Association of platelet satellitism with immune thrombocytopenia: A case report and review of literature.

Platelet satellitism refers to the rosetting of the platelets around white blood cells, mostly neutrophils that could lead to spuriously low platelet counts on automated analyzers. The phenomenon has usually been described in EDTA processed blood samples. We describe the clinical course of a patient with immune thrombocytopenia with platelet satellitism in both EDTA as well as non EDTA processed blood samples. We also review the literature describing two other reports of the platelet satellitism in patients with immune thrombocytopenia. We also reference the literature describing the heterogeneity of the presence of platelet satellitism in different clinical and laboratory settings.

Influenza Vaccinations During the COVID-19 Pandemic - 11 U.S. Jurisdictions, September-December 2020.

Influenza causes considerable morbidity and mortality in the United States. Between 2010 and 2020, an estimated 9-41 million cases resulted in 140,000-710,000 hospitalizations and 12,000-52,000 deaths annually (1). As the United States enters the 2021-22 influenza season, the potential impact of influenza illnesses is of concern given that influenza season will again coincide with the ongoing COVID-19 pandemic, which could further strain overburdened health care systems. The Advisory Committee on Immunization Practices (ACIP) recommends routine annual influenza vaccination for the 2021-22 influenza season for all persons aged ≥6 months who have no contraindications (2). To assess the potential impact of the COVID-19 pandemic on influenza vaccination coverage, the percentage change between administration of at least 1 dose of influenza vaccine during September-December 2020 was compared with the average administered in the corresponding periods in 2018 and 2019. The data analyzed were reported from 11 U.S. jurisdictions with high-performing state immunization information systems.* Overall, influenza vaccine administration was 9.0% higher in 2020 compared with the average in 2018 and 2019, combined. However, in 2020, the number of influenza vaccine doses administered to children aged 6-23 months and children aged 2-4 years, was 13.9% and 11.9% lower, respectively than the average for each age group in 2018 and 2019. Strategic efforts are needed to ensure high influenza vaccination coverage among all age groups, especially children aged 6 months-4 years who are not yet eligible to receive a COVID-19 vaccine. Administration of influenza vaccine and a COVID-19 vaccine among eligible populations is especially important to reduce the potential strain that influenza and COVID-19 cases could place on health care systems already overburdened by COVID-19.

Outcomes of dialectical behavior therapy administered by an interdisciplinary team.

INTRODUCTION: 87 female and 10 male adult outpatients with BPD diagnoses presenting with acute suicidal and self-harm behaviors were offered a 12-Month Intensive DBT Program delivered by an interdisciplinary team of psychotherapists, including social workers, nurses, and a psychologist. METHODS: Clients were administered self-report measures at pre-treatment, and at 3-, 6-, and 12-month intervals in a single-group longitudinal design. Our analyses of treatment outcomes (ANOVA and Bonferroni-corrected comparisons) considered: BPD-specific symptoms, using the BSL-23 (n = 44), ZAN-BPD (n = 39), and DBT-WCCL Adaptive Skills Use and Dysfunctional Coping subscales (n = 43); transdiagnostic psychiatric symptoms, using the BSL Global Severity Index (n = 35); and quality of life, using QOLI t-scores (n = 42). We also evaluated changes in the proportions of clients who used services for mental health-related crises, visited the ER, or were admitted as inpatients. RESULTS: Significant reductions in both BPD-specific and transdiagnostic psychiatric symptoms were found. Quality of life improved. DBT skills use notably increased and dysfunctional coping scores declined inversely. Fewer clients tended to use crisis services and visit the ER. DISCUSSION: These results illustrate the potential for accessible, effective treatment for BPD delivered by interdisciplinary staff.

RNNbow: Visualizing Learning Via Backpropagation Gradients in RNNs.

We present RNNbow, an interactive tool for visualizing the gradient flow during backpropagation in training of recurrent neural networks. By visualizing the gradient, as opposed to activations, RNNbow offers insight into how the network is learning. We show how it illustrates the vanishing gradient and the training process.

Integrated Care Increases Treatment and Improves Outcomes of Patients With Chronic Hepatitis C Virus Infection and Psychiatric Illness or Substance Abuse.

BACKGROUND & AIMS: Patients with hepatitis C virus (HCV) infection with psychiatric disorders and/or substance abuse face significant barriers to antiviral treatment. New strategies are needed to improve treatment rates and outcomes. We investigated whether an integrated care (IC) protocol, which includes multidisciplinary care coordination and patient case management, could increase the proportion of patients with chronic HCV infection who receive antiviral treatment (a combination of interferon-based and direct-acting antiviral agents) and achieve a sustained virologic response (SVR). METHODS: We performed a prospective randomized trial at 3 medical centers in the United States. Participants (n = 363 patients attending HCV clinics) had been screened and tested positive for depression, post-traumatic stress disorder, and/or substance use; they were assigned randomly to groups that received IC or usual care (controls) from March 2009 through February 2011. A midlevel mental health practitioner was placed at each HCV clinic to provide IC with brief mental health interventions and case management, according to formal protocol. The primary end point was SVR. RESULTS: Of the study participants, 63% were non-white, 51% were homeless in the past 5 years, 64% had psychiatric illness, 65% were substance abusers within 1 year before enrollment, 57% were at risk for post-traumatic stress disorder, 71% had active depression, 80% were infected with HCV genotype 1, and 23% had advanced fibrosis. Over a mean follow-up period of 28 months, a greater proportion of patients in the IC group began receiving antiviral therapy (31.9% vs 18.8% for controls; P = .005) and achieved a SVR (15.9% vs 7.7% of controls; odds ratio, 2.26; 95% confidence interval, 1.15-4.44; P = .018). There were no differences in serious adverse events between groups. CONCLUSIONS: Integrated care increases the proportion of patients with HCV infection and psychiatric illness and/or substance abuse who begin antiviral therapy and achieve SVRs, without serious adverse events. ClinicalTrials.gov # NCT00722423.

Group medication management for buprenorphine/naloxone in opioid-dependent veterans.

OBJECTIVE: Substance use disorders are a key concern among US veterans. Substance use disorder pharmacotherapies with support for effectiveness are limited. Buprenorphine/naloxone (Suboxone) is an effective opioid replacement treatment option for opioid use disorder when used as part of a comprehensive treatment program. In June 2011, the Veterans Affairs San Diego Healthcare System began using a group format to prescribe buprenorphine/naloxone. This study aimed at examining outcomes of retention rates and percentage opioid negative urine samples. Results were compared for veteran patients seen in group versus individual formats. METHODS: This retrospective chart review included data from 32 patients who were prescribed buprenorphine/naloxone between a 3-year window (ie, January 1, 2010, and December 31, 2012). RESULTS: Overall results were 46% retention in treatment after 1 year, and 94% of opioid urine samples were negative. More patients seen in group were retained in treatment at 1 year compared with those seen individually (69% vs 27%, respectively; P < 0.03). CONCLUSIONS: This study found that veterans prescribed buprenorphine/naloxone in a group setting as part of a drug and alcohol treatment program were retained in treatment longer than veterans prescribed this medication individually. Because of inherent limitations in the study design, no causality can be determined; however, given the results found here, group medication management of buprenorphine/naloxone should be explored further.

Clinical practice guideline: tinnitus.

OBJECTIVE: Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient's quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome. PURPOSE: The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers. ACTION STATEMENTS: The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Clinical practice guideline: tinnitus executive summary.

The American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Characteristics and impact of methamphetamine use in patients with chronic hepatitis C.

OBJECTIVES: Methamphetamine (MA) use has increased in the United States in the last 20 years and is a risk factor for hepatitis C virus(HCV) infection. The purpose of this study was to determine the characteristics and HCV infection outcomes of patients with a history of MA use. METHODS: Subjects consisted of newly entered patients in the Veterans Affairs (VA) HCV registry at a single VA medical center from January 1, 2004, to June 30, 2004, and from January 1, 2007, to June 30, 2007. Univariate and multivariate analyses related to HCV infection antiviral treatment outcomes through 2010 was performed. RESULTS: A total of 198 consecutive eligible HCV registry patients were analyzed, and 40% had a history of MA use. Of patients with MA use history, 46% (36/79) had active use (within 6 months) at initial contact. Active MA users were significantly younger (mean age, 45.5 years), with more concomitant drug use (86%), compared with patients without MA use (mean age, 53.5 years; 42% minority; 29% other drug use). Overall, 71% of the 198 patients reported a history of problematic alcohol use, and 47% of those reported active abuse. Logistic regression analyses indicated that MA use did not significantly adversely affect antiviral treatment initiation, completion, or sustained virological response rates compared with that in patients without MA use. Active alcohol users had lower treatment initiation than patients without alcohol use. CONCLUSIONS: MA use is common in recent US veterans with HCV infection and occurs in younger patients with polysubstance use. Prior history or active MA use does not seem to adversely affect HCV infection clinic treatment compared with that in HCV-infected patients without MA use.

Group management of pharmacotherapy for alcohol dependence: feasibility and impact on adoption.

One of the barriers to initiating patients on medications for alcohol dependence is concern about the work involved in providing ongoing medication management. In this brief report, we describe our initial experiences with a medication management group, initially implemented to provide continued access during a staffing shortage. We describe the group structure and functioning, and provide initial analysis of the groups' impact on access and adoption of pharmacotherapy for alcohol dependence. Results of an interrupted time series analysis in one Veterans Health Administration (VHA) facility provide support for the notion that the group format is not only feasible but can actually increase access to these under-utilized medications (e.g., naltrexone and acamprosate). The number of patients receiving these medications was already increasing in this facility before the switch to group appointments, but this rate of initiation increased almost 3-fold after the onset of the groups.

Review of biological mechanisms and pharmacological treatments of comorbid PTSD and substance use disorder.

Posttraumatic stress disorder (PTSD) and alcohol/substance use disorder (A/SUD) are frequently comorbid. Comorbidity is associated with poorer psychological, functional, and treatment outcomes than either disorder alone. This review outlines biological mechanisms that are potentially involved in the development and maintenance of comorbid PTSD and A/SUD including neurotransmitter and hypothalamic-pituitary-adrenal dysregulation, structural differences in the brain, and shared genetic risk factors. The literature regarding pharmacological treatments that have been investigated for comorbid PTSD and A/SUD is also reviewed. Empirical data for each proposed mechanism and pharmacological approach is reviewed with the goal of making recommendations for future research. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Predictors of treatment retention for substance-dependent adults with co-occurring depression.

Low attendance in addiction treatment, particularly in cases of comorbidity, has been identified as a pervasive challenge. We examine predictors of treatment retention in a sample of veterans (N = 253) participating in a clinical trial comparing two types of psychotherapy for co-occurring depression and substance use disorders. The study protocol included 24 weeks of outpatient group psychotherapy in either a newly developed Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy (TSF). Using a model of treatment utilization developed by Aday and Anderson, we analyzed predictors categorized into predisposing factors, enabling resources, need for treatment, and type of treatment received. Outcome included total number of sessions attended (maximum of 36 sessions). Treatment retention did not differ between the two study interventions. Bivariate analyses indicated that predisposing factors were most predictive, with older participants, Caucasians, and those using only alcohol in the month before treatment attending more sessions, and individuals who had recently experienced a health event remained in treatment longer. Importantly, several factors were not related to treatment retention: marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity. In the combined model of predisposing, enabling and need factors, age and ethnicity were the only significant predictors.

Alcohol attenuates activation in the bilateral anterior insula during an emotional processing task: a pilot study.

AIMS: Alcohol acutely reduces agitation and is widely used in social situations, but the neural substrates of emotion processing during its intoxication are not well understood. We examine whether alcohol's social stress dampening effect may be via reduced activity in the cortical systems that subserve awareness of bodily sensations, and are associated with affective distress. METHODS: Blood oxygen level-dependent activation was measured through 24 functional magnetic resonance imaging sessions in 12 healthy volunteers during an emotional face-processing task following ingestion of a moderate dose of alcohol and a placebo beverage. RESULTS: Results revealed that bilateral anterior insula response to emotional faces was significantly attenuated following consumption of alcohol, when compared with placebo (clusters >1472 µl; corrected P < 0.05). CONCLUSION: Attenuated response in the anterior insula after alcohol intake may explain some of the decreased interoceptive awareness described during intoxication.

Patterns of associations between eating disordered behaviors and substance use in two non-clinical samples: a university and a community based sample.

This study examined shared patterns of associations between disordered eating behaviors and substance use in two different non-clinical samples of young women. Participants were recruited from a university (526 women) and varied community (517 women) settings. Participants completed the Women's Health Survey, examining engagement in a wide range of licit and illicit substances and disordered eating patterns during the past 12 months. In both samples, the cluster of bingeing, dieting and purging was significantly associated with binge drinking, drinking associated with negative consequences, and with cocaine use. The cluster of dieting and purging was associated with the use of stimulants/amphetamines. Health services, including assessment and treatment, and health promotion activities, should consider these patterns of comorbidity.

Acute ethanol effects on brain activation in low- and high-level responders to alcohol.

BACKGROUND: A low level of response (LR) to alcohol is an important endophenotype associated with an increased risk of alcoholism. However, little is known about how neural functioning may differ between individuals with low and high LRs to alcohol. This study examined whether LR group effects on neural activity varied as a function of acute alcohol consumption. METHODS: A total of 30 matched high- and low-LR pairs (N = 60 healthy young adults) were recruited from the University of California, San Diego, and administered a structured diagnostic interview and laboratory alcohol challenge followed by two functional magnetic resonance imaging (fMRI) sessions under placebo and alcohol conditions, in randomized order. Task performance and blood oxygen level-dependent response contrast to high relative to low working memory load in an event-related visual working memory (VWM) task were examined across 120 fMRI sessions. RESULTS: Both LR groups performed similarly on the VWM task across conditions. A significant LR group by condition interaction effect was observed in inferior frontal and cingulate regions, such that alcohol attenuated the LR group differences found under placebo (p < 0.05). The LR group by condition effect remained even after controlling for cerebral blood flow, age, and typical drinking quantity. CONCLUSIONS: Alcohol had differential effects on brain activation for low- and high-LR individuals within frontal and cingulate regions. These findings represent an additional step in the search for physiological correlates of a low LR and identify brain regions that may be associated with the low LR response.

Management of chronic hepatitis C in veterans: the potential of integrated care models.

The prevalence of hepatitis C virus (HCV) infection is higher among veterans than nonveterans, but only about 14% of all identified infected veterans have ever received antiviral therapy. High rates of comorbid psychiatric and substance use disorders are major barriers to receiving antiviral treatment for veterans, and characteristics associated with poor virologic response are more common in this population. However, accumulating evidence indicates that patients with psychiatric and substance use disorders can successfully receive interferon-based antiviral therapies in an integrated or multidisciplinary health-care setting. The broad aims of integrated care models include reducing fragmentation and improving continuity and coordination of care. Although, to date, there are no randomized controlled trials of specific care models for patients with HCV, studies of integrated care for other chronic diseases suggest several strategies for optimizing outcomes for patients with HCV. Components of an HCV clinic incorporating these principles have been tested in a nonrandomized setting and include routine screening of all patients for psychiatric and substance use disorder risk factors, collaboration with mental health providers within the HCV clinic, following a defined integrated medical/psychiatric clinical protocol, provision of ongoing integrated support during antiviral treatment or retreatment, and educating patients on principles of chronic disease self-management.

A randomized controlled trial of cognitive-behavior therapy for tinnitus.

This study is a randomized, waitlist-controlled trial testing the effect of a brief, "manualized" cognitive-behavioral group therapy on distress associated with tinnitus, quality of well-being, psychological distress including depression, and internal focus. Cognitive-behavioral therapy (CBT) included training in activity planning, relaxation training and, primarily, cognitive restructuring. Sixty-five participants were recruited, and 41 completed treatment. Participants were randomly assigned to receive 8 weeks of manualized group CBT either immediately or after an 8-week waiting period. Participants completed outcome measures at the time of their random assignment and at 8, 16, and 52 weeks later. Repeated-measure analysis of covariance revealed significant group-by-time interactions on measures of tinnitus distress and depression, indicating that CBT led to greater improvement in those symptoms. The current results suggest that CBT, applied in a group format using a manual, can reduce the negative emotional distress, including depression, associated with tinnitus.

Disordered eating behaviors and substance use in women: a comparison of perceived adverse consequences.

The study investigated the adverse consequences on varied life domains of dieting, binging, vomiting and laxative use and compared them to the adverse consequences of alcohol drinking, tobacco smoking, and marijuana use. Results showed that the percentages of women who reported adverse consequences related to eating disordered behaviors were often comparable, if not higher, than the percentages of women who reported adverse consequences related to their substance use. This is the first study to compare the adverse consequences of disordered eating patterns and substance use behaviors. Results suggest the importance of recognizing the adverse consequences of disordered eating patterns.

Antidepressants for treatment of tinnitus.

Antidepressants are commonly prescribed for tinnitus. Research thus far provides some support for that treatment, but the literature also raises concerns because tinnitus is a side effect of antidepressant medication. In this chapter, four published double blind placebo-controlled trials of antidepressants for tinnitus are reviewed. Explanations for the discrepant results are offered, including that antidepressants appear to work best for tinnitus patients who are depressed or anxious, who have more severe tinnitus or who are treated for a longer time with an adequate dose of medication. Possible mechanisms of action are reviewed, with serotonergic and antimuscarinic mechanisms appearing to be the most important. At this time there is no indication that one specific type of antidepressant is more likely to lead to tinnitus as a side effect, or have a beneficial effect on tinnitus. Given SSRIs are tolerated better, these antidepressants have advantages over tricyclic antidepressants and should be used as a first line of treatment.