Office of inspector general-An atypical job for a psychologist.

This article outlines the career of Dr. Dana Moore, who began her federal career as a clinical psychologist at the VA Medical Center in Nashville, TN. Following her husband's transfer to Washington, DC, she moved into VA Central Office training and management positions, which eventually led her to become a Senior Executive in VA's Office of Inspector General. She encourages readers to consider making career choices that open up new opportunities for their future. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychometric Properties of the Assessment of Perceived Access to Care (APAC) Instrument.

Valid measures of perceived access are needed to measure whether health care systems are providing adequate access. This research reports on the psychometric properties of the Assessment of Perceived Access to Care (APAC), which was administered to 1004 Community Health Center patients screening positive for psychiatric disorders. Known-group validity was good, with 6 of the 8 hypothesized associations between social determinants of access and perceived access being significant (P < .01). Better access was significantly (P < .01) correlated with more outpatient mental health visits, indicating good convergent validity. The test-retest Pearson correlation coefficient (0.64) was statistically significant (P < .01). The APAC has acceptable psychometric properties.

Does gender influence cognitive outcome after traumatic brain injury?

The aim of this study was to determine whether males and females differ in post-acute cognitive outcome following traumatic brain injury (TBI). Performances of 83 men and 75 women with mild to severe TBI were compared on measures of cognitive functions typically impacted by TBI (i.e., processing speed, executive functioning, and memory). Participants completed selected subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB). Among the participants with mild TBI, women scored significantly higher than men on a test of visual memory. There were no other significant gender differences in cognitive outcomes. These findings overall suggest that cognitive outcome after TBI does not differ according to gender, with the possible exception of memory functioning. Further research is needed to replicate this finding and determine which moderating variables may impact on the relationship between gender and cognitive outcome after TBI.

Design and Implementation of an Analgesia, Sedation, and Paralysis Order Set to Enhance Compliance of pro re nata Medication Orders with Joint Commission Medication Management Standards in a Pediatric ICU.

BACKGROUND: The use of pro re nata (PRN) medication orders increases nursing flexibility and efficiency of bedside patient care. However, misuse and/or ambiguity of PRN medication orders may increase the propensity for medication errors. The Joint Commission has Medication Management (MM) standards to mitigate such risks. This quality improvement study with a pre-post design aimed to increase compliance of PRN sedative and analgesic orders with use of failure mode and effects analysis (FMEA) and human factors risk assessment methodologies in a pediatric ICU (PICU). METHODS: Staff education and a PICU analgesia, sedation, and paralysis order set, with predefined PRN orders, were implemented to enhance PRN medication compliance with Joint Commission MM standards. The primary goal was to achieve and maintain a weekly average compliance of ≥ 90%. Proportions of compliant PRN analgesic and sedative orders before and after interventions were compared. RESULTS: Weekly average PRN orders compliance increased from 62.0% ± 9.2% to 77.7% ± 10.1% after staff education was implemented (p = 0.013). After order set implementation, weekly average compliance further increased to 93.2% ± 3.6% (p < 0.0001) and remained > 90% until the end of the study period. CONCLUSION: Interdisciplinary synthesis using FMEA and human factors risk assessment is effective for identifying system failure modes associated with Joint Commission MM standard noncompliance. Implementation of an order set with forced functionality to include order information compliant with Joint Commission MM standards can enhance and maintain Joint Commission-compliant PRN medication orders.

Hemispheric connectivity and the visual-spatial divergent-thinking component of creativity.

BACKGROUND/HYPOTHESIS: Divergent thinking is an important measurable component of creativity. This study tested the postulate that divergent thinking depends on large distributed inter- and intra-hemispheric networks. Although preliminary evidence supports increased brain connectivity during divergent thinking, the neural correlates of this characteristic have not been entirely specified. It was predicted that visuospatial divergent thinking would correlate with right hemisphere white matter volume (WMV) and with the size of the corpus callosum (CC). METHODS: Volumetric magnetic resonance imaging (MRI) analyses and the Torrance Tests of Creative Thinking (TTCT) were completed among 21 normal right-handed adult males. RESULTS: TTCT scores correlated negatively with the size of the CC and were not correlated with right or, incidentally, left WMV. CONCLUSIONS: Although these results were not predicted, perhaps, as suggested by Bogen and Bogen (1988), decreased callosal connectivity enhances hemispheric specialization, which benefits the incubation of ideas that are critical for the divergent-thinking component of creativity, and it is the momentary inhibition of this hemispheric independence that accounts for the illumination that is part of the innovative stage of creativity. Alternatively, decreased CC size may reflect more selective developmental pruning, thereby facilitating efficient functional connectivity.

A multivariate approach to aggression and the orbital frontal cortex in psychiatric patients.

The association between orbital frontal cortex (OFC) volume and aggression was investigated in an at-risk psychiatric population. Forty-one psychiatric patients were referred for magnetic resonance imaging and a standardized psychometric assessment of aggression (Lifetime History of Aggression-Revised). Nineteen matched controls had lower levels of aggression and greater OFC volume, establishing the appropriateness of the psychiatric group for studying aggression pathophysiology. Consistent with study hypotheses, left OFC gray matter volume predicted 34% of the variance in self-reported aggression ratings. When impulsivity was not controlled for, left OFC gray matter only accounted for 26% of aggression variance, suggesting a complex relationship between impulsivity and OFC-aggression pathophysiology. Contrary to study hypotheses, right OFC gray matter volume did not predict degree of aggressive behavior. Current models do not account for lateralization, yet this may be quite important. Greater consideration should be given to laterality in OFC regulation of social/emotional behavior. Regulatory focus theory, positing two motivational systems, promotion and prevention, lateralized to the left and right hemispheres, respectively, may provide an explanatory framework for these results. Dysregulation of the left hemisphere 'promotion' motivational system may help to explain the aggressive behavior present in psychiatric populations.

Popliteal Artery Entrapment Syndrome (PAES) in a 17-Year-Old Adolescent.

INTRODUCTION: Popliteal artery entrapment syndrome (PAES) is caused by compression of the popliteal artery (PA) due to deranged myotendinous structures. It can be asymptomatic or may present with exercise intolerance, claudication, or even limb-threatening ischemia. The clinical picture depends on the anatomy and degree of vascular compromise. CASE DESCRIPTION: We report a case of a 17-year-old Caucasian male with PAES Type II presenting with intermittent claudication and progression towards acute limb ischemia. DIAGNOSTICS: MRI and MRA helped identifying the aberrant anatomy and thrombotic occlusion. Doppler ultrasound and conventional angiography have also been employed in a stepwise approach. INTERVENTION: The thrombus at the site of occlusion was removed by the use of catheter-directed lysis. Subsequently, popliteal artery release was achieved by myotomy of the aberrant medial head of gastrocnemius muscle (MHGM) and muscle transfer to the medial femoral condyle. A three-month regimen of 60mg edoxaban was recommended after surgery. OUTCOME: Surgical correction of the anomalous anatomy and postoperative anticoagulation led to freedom of symptoms. LESSON: Clinical presentation of PAES mimicking peripheral artery occlusive disease is very rare but potentially limb-threatening. PAES should be considered in young and otherwise healthy individuals.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study.

OBJECTIVE: The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings. BACKGROUND: Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking. METHODS: We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists. RESULTS: A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial. CONCLUSION: A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.

Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.

BACKGROUND: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. METHODS: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. RESULTS: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96%. Pre-Epic audits had shown a mean compliance of only 86%, mainly reflecting a lack of paper blood component requisitions. CONCLUSION: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.

A check-up for safety culture in "my patient care area".

The two-page Culture Check-Up Tool, which takes 30 to 60 minutes to complete as a group exercise, can help clinicians recognize and fix culture problems.

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

BACKGROUND: An organization's ability to change is driven by its culture, which in turn has a significant impact on safety. The six-step Comprehensive Unit-Based Safety Program (CUSP) is intended to improve local culture and safety. A Web-based project management tool for CUSP was developed and then pilot tested at two hospitals. HOW ECUSP WORKS: Once a patient safety concern is identified (step 3), a unit-level interdisciplinary safety committee determines issue criticality and starts up the projects (step 4), which are managed using project management tools within eCUSP (step 5). On a project's completion, the results are disseminated through a shared story (step 6). CASE STUDIES: OSF St. Joseph's Medical Center-The Medical Birthing Center (Bloomington, Illinois), identified 11 safety issues, implemented 11 projects, and created 9 shared stories--including one for its Armband Project. The Johns Hopkins Hospital (Baltimore) Medical Progressive Care (MPC4) Unit identified 5 safety issues and implemented 4 ongoing projects, including the intravenous (IV) Tubing Compliance Project. DISCUSSION: The eCUSP tool's success depends on an organizational commitment to creating a culture of safety.

A pilot study of quantitative MRI measurements of ventricular volume and cortical atrophy for the differential diagnosis of normal pressure hydrocephalus.

Current radiologic diagnosis of normal pressure hydrocephalus (NPH) requires a subjective judgment of whether lateral ventricular enlargement is disproportionate to cerebral atrophy based on visual inspection of brain images. We investigated whether quantitative measurements of lateral ventricular volume and total cortical thickness (a correlate of cerebral atrophy) could be used to more objectively distinguish NPH from normal controls (NC), Alzheimer's (AD), and Parkinson's disease (PD). Volumetric MRIs were obtained prospectively from patients with NPH (n = 5), PD (n = 5), and NC (5). Additional NC (n = 5) and AD patients (n = 10) from the ADNI cohort were examined. Although mean ventricular volume was significantly greater in the NPH group than all others, the range of values overlapped those of the AD group. Individuals with NPH could be better distinguished when ventricular volume and total cortical thickness were considered in combination. This pilot study suggests that volumetric MRI measurements hold promise for improving NPH differential diagnosis.

Cortical morphology of visual creativity.

BACKGROUND AND OBJECTIVE: The volume of cortical tissue devoted to a function often influences the quality of a person's ability to perform that function. Up to now only white matter correlates of creativity have been reported, and we wanted to learn if the creative visuospatial performance on the figural Torrance Test of Creative Thinking (TTCT) is associated with measurements of cerebral gray matter volume in the regions of the brain that are thought to be important in divergent reasoning and visuospatial processing. METHODS: Eighteen healthy college educated men (mean age=40.78; 15 right-handers) were recruited (via advertisement) as participants. High-resolution MRI scans were acquired on a 1.5T MRI scanner. Voxel-based morphometry regression analyses of TTCT to cortical volume were restrained within the anatomic regions identified. RESULTS: One significant positive focus of association with TTCT emerged within the right parietal lobe gray matter (MNI coordinates: 44, -24, 63; 276 voxels). CONCLUSIONS: Based on theories of parietal lobe function and the requirements of the TTCT, the area observed may be related due to its dominant role in global aspects of attention and visuospatial processing including the capacity for manipulating spatial representations.

Atrazine does not affect algal biomass or snail populations in microcosm communities at environmentally relevant concentrations.

The herbicide atrazine is a photosynthetic inhibitor used around the world in agricultural applications. Contamination of surface waters adjacent to treated areas can directly reduce growth of nontarget aquatic autotrophs, but the severity of impacts is highly dependent on species sensitivity and exposure concentration. Secondary effects resulting from macrophyte or phytoplankton decline may include an expansion of the more tolerant periphyton community. Recently, this shift in the autotrophic community has been proposed as a mechanism for increased rates of parasite infections in amphibians via augmented populations of aquatic snails which act as intermediate hosts to larval trematodes. To further clarify this relationship, an outdoor microcosm study was conducted to examine the effects of atrazine on primary production and snail populations over a range of environmentally relevant concentrations. In July 2009, 15 experimental ponds were treated to achieve initial concentrations of 0, 1, 10, 30, and 100 µg/L atrazine. Over a period of 73 d, measures were taken of macrophyte, phytoplankton, and periphyton biomass, growth, and fecundity of caged snails (Physella spp. and Stagnicola elodes) and free-living snails (Physella spp.). Except for declines in macrophyte biomass at the highest treatment level, no consistent relationships were found between atrazine concentration and any measured parameter. Comparison of these results with previous findings highlights the variability of responses to atrazine exposure between similarly constructed freshwater communities, even at concentrations up to 20 times higher than sustained environmental levels.

Army women's evaluations of a self-administered intervention to prevent sexually transmitted diseases during travel.

BACKGROUND: Military personnel experience seven times the sexually transmitted infections of civilians. Military women are especially vulnerable. No self-administered interventions to promote safer sexual behaviors are available for use by military personnel while on duty in austere locations. The purpose of this study was to ascertain Army women's evaluations of a new theory-based, self-administered, and portable intervention designed to promote safer sexual practices during duty abroad. METHOD: Two focus groups were conducted at a large military installation in the Pacific Northwest. Army women (N=20) ages 18-49 years participated in the groups. Women first examined the intervention and then their reactions to the intervention were elicited with open-ended questions. The qualitative data then were content analyzed. RESULTS: All participants would either recommend or personally use the intervention. Positive features of the intervention included the type of information, a user-friendly and self-explanatory format, and that it was an aid to decision making about safer sex. Concerns included a tendency toward too much information and fears of non-acceptance by peers or sexual partners. CONCLUSION: Minor changes have been made based upon these results. The intervention will be reviewed again and proceed to clinical trials with female military personnel and other travelers.

A prospective, controlled trial of a protocol-based strategy to discontinue mechanical ventilation.

Weaning protocols can improve outcomes, but their efficacy may vary with patient and staff characteristics. In this prospective, controlled trial, we compared protocol-based weaning to usual, physician-directed weaning in a closed medical intensive care unit (ICU) with high physician staffing levels and structured, system-based rounds. Adult patients requiring mechanical ventilation for more than 24 hours were assigned to usual care (UC) or protocol weaning based on their hospital identification number. Patients assigned to UC (n=145) were managed at their physicians' discretion. Patients assigned to protocol (n=154) underwent daily screening and a spontaneous breathing trial by respiratory and nursing staff without physician intervention. There were no significant baseline differences in patient characteristics between groups. The proportion of patients (protocol vs. UC) who successfully discontinued mechanical ventilation (74.7% vs. 75.2%, p=0.92), duration of mechanical ventilation (median [interquartile range]: 60.4 hours [28.6-167.0 hours] vs. 68.0 hours [27.1-169.3 hours], p=0.61), ICU (25.3% vs. 28.3%) and hospital mortality (36.4% vs. 33.1%), ICU length of stay (115 vs. 146 hours), and rates of reinstituting mechanical ventilation (10.3% vs. 9.0%) was similar. We conclude that protocol-directed weaning may be unnecessary in a closed ICU with generous physician staffing and structured rounds.