnerability that involve the partner (i.e., partner-inclusive) compared to disclosures that do not involve the partner (i.e., partner-exclusive). This research is an extension of findings from that experimental study and examines how individual differences in mindfulness and disclosure specificity are associated with perceived partner responsiveness during disclosures of partner-inclusive and partner-exclusive vulnerabilities. Cohabiting couples (N = 82) were randomly assigned to engage in either partner-inclusive or -exclusive vulnerability discussions. Each couple engaged in 2 video-recorded discussions so that each person took a turn as discloser and responder. Trained coders rated disclosures for specificity (i.e., whether or not the discloser used specific examples). Following each discussion, couples rated perceived partner responsiveness. Hypotheses were tested with multilevel modeling. Findings suggest that individuals perceived their partners' reactions as less responsive when they disclosed specific, partner-inclusive vulnerabilities and their partners had lower mindfulness. When partners had higher mindfulness, individuals perceived their partners as similarly responsive when disclosing partner-inclusive and -exclusive vulnerabilities, regardless of specificity. Mindfulness may enable couples to remain engaged during partner-inclusive vulnerability discussions leading to higher perceived responsiveness-an integral component of intimacy development. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Short Hospice Length of Service in a Comprehensive Cancer Center.

Background: The benefits of hospice for patients with advanced cancer are well established. Short hospice length of service (LOS) is a marker of poor quality care and patient and family dissatisfaction. Interventions based on behavioral science might reduce suboptimal hospice use. Objective: To assess effects of peer comparisons on rates of short hospice LOS for cancer patients at a tertiary comprehensive cancer center. Design: Pre-post design utilizing a peer-comparison feedback intervention comparing individual oncologist hospice data. Setting: Urban, academic, comprehensive cancer center in Maryland. Measurements: Hospice enrollment rate. Median hospice LOS and percentage short hospice LOS (defined as ≤7 days). Results: Sixty oncologists received the intervention. Before the intervention, 394 patients enrolled in hospice for a period of 21 months (18.76 enrollments per month). Median hospice LOS was 14.5 days. After the intervention, 418 patients enrolled in hospice for 14 months (29.85 enrollments per month). Median hospice LOS was nine days. The percentage of patients experiencing a short hospice LOS increased from 33.3% to 43.5%. Conclusions: The methods are not sufficient to conclude that the intervention does not improve hospice use. A substantial number of patients with cancer who used hospice had LOS ≤7 days, a marker of poor quality. Using peer comparison in combination with additional behavioral interventions should be considered to improve end-of-life care.

Creating a Program to Support Registering and Reporting Clinical Trials at Johns Hopkins University.

PROBLEM: The Food and Drug Administration Amendments Act of 2007 (FDAAA) and the National Institutes of Health (NIH) require that many clinical trials register and report results on ClinicalTrials.gov. Noncompliance with these policies denies research participants and scientists access to potentially relevant findings and could lead to monetary penalties or loss of funding. After discovering hundreds of potentially noncompliant trials affiliated with the institution, the Johns Hopkins University School of Medicine (JHUSOM) sought to develop a program to support research teams with registration and reporting requirements. APPROACH: JHUSOM conducted a baseline assessment of institutional compliance in 2015, launched the ClinicalTrials.gov Program in June 2016, and expanded the program to the Sidney Kimmel Comprehensive Cancer Center in April 2018. The program is innovative in its comprehensive approach, and it was among the first to bring a large number of trials into compliance. OUTCOMES: From September 2015 to September 2020, JHUSOM brought completed and ongoing trials into compliance with FDAAA and NIH policies and maintained almost perfect compliance for new trials. During this period, the proportion of trials potentially noncompliant with the FDAAA decreased from 44% (339/774) to 2% (32/1,304). NEXT STEPS: JHUSOM continues to develop and evaluate tools and procedures that facilitate trial registration and results reporting. In collaboration with other academic medical centers, JHUSOM plans to share resources and to identify and disseminate best practices. This report identifies practical lessons for institutions that might develop similar programs.

Uniformed Services University Occupational and Environmental Medicine Residency Program.

In 2019, the Uniformed Services University of the Health Sciences (USU) F. Edward Hébert School of Medicine celebrated the 30th anniversary of its Occupational and Environmental Medicine (OEM) Residency program. This unique program is among the largest preventive medicine residency programs in the United States. Residents from the US Army, Navy, Air Force, other federal institutions, and the Canadian Forces come to Bethesda, Maryland, to become OEM specialists in a unique training program encompassing both military and civilian OEM settings. This publication describes the historical development and practice of OEM in the military leading to the development of the USU OEM Residency Program, along with the program's past accomplishments and current operation. Finally, the publication explores potential future directions for this relatively small but important preventive medicine specialty in the practice of military medicine, considering the impacts of reorganization of the Military Health System along with the opportunities this reorganization presents for the USU OEM Residency program.

Effect of a Brief Mindfulness-Based Program on Stress in Health Care Professionals at a US Biomedical Research Hospital: A Randomized Clinical Trial.

Importance: Stress among health care professionals is well documented. The use of mindfulness-based interventions to reduce stress has shown promising results; however, the time commitment of typical programs can be a barrier to successful implementation in health care settings. Objective: To determine the efficacy and feasibility of a brief mindfulness-based program to reduce stress during work hours among health care professionals. Design, Setting, and Participants: This intent-to-treat randomized clinical trial was conducted among full-time health care professionals at the Clinical Center at the National Institutes of Health in Bethesda, Maryland, between September 2017 and May 2018. Participants were randomized to receive mindfulness-based self-care (MBSC) training or life-as-usual control. Data were analyzed from June 2018 to January 2020. Interventions: The MBSC intervention included 5 weekly, 1.5-hour in-class mindfulness practice sessions. Main Outcomes and Measures: Stress level was the primary outcome, assessed with the Perceived Stress Scale 10-Item version. Secondary outcomes included anxiety, burnout, positive and negative affect, mindfulness (trait and state), and self-care. Assessments were taken at baseline and at the end of the intervention (week 5) in the intervention and control groups, and at follow-up (week 13) in the intervention group to test for a maintenance effect. A postprogram evaluation was also obtained. Results: Of 82 randomized participants, 78 who completed the study at week 5 were included in the modified intent-to-treat analysis (median [interquartile range] age, 32 [23-48] years; 65 [83%] women), including 43 participants in the MBSC group and 35 participants in the control group. At the end of the intervention, compared with the control group, the MBSC group had reduced levels of stress (mean [SD] score, 17.29 [5.84] vs 18.54 [6.30]; P = .02) and anxiety (mean [SD] score, 2.58 [1.52] vs 4.23 [1.73]; P < .001), and improved positive affect (mean [SD] score, 35.69 [7.12] vs 31.42 [7.27]; P < .001), state mindfulness (mean [SD] score, 3.74 [1.18] vs 2.78 [1.16]; P < .001), and mindful self-care (mean [SD] score, 7.29 [2.44] vs 5.54 [2.77]; P < .001). Burnout, negative affect, and trait mindfulness levels did not differ between groups. Changes within the MBSC group through follow-up included sustained reductions in stress (change, -6.14; 95% CI, -7.84 to -4.44; P < .001), anxiety (change, -1.46; 95% CI, -1.97 to -0.94; P < .001), trait mindfulness (change, 0.63; 95% CI, 0.36 to 0.90; P < .001), and state mindfulness (change, 1.89; 95% CI, 1.39 to 2.39; P < .001). Conclusions and Relevance: This randomized clinical trial found that this brief mindfulness-based intervention was an effective and feasible means to reduce stress in health care professionals. Larger studies are needed to assess the effects on clinical care and patient outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT03781336.

The effects of the Maryland Medicaid Health Home Waiver on Emergency Department and inpatient utilization among individuals with serious mental illness.

OBJECTIVE: The Maryland Medicaid health home program, established through the Affordable Care Act's Medicaid health home waiver, integrates primary care services into specialty mental health programs for adults with serious mental illness (SMI). We evaluated the effect of this program on all-cause, physical, and behavioral health emergency department (ED) and inpatient utilization. METHOD: Using marginal structural modeling to control for time-invariant and time-varying confounding, we analyzed Medicaid administrative claims data for 12,232 enrollees with SMI from October 1, 2012 to December 31, 2016; 3319 individuals were enrolled in a BHH and 8913 were never enrolled. RESULTS: Health home enrollment was associated with reduced probability of all-cause (PP: 0.23 BHH enrollment vs. 0.26 non-enrollment, p < 0.01) and physical health ED visits (PP: 0.21 BHH enrollment vs. 0.24 non-enrollment, p < 0.01) and no effect on inpatient admissions per person-three-month period. CONCLUSION: These results suggest the Maryland Medicaid health home waiver's focus on supporting physical health care coordination by specialty mental health programs may be preventing ED visits among adults with SMI, although effect sizes are small.

Impact of vegetation selection on nitrogen and phosphorus processing in bioretention containers.

A year-long bioretention container study in Maryland, USA, measured the relationship between three plant species (Eutrochium dubium, Iris versicolor, and Juncus effusus) and N ( NO 3 - , NO 2 - , NH 4 + , total nitrogen [TN], total dissolved nitrogen [TDN], dissolved organic nitrogen, particulate organic nitrogen [PON]) and total phosphorus (TP) removal from synthetic stormwater. Statistically significant removal was only found for NO 3 - and TP. Plant-independent NO 3 - removal occurred 9 months after planting, and then changed to removal only by the least-densely planted Juncus treatment. Removal in higher-density Juncus plantings was suspected to be limited by preferential pathways created by high root density. Juncus' low-density NO 3 - removal success correlates with its high growth rate, root mass and length, and large biomass, matching previous literature. TP removal was plant-independent. Shoot harvesting of one plant of each species after 1 year would remove 0.61 g N. Of the plant species in this study, Juncus effusus is most highly recommended for bioretention for its nutrient removal dynamics and year-round green aesthetics. PRACTITIONER POINTS: Only the one-Juncus density treatment had significant NO 3 - removal. All Juncus treatments as well as non-Juncus treatments prevented the PON, TN, or TDN export seen in the No-plants control. TP removal was plant-independent. Juncus had the greatest biomass increase and biomass N. Shoots contain the majority of biomass N for each plant species. Juncus and Iris had high survivorship. Joe Pye had low survivorship. These, and all other study results, need field-scale verification.

Phylogenetic Position and Description of a New Species of Medicinal Leech from the Eastern United States.

A new species of medicinal leech, Macrobdella mimicus n. sp., is described from specimens collected in Maryland; this is the first description of a North American macrobdellid since 1975. Superficially, the new species resembles the well-known Macrobdella decora, as both species possess 4 accessory pores arranged symmetrically on the ventral surface, yet the new species is distinguished from M. decora in possessing 4-4½ annuli (rather than 3½) between the gonopores and 4 annuli (rather than 5 annuli) between the female gonopore and the first pair of accessory pores. Phylogenetic analyses, based on 2 mitochondrial and 2 nuclear loci for a set of closely related taxa, confirms the placement of the new species within the family Macrobdellidae and places it as the sister taxon to M. decora and M. diplotertia.

Leveraging the electronic health record to eliminate hepatitis C: Screening in a large integrated healthcare system.

Highly efficacious and tolerable treatments that cure hepatitis C viral (HCV) infection exist today, increasing the feasibility of disease elimination. However, large healthcare systems may not be fully prepared for supporting recommended actions due to knowledge gaps, inadequate infrastructure and uninformed policy direction. Additionally, the HCV cascade of care is complex, with many embedded barriers, and a significant number of patients do not progress through the cascade and are thus not cured. The aim of this retrospective cohort study was to evaluate a large healthcare system's HCV screening rates, linkage to care efficiency, and provider testing preferences. Patients born during 1945-1965, not previously HCV positive or tested from within the Electronic Health Record (EHR), were identified given that three-quarters of HCV-infected persons in the United States are from this Birth Cohort (BC). In building this HCV testing EHR prompt, non-Birth Cohort patients were excluded as HCV-specific risk factors identifying this population were not usually captured in searchable, structured data fields. Once completed, the BC prompt was released to primary care locations. From July 2015 through December 2016, 11.5% of eligible patients (n = 9,304/80,556) were HCV antibody tested (anti-HCV), 3.8% (353/9,304) anti-HCV positive, 98.1% (n = 311/317) HCV RNA tested, 59.8% (n = 186/311) HCV RNA positive, 86.6% (161/186) referred and 76.4% (n = 123/161) seen by a specialist, and 34.1% (n = 42/123) cured of their HCV. Results from the middle stages of the cascade in this large healthcare system are encouraging; however, entry into the cascade-HCV testing-was performed for only 11% of the birth cohort, and the endpoint-HCV cure-accounted for only 22% of all infected. Action is needed to align current practice with recommendations for HCV testing and treatment given that these are significant barriers toward elimination.

Chesapeake Bay's "forgotten" Anacostia River: eutrophication and nutrient reduction measures.

The Anacostia River, a Chesapeake Bay tributary running through Washington, D.C., is small but highly polluted with nutrients and contaminants. There is currently a multi-billion dollar tunnel project underway, being built in several phases, aimed at diverting effluent to sewage treatment, especially during high flow periods, and improving water quality of the Anacostia and the river into which it flows, the Potomac. Here, 4 years of biweekly to monthly nutrient and phytoplankton data are analyzed to assess pre-tunnel eutrophication status and relationships to flow conditions. Under all flow conditions, nutrients prior to tunnel implementation were well in excess of values normally taken to be limiting for growth, and hypoxia was apparent during summer. Chlorophyll a was higher in summer (averaging 26.9 µg L-1) than in spring (averaging 14.8 µg L-1), and based on pigment composition, summer communities had proportionately more cyanobacteria (> 2-fold higher zeaxanthin to chlorophyll a ratios) compared to spring, which had proportionately more diatoms (> 2-fold higher fucoxanthin to chlorophyll a ratios). When all data from all years and sites were considered, there was a decrease in diatoms and increase in cyanobacteria with decreasing NO3- and increasing NH4+ concentrations, increasing ratios of NH4+ to NO3-, and increasing temperature. Tunnel implementation and associated nutrient reductions may reduce the severity of summer blooms but reductions of spring assemblages may be even greater because river flows are typically higher at that time of year.

Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis.

BACKGROUND: Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice. STUDY DESIGN AND METHODS: Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes. RESULTS: The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events. CONCLUSION: These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted.

Quality Metrics and Health Care Utilization for Adult Patients with Sickle Cell Disease.

BACKGROUND: To date, there are no standardized, well-accepted, quality metrics that guide care for adults with sickle cell disease (SCD). The primary objective of this study was to evaluate the quality metrics that are in use at the Adult Sickle Cell Disease Program at Johns Hopkins Hospital (JHH) and the applicability of the metrics to Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated healthcare system with a developing adult sickle cell disease program. METHODS: We performed a retrospective cross-sectional study of 146 KPMAS and 308 JHH patients from January 1, 2014-December 31, 2015. Demographics, genotype and data on several key quality metrics (yearly screening labs, documented vaccinations and appropriate hydroxyurea prescriptions) were collected from electronic health records (EPIC Systems). We defined hydroxyurea adherence as having had at least 6 months of refills prescribed during the two years of study by either EHR or patient report. RESULTS: Patients at KPMAS were older than those at JHH (median age 44 and 33 respectively) and less likely to have hemoglobin SS disease (29% and 66% respectively). Among KPMAS patients, 85% had documentation of any pneumococcal vaccination compared to 87% at JHH. 21 of 54 eligible patients at KPMAS and 95 of 165 eligible patients at JHH were prescribed hydroxyurea. At both institutions, 62% of patients were adherent to hydroxyurea. There were limitations to diagnosis coding and availability of vaccination and refill documentation. CONCLUSIONS: Interventions to improve preventative care adherence are needed to improve outcomes in both academic medical centers and integrated health systems.

Hybrid Fractional Laser: A Multi-Center Trial on the Safety and Efficacy for Photorejuvenation

BACKGROUND: Laser skin resurfacing has continued to evolve over the past two decades. One of the most recent advances included a hybrid fractional laser resurfacing system that can sequentially utilize two wavelengths in its delivery, non-ablative coagulation with 1470 nm, and ablative vaporization with 2940 nm. The 1470 nm laser wavelength is absorbed by water, which is ideal for creating controlled zones of coagulation to chosen depths into the dermis up to 700 micrometers. The 2940 nm laser wavelength has a large water absorption coefficient, which results in precise ablation as desired in the epidermis up to 110 micrometers. This combination allows for fractionated non-ablative and ablative skin resurfacing simultaneously resulting in a cosmetic improvement in pigmentation, tone, texture of skin as well as other effects of photoaging. METHODS: Open-label prospective, multi-center study in which 34 female subjects were enrolled with Fitzpatrick skin types I-IV, mean age of 52 ± 14 years. Each subject underwent two treatments, spaced 4-6 weeks apart. Follow up visits at 1 week, 2 weeks, and 1, 2, and 3 months after the first treatment. Photographs, numeric pain scores during treatment, and subject satisfaction survey questionnaires were evaluated. Photographs were analyzed by six blinded evaluators. The primary endpoint was to evaluate safety and efficacy of hybrid laser treatments for photodamage and dyschromia. The secondary endpoints included evaluating the tolerability of the treatment using the Wong Baker Face scale and patient satisfaction survey results. RESULTS: Of the 29 subjects completing the study, 80% showed significant skin improvement on photographic analysis. Average numeric pain score was a 4 on a 0-10 scale. Survey results showed 100% satisfaction with treatment and achieved results. Two patients experienced post-inflammatory hyperpigmentation that resolved within 90 days. No other adverse events were reported. CONCLUSION: The non-ablative and ablative hybrid fractional laser can be used to safely and efficaciously treat photodamaged skin with high patient satisfaction and minimal adverse events. J Drugs Dermatol. 2018;17(11):1164-1168.

Observational study of associations between visual imagery and measures of depression, anxiety and post-traumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center.

OBJECTIVES: The study aimed tocompare recurring themes in the artistic expression of military service members (SMs) with post-traumatic stress disorder (PTSD), traumatic brain injury and psychological health (PH) conditions with measurable psychiatric diagnoses. Affective symptoms and struggles related to verbally expressing information can limit communication in individuals with symptoms of PTSD and deployment-related health conditions. Visual self-expression through art therapy is an alternative way for SMs with PTSD and other PH conditions to communicate their lived experiences. This study offers the first systematic examination of the associations between visual self-expression and standardised clinical self-report measures. DESIGN: Observational study of correlations between clinical symptoms of post-traumatic stress, depression and anxiety and visual themes in mask imagery. SETTING: The National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, Bethesda, Maryland, USA. PARTICIPANTS: Active-duty military SMs (n=370) with a history of traumatic brain injury, post-traumatic stress symptoms and related PH conditions. INTERVENTION: The masks used for analysis were created by the SMs during art therapy sessions in week 1 of a 4-week integrative treatment programme. PRIMARY OUTCOMES: Associations between scores on the PTSD Checklist-Military, Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale on visual themes in depictions of aspects of individual identity (psychological injury, military symbols, military identity and visual metaphors). RESULTS: Visual and clinical data comparisons indicate that SMs who depicted psychological injury had higher scores for post-traumatic stress and depression. The depiction of military unit identity, nature metaphors, sociocultural metaphors, and cultural and historical characters was associated with lower post-traumatic stress, depression and anxiety scores. Colour-related symbolism and fragmented military symbols were associated with higher anxiety, depression and post-traumatic stress scores. CONCLUSIONS: Emergent patterns of resilience and risk embedded in the use of images created by the participants could provide valuable information for patients, clinicians and caregivers.