Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression.

BACKGROUND: Electroconvulsive therapy (ECT) and subanesthetic intravenous ketamine are both currently used for treatment-resistant major depression, but the comparative effectiveness of the two treatments remains uncertain. METHODS: We conducted an open-label, randomized, noninferiority trial involving patients referred to ECT clinics for treatment-resistant major depression. Patients with treatment-resistant major depression without psychosis were recruited and assigned in a 1:1 ratio to receive ketamine or ECT. During an initial 3-week treatment phase, patients received either ECT three times per week or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice per week. The primary outcome was a response to treatment (i.e., a decrease of ≥50% from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report; scores range from 0 to 27, with higher scores indicating greater depression). The noninferiority margin was -10 percentage points. Secondary outcomes included scores on memory tests and patient-reported quality of life. After the initial treatment phase, the patients who had a response were followed over a 6-month period. RESULTS: A total of 403 patients underwent randomization at five clinical sites; 200 patients were assigned to the ketamine group and 203 to the ECT group. After 38 patients had withdrawn before initiation of the assigned treatment, ketamine was administered to 195 patients and ECT to 170 patients. A total of 55.4% of the patients in the ketamine group and 41.2% of those in the ECT group had a response (difference, 14.2 percentage points; 95% confidence interval, 3.9 to 24.2; P<0.001 for the noninferiority of ketamine to ECT). ECT appeared to be associated with a decrease in memory recall after 3 weeks of treatment (mean [±SE] decrease in the T-score for delayed recall on the Hopkins Verbal Learning Test-Revised, -0.9±1.1 in the ketamine group vs. -9.7±1.2 in the ECT group; scores range from -300 to 200, with higher scores indicating better function) with gradual recovery during follow-up. Improvement in patient-reported quality-of-life was similar in the two trial groups. ECT was associated with musculoskeletal adverse effects, whereas ketamine was associated with dissociation. CONCLUSIONS: Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis. (Funded by the Patient-Centered Outcomes Research Institute; ELEKT-D ClinicalTrials.gov number, NCT03113968.).

A Scoping Review of Recommendations and Training to Respond to Patient Microaggressions.

OBJECTIVE: Patient microaggressions affect practitioners in all fields of healthcare and especially psychiatry. In multiple studies, healthcare professionals reported high rates of patient microaggressions and discrimination. To date, this is the first scoping review of recommendations and trainings on patient microaggressions. METHOD: A scoping review of articles indexed in PubMed, PsycINFO, Medline, ERIC, and MedEdPORTAL was conducted from July 2020 to August 2020 to identify recommendations and solutions for healthcare professionals on responding to patient microaggressions. RESULTS: The review identified 27 studies that provide recommendations and trainings for healthcare professionals to address patient microaggressions. Twenty studies outlined recommendations for healthcare professionals and systems on how to respond to patient offenses. These 20 studies were grouped into establishing a supportive culture, addressing the microaggression, supporting the targets of microaggressions, discriminatory requests, and institutional responses. Six articles described trainings that equip providers with tools to address patient microaggressions, including the ERASE framework ("Expect/Recognize/Address/Support/Establish, Encourage"); Stop, Talk, and Roll; interrupting microaggressions; XYZ ("I felt X when Y because Z"); the ACTION model ("Ask/Come/Tell/Impact/Own/Next"); and the OWTFD tool ("Observe/Why/Think/Feel/Desire"). CONCLUSION: Recommendations and trainings for the response to microaggressions are emerging, and results of trainings are encouraging. However, more work is needed to evaluate the effectiveness of these trainings in clinical settings and longitudinally.

Association of MBL2 Gene Polymorphism with Dental Caries in Saudi Children.

The high prevalence of dental caries in children worldwide is a major oral health problem which requires early intervention. Dental caries is mainly caused by the action of acids produced by bacteria in addition to many other factors. Recent genetic studies have reported that a number of genes are associated with the susceptibility to dental caries. The majority of these genes are associated with inflammation, increased susceptibility to infection, and dentine matrix formation. Using the TaqMan assay and direct DNA sequencing, the prevalence of 6 single-nucleotide polymorphisms (SNPs) in MMP9, MBL2, MMP2, and TIMP2 genes was determined in 102 children with caries and in 100 age-matched caries-free controls. Out of the 6 SNPs tested in the 4 selected genes, only rs11003125 in the MBL2 gene was shown to be associated with a high prevalence of caries in our cohort. In addition, haplotype analysis of the 6 SNPs tested revealed that certain haplotypes, namely GT of rs11003125G and rs7501477T and GT of rs7096206G and rs7501477T, were found to be associated with a high prevalence of dental caries in our cohort, while haplotype AG of rs17576A and rs7501477G was found to have a protective effect against dental caries. In conclusion, the data indicate that rs11003125 in the MBL2 gene was shown to be associated with a high prevalence of caries in our cohort, and 2 haplotypes are also involved in the increased susceptibility to dental caries.

Novel Monosulfonated Azo Dyes: Design, Synthesis, and Application as Disperse Dyes on Polyester Fabrics.

This study synthesizes and characterizes a series of disperse dyes based on azo Schiff bases, compounds 8-10. Their structures were identified using various analytical techniques, such as FT-IR, 1H/13C NMR, and mass spectrometry. The study's primary objective was to investigate the behavior of disperse dyes 8-10 when used for dyeing polyester fabrics under different conditions, including variations in time, temperature, shade, and pH. The polyester fabric was chosen for this research due to its wide usage and popularity in the textile industry. By examining the effect of temperature and time on the dyeing process, it was observed that increasing the dyeing temperature from low to high (ranging from 90 to 120 °C) and extending the dyeing time from 10 to 30 min resulted in higher K/S values for the polyester samples dyed with disperse dyes. Additionally, dyes 9 and 10 exhibited the most excellent K/S values among the tested dyes. Furthermore, the study found that dye 8 showed the best dyeing performance as the pH of the dye bath increased to 6.

Veterans Administration Readjustment Counseling Service Counselors' Training Needs: Results of a National Needs Assessment.

The Department of Veteran Affairs established Readjustment Counseling Service (RCS) to meet the mental health needs of active-duty service members, veterans, and their families. A diverse therapeutic skill set is needed to serve this complex population. To assess training needs, a national mixed-methods needs assessment consisting of a survey for RCS counselors and focus groups among counselors, RCS educational trainers, and national leadership was conducted. Survey results (n = 681) showed that RCS counselors were most interested in trainings on moral injury, acceptance and commitment therapy, and military sexual trauma (MST). Desired trainings aligned with populations served. Themes from focus groups revealed the need for foundational trainings so that all RCS counselors are adept in treating MST, moral injury, and posttraumatic disorder and proficient in caring for couples. Additionally, counselors desired advanced trainings tailored to individual counselors' needs. RCS counselors identified multiple trainings to help them treat those they serve.

The effects of packaging type and storage temperature on some of UHT milk quality indexes.

The objective of the present study was to illustrate the changes in physicochemical properties in ultra-high temperature (UHT) milk packed into a pouch and Tetra Brik during storage. UHT milk samples were kept at 5 and 25 °C for 3 months and regularly analyzed monthly. During storage, significant increases (p < 0.05) in titratable acidity (TA), water-soluble nitrogen (WSN), and non-protein nitrogen (NPN) when UHT milk was packed into pouch versus Tetra Brik and stored at 25 versus 5 °C. Neither type of packaging nor storage temperature affect pH values during storage. Spore-forming bacterial (SFB) count was always higher in UHT milk packed into pouch versus Tetra Brik. Refrigerated storage kept UHT milk without detectable SFB compared to UHT milk held at 25 °C. Pouch packages were responsible for the migration of phthalate derivatives [dimethyl phthalate "DMP", diethyl phthalate "DEP", dibutyl phthalate "DBP", and di-(2-Ethylhexyl) phthalate "DEHP"] into milk with significantly greater levels than milk filled into Tetra Brik. The total sensory scores were decreased significantly during storage, which was more pronounced in UHT milk filled into pouch versus Tetra Brik or stored at 25 °C versus 5 °C. It is concluded that UHT milk filled into Tetra Brik stored at 5 and 25 °C is better in terms of quality and safety indexes than such filled into a pouch.

Making an Impact: Evaluation of an Enduring Online Training Empowering Clinicians to Respond to Hate Speech.

Mental health clinicians frequently experience hate speech during patient care, resulting in an ethical dilemma. This study evaluated a 1-hour webinar discussing the ethics of working with Veterans who use hate speech, motivations and intentions of hate speech, and guidance on how to respond. The webinar was offered through the virtual Community-Based Outpatient Clinic Mental Health Grand Rounds session at the Veterans Health Administration (VHA). Rural mental health clinicians were the target audience; however, all VHA clinicians could attend. Participants were VHA clinicians who completed the evaluation for the training and received one continuing education unit for this training (n = 668). They were highly satisfied with the training and would recommend it to others. They also reported the intention to talk with coworkers and trainees about responding to hate speech and requested additional training. The recorded training can be viewed for free at https://www.mirecc.va.gov/visn16/working-with-patients-who-use-hate-speech.asp.

The use of Mitek bone anchors for synthetic mesh fixation to repair recalcitrant abdominal hernias.

INTRODUCTION: Repair of recurrent abdominal hernias is a surgical challenge. These patients usually present to the plastic surgeon as a last resort for treatment. Such recalcitrant hernias cause enormous morbidity and constitute a financial burden to any health service. It is important to explore novel and potentially effective repair methods. We report on a technique using overlay prolene mesh fixed to bone by Mitek anchors. METHODS: All patients who had Mitek bone anchor fixation of synthetic mesh, to repair recurrent iatrogenic abdominal hernias between 2003 and 2010 by one surgeon (C.M.M.), were retrospectively reviewed. The indications, operative details, and clinical outcomes were documented. RESULTS: A total of 7 patients (6 females, 1 male) aged 35 to 60 (average 53) years were included in the study. The causes of herniation were previous surgical incisions (3) and abdominal flap harvests (4). They had had a median of 3 hernia repairs before referral to plastic surgery. The operations lasted for a mean of 6 hours (range, 3-10½ hr). There were no major intra- and postoperative problems although 1 patient requested removal of 2 of his 8 Mitek anchors because of persistent localized pain and tenderness. After a mean follow-up of 24 months (range, 4-34), only 1 patient developed a recurrent lower abdominal bulge. CONCLUSION: Our single operator series demonstrated that Mitek bone anchor fixation of prosthetic mesh reinforcement of abdominal wall hernia repair is an effective treatment technique associated with a low morbidity. This method of recalcitrant hernia repair may be a useful addition to the armamentarium of the plastic surgeon.

Vanin 1 Gene Role in Modulation of iNOS/MCP-1/TGF-ß1 Signaling Pathway in Obese Diabetic Patients.

Introduction: Cysteamine, a powerful endogenous antioxidant, is produced mostly by the vanin-1 with pantetheinase activity. With regard to glycemic, inflammatory, and redox factors, the current study sought to evaluate the association between the expression of the vanin-1 gene, oxidative stress, and inflammatory and iNOS signaling pathway in obese diabetic patients. Methods: We enrolled 67 male subjects with an average age of 53.5 ± 5.0 years, divided into 4 groups according to the WHO guideline. We determined their plasma levels of glucose, insulin, IRI, HbA1c, TC, TG, HDL-C, TNF- α, MCP-1, TGF-ß1, SOD, CAT, and TBARs, as well as expression of the iNOS and Vanin1 genes. Results: Overweight and obese class I and II diabetics had significantly higher levels of plasma glucose, insulin, HbA1c, TNF-α, MCP-1, TGF-ß1, CAT, and TBAR as well as iNOS and vanin-1 gene expression compared to healthy control individuals. In addition, as compared to healthy control individuals, overweight obese class I and II diabetics' plasma HDL-C levels and blood SOD activity were significantly lower. In addition, ultrasound and computed tomography showed that the presence of a mild obscuring fatty liver with mild hepatic echogenicity appeared in overweight, class I and II obese diabetic patients. Conclusion: These findings provide important information for understanding the correlation between Vanin 1 and glycemic, inflammatory, and redox factors in obese patients. Furthermore, US and CT analysis were performed to visualize the observed images of fatty liver due to obesity.

Antitumor and Protective Activity of TVLE against CdCl2-Induced Renal Damage in Rats.

<b>Background and Objective:</b> Cadmium is a heavy metal that has a wide range of applications in human existence. Cadmium may bind to the protein metallothionein and decrease kidney function once it enters the body. The purpose of this study was to investigate the renal protective activity of TVLE against CdCl₂-induced renal toxicity in rats. <b>Materials and Methods:</b> TVLE was prepared and characterized using instrumental analysis and spectral data. Furthermore, the IC₅₀ of TVLE against the Vero renal carcinoma cell line was calculated. Adult albino rats were used to assess the renal protective activity of TVLE (150 and 300 mg kg¹ b.wt.) in CdCl₂-treated rats. <b>Results:</b> IC₅₀of TVLE against Vero cell line equals 148.25 µg mL¹. The daily oral administration of TVLE at concentrations of 150 and 300 mg kg¹ b.wt. for 21 days to CdCl₂-treated rates resulted in a significant improvement in tumour volume and tumour weight, urea, creatinine, uric acid, TNF-α, NOx, TBARs, GSH, CAT, SOD, GPx and VEGF-C gene expression in CdCl₂-treated rats. Furthermore, TVLE almost normalized these effects in renal histoarchitecture. <b>Conclusion:</b> The biochemical, histological and MRI examinations of the current study suggested that TVLE have renal protective activity against CdCl₂-induced renal toxicity in rats.

A Randomized Controlled Trial to Assess the Cost-effectiveness of a Novel, Simple Modification to the Negative Pressure Wound Therapy System.

BACKGROUND: Negative pressure wound therapy (NPWT) has shown remarkable adaptation in wound management worldwide. Numerous studies have provided evidence that demonstrates both the medical and financial advantages of NPWT. In this study, the VAC Therapy System, one of the leading commercially used NPWT systems, has been utilized to treat patients with either acute or chronic wounds requiring surgical intervention, with the aim of demonstrating the efficacy of using a modified version of the VAC system while reducing the total associated cost. METHOD: The patients were divided into two randomly selected groups using randomization generator software. A modification was made by replacing the disposable canister provided by Kinetic Concepts Inc., with an alternative reusable canister (Baxter, Inc.); one group was assigned to use the conventional VAC Therapy System, and the other was assigned to use the modified version. Our study aimed to investigate whether this modification would lower the cost of the VAC Therapy System while still achieving the desired outcome. RESULTS: The VAC Therapy System contributed to improving the wound bed score in both groups, which supports previous findings on the effectiveness of NPWT while reflecting that the modification did not negatively impact the functionality and the integrity of the VAC Therapy System. Furthermore, the average daily consumables cost was markedly reduced in the modified group compared with the standard group, which reduced the overall cost of treatment. CONCLUSION: It is possible to use the VAC Therapy System to its full advantage, while minimizing the financial burden of using it.

Resveratrol: Isolation, and Its Nanostructured Lipid Carriers, Inhibits Cell Proliferation, Induces Cell Apoptosis in Certain Human Cell Lines Carcinoma and Exerts Protective Effect Against Paraquat-Induced Hepatotoxicity.

Resveratrol (RES) (trans-3, 5,-4'-trihydroxystilebene) is a multi-biofunctional compound found in a variety of plants such as grapes and mulberries. Studies of nanoencapsulated resveratrol have indicated that this compound can inhibit the growth of cancer cells and free radicals. The aim of this study was to isolate resveratrol from Vitis vinifera, develop and evaluate resveratrol nanostructured lipid carriers (NLCs) and/or resveratrol encapsulated chitosan-coated nanostructured lipid carriers (CSNLCs) using low-viscous chitosan for anticancer therapy. In addition, our study was carried out to examine the prophylactic potential of RES, NLC, and CSNLC on paraquat-induced injury in rat hepatocytes. In this study we isolated resveratrol and encapsulated NLCs in phosphate-buffered saline solution using a phase inversion method. In addition, CSNLCs were prepared by ionic gelation method of NLCs using chitosan. NLCs and CSNLCs were then characterized for their particle size, zeta potential, morphology, and entrapment efficiency. Furthermore, NLCs and CSNLCs were evaluated for their cytotoxic effect on Hep-G2, human HCT-116 (colorectal cancer cell line), lymphoblastic leukemia (1301), and human MCF-7 (Michigan Cancer Foundation-7) cells as well as their effect on caspase-3 and death receptor (DR-4). In addition, incubation of hepatocytes with paraquat resulted in increased formation of TBARS (thiobarbituric acid reactive substances) with a parallel increase in lactate dehydrogenase (LDH) leakage at 1 h after incubation. Time-dependent depletion of cellular glutathione (GSH) was observed starting 2 h after incubation with paraquat. The mean particle size of NLC and CSNLC were 67.0 and 98.41 nm, zeta potential were (-) 24.8 and (+) 31.6 mV, entrapment efficiency were 74.15% and 85.46%, respectively, with the observed shapes of nanoparticle being spherical. The treatment of Hep-G2, human HCT-116, lymphoblastic leukemia (1301), and human MCF-7 cells with NLC led to high inhibition in the cell proliferation as concluded by the low IC50 values 27.7, 17.43, 35.39, and 47.66 µg/mL, respectively, whereas CSNLC had high cytotoxic effect on Hep-G2, human HCT-116, lymphoblastic leukemia (1301), and human MCF-7 cells with low IC50 values 13.29, 10.56, 16.79 and 22.60 µg/mL, respectively. Both NLC and CSNLC possess apoptotic properties through activation of the caspase-3 and death receptor (DR-4). In addition, incubation of hepatocytes with RES, NLC, and CSNLC markedly protected against paraquat-induced formation of TBARS, increase in LDH leakage, and prevented GSH depletion. The most effective doses for ethyl acetate, ethanolic, and aqueous extracts were 7.5, 10, and 12.5 µg, respectively. The results presented here may suggest that nanoencapsulated resveratrol isolated from the stems of V. vinifera to obtain NLC and CSNLC possess anticancer and apoptotic effects on cell proliferation, and therefore, can be used as new approach of pharmaceutical drugs. In addition, the results clearly suggest that the RES, NLC, and CSNLC exerted protective effect against cytotoxicity induced by paraquat. On the contrary, the effect decreased in order of CSNLC, NLC, and RES.

Phenolic Profiling and Therapeutic Potential of Certain Isolated Compounds from Parkia roxburghii against AChE Activity as well as GABAA α5, GSK-3ß, and p38α MAP-Kinase Genes.

Parkia roxburghii belongs to the family Mimosaceae; it has been used since ancient times as a cure for different health complications; such as inflammatory and gynecological diseases and hemiplegia. In this investigation, a reversed-phase-high-performance liquid chromatography (RP-HPLC) profile was carried out for P. roxburghii; also, the isolated bioactive compounds including quercetin, catechin, and biochaninA were individually and/or in combination investigated for their inhibitory effects on scopolamine-induced memory impairments in mice, implying that they have the ability to reduce the neurodegenerative effects of scopolamine and thus could be employed as a more effective therapeutic agent in the treatment of Alzheimer's disease (AD) in humans. The possible interactions of Parkia flavonoids with acetylcholinesterase (AChE), γ-aminobutyric acid A receptor, alpha5 (GABAA α5), glycogen synthase kinase-3 (GSK-3), p38 mitogen-activated protein kinase (p38MAP-kinase), signal-regulated kinase (ERK), and protein-serine/threonine kinase (Akt) were then determined using molecular docking.

Wellness for Warriors: Developing and Disseminating a Veteran-centric Wellness Guide.

BACKGROUND: Evidence-based self-help wellness interventions have several benefits, including low cost, brevity, and lack of need for a health care professional. Veterans, in particular, may benefit from a self-guided resource, given a culture of self-reliance, mental health help-seeking stigma, and a high need for mental health care. Despite the high need, few self-help resources are designed for veterans. OBJECTIVES: The goal of this project was to create the Veteran Wellness Guide, a self-guided resource comprising SMART goal setting and evidence-based interventions for veterans (e.g., self-kindness, gratitude, diaphragmatic breathing, mindfulness). METHODS: First, a Veteran Engagement Group reviewed the guide and provided feedback on veteran-centric content and design. After the authors revised the guide, a subset of the group approved changes. Additional veterans used it for 2 weeks and provided feedback. RESULTS: Veterans reported the guide as being highly useful, were willing to recommend it to other veterans, and identified a need for it in the veteran community. Veterans and Veterans Health Administration clinicians and leadership helped to craft a dissemination plan to reach veterans whether they receive care through the Veterans Health Administration or the community. CONCLUSIONS: Partnering with veterans in the creation of the wellness guide led to a veteran-centric product tailored to meet the unique wellness needs of veterans. The guide has been nationally disseminated and downloaded over 3000 times and can be downloaded for free from our website.

A high-need, high-impact educational session on firearms and death by suicide.

BACKGROUND: The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans. AIMS: This study evaluates a one-hour educational seminar for clinicians on lethal means safety. MATERIALS AND METHODS: One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later. RESULTS: After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety. DISCUSSION: Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms. CONCLUSIONS: This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

Virtual Synchronous Motivational Interviewing Training for Geographically Dispersed Interprofessional Learners.

INTRODUCTION: Behavioral health and other preventable factors account for nearly half of all premature deaths in the United States. Motivational interviewing (MI) is effective for engaging ambivalent patients in behavior change. However, many clinicians report barriers to receiving MI training, including time, cost, and travel. This study examined the effect of a 2-day virtual MI training built around didactic and real-play learning activities. METHODS: Thirty interprofessional clinicians from eight Veterans Affairs medical centers and their community-based outpatient clinics across 4 US states attended a 2-day virtual MI training. Participants completed a posttraining evaluation and a 3-month posttraining evaluation. RESULTS: Participants reported that they learned new knowledge and skills, and they would be able to apply these to their practice (M > 4).They reported high satisfaction with the training and platform and found the technology easy to use (M > 4). In the 3-month posttraining survey, participants reported that they were using MI in their practice (M = 4.19) and that they would like additional support, such as additional reading (n = 8). DISCUSSION: This study demonstrates the effect of a 2-day virtual MI training built around didactic and real-play learning activities. Virtual training particularly enhances training opportunities in rural settings. Our training removed travel and payment as barriers to participation.

Obsessive-Compulsive Disorder in Older Adults: A Comprehensive Literature Review.

We reviewed English-language articles concerning obsessive-compulsive disorder (OCD) in older adults. PubMed was searched using key words that included obsessive-compulsive disorder, geriatric, elderly, aging, and older. Of the 644 articles identified, we included 78 that were relevant to the topic. Articles that were excluded as irrelevant included studies that were not focused on OCD in older adults, animal studies, and older case reports if we identified similar more recent case reports. The literature contains very little information about the epidemiology, diagnosis, psychopathology, and treatment of OCD in older adults. Even though the diagnostic criteria for OCD are the same for older and younger adults, different manifestations and progression in older patients have been reported. While the domains and severity of symptoms of OCD do not change with age, pathologic doubt may worsen. The Yale-Brown Obsessive Compulsive Scale is used for diagnosing and evaluating illness severity, and the Obsessive-Compulsive Inventory-Revised is another valuable tool for use in older adults. Psychotherapy, specifically exposure and response prevention, is the first-line treatment for OCD because of minimal adverse effects and reported benefit. Although the US Food and Drug Administration has not approved any medications specifically for OCD in older adults, pharmacotherapy is a consideration if psychotherapy is not successful. Selective serotonin reuptake inhibitors have the fewest side effects, while the cardiovascular and anticholinergic side effects of tricyclic antidepressants are especially worrisome in older adults. OCD in older adults has received little attention, and further studies are needed.

Transforming Veterans Health Administration Mental Health Clinician Education and Practices: 20 Years of Educational Initiatives by a Center of Excellence.

Twenty years ago, the US Congress articulated a need to decrease the time it takes clinical best practices to move from the literature to daily clinical practice. The Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center was one of several centers of excellence established to address this need. It is also unique in that it focuses on rural and underserved veterans. This article summarizes the education accomplishments of the South Central Mental Illness Research, Education, and Clinical Center thus far in providing educational resources and trainings to frontline Veterans Affairs mental health staff with the goal of bringing best practices to routine clinical care, thus improving mental health services. We describe the use of implementation science to support dissemination of information, such as the monthly mental health grand rounds, especially for rural staff to receive continuing education, and the adoption of evidence-based psychotherapy trainings. The Clinical Educator Grants program allows clinicians to share their clinical expertise through development of practical tools for practice gaps they identify. We describe some future directions to meet the evolving needs of Veterans Affairs and community clinicians to provide the best possible care to Veterans. Take-away messages are that, for trainings to be successful, an implementation plan is critical and that an effective educational program requires funding and leadership commitment.

Trigeminal Neuralgia: A Clinical Review for the General Physician.

General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article.