Grand Junction VA Medical Center

Last month, you probably analyzed more data than a 1990s Fortune 500 company. Your fitness tracker counted steps, your banking app categorized spending, your streaming service tracked viewing habits, and your brain processed it all without a single statistics course. The only difference between you and a "data analyst" is they get paid to do what you do naturally. With Claude as your analytical partner, you're about to discover that statistics tell stories, pattern recognition is your superpower, and creating visualizations beats staring at endless numbers every time.

The incidence of acute kidney injury (AKI) associated with ultramarathon running is varied partially because onsite measurement of serum creatinine concentration (Cr) is rarely performed at races due to logistical challenges. We conducted a prospective observational study using blood samples from volunteer athletes before and immediately after the Leadville Trail 100 Run in August 2014. The goals of our study were to determine the incidence of those meeting the AKI criteria immediately following the ultramarathon race and to evaluate the utility of using medical equations to back-calculate creatinine levels for runners without known baseline creatinine levels and to identify possible risk factors for developing AKI. We were able to collect pre-race and post-race blood samples on 64 and 84 volunteers, respectively. AKI was defined as a Cr increase (≥1.5 times or ≥0.3 mg/dl from baseline). Of the 37 runners for whom we had both pre- and post-race blood samples, 18 (49%) met the criteria for AKI. Using two different methods of back-calculating baseline estimated creatinine (a fixed eGFR [estimated glomerular filtration rate] and an aged-based eGFR), 6 (16%) and 22 (59%) of 37 runners met the criteria for AKI, respectively. We found that there is no accurate way to estimate baseline Cr in this population.

Adrenocortical carcinoma (ACC) is a rare orphan disease with a dismal prognosis. Surgery remains the first-line treatment, but most patients eventually develop metastatic disease. Mitotane is often used with chemotherapy with modest success. Little information is available concerning the efficacy of immunotherapy in combination with mitotane. We conducted a retrospective review of our initial six patients with metastatic ACC, for whom mitotane alone or with chemotherapy failed, and who were subsequently treated with a combination of pembrolizumab and mitotane, between July 2016 and March 2019. Imaging was analyzed per Response Evaluation Criteria in Solid Tumours 1.1 criteria. Two patients had a partial response and four patients had stable disease (8 to 19 months). One patient had grade 3 hepatitis and pembrolizumab was discontinued after 8 months. She died with disease progression 16 months after initiating pembrolizumab. One patient developed brain metastasis after 19 months of treatment and was transitioned to hospice. One patient had focal pneumonitis after 18 months of treatment, and pembrolizumab was discontinued. Three remaining patients continue pembrolizumab plus mitotane at the time of this writing. The current standard of care for ACC is a combination of etoposide, doxorubicin, cisplatin, and mitotane with an overall survival of 14.8 months. All six patients lived for at least 16 months after starting pembrolizumab added to mitotane therapy. The therapy appeared to be effective in both microsatellite instability-high and microsatellite stable tumors, suggesting some synergistic effect with mitotane. Combined immunotherapy and mitotane should be considered in future clinical trials in patients with ACC.

OBJECTIVE: The primary aim of this study was to determine if donepezil (a centrally acting cholinesterase inhibitor) improves measures of balance in persons with Parkinson’s disease (PD) compared to a placebo. BACKGROUND: Cholinesterase inhibitors have a positive impact on cognitive function in persons with PD and cognitive impairment or dementia.(Cochrane 2012) A small study also showed a reduction in falls in persons with PD without dementia.(Chung 2010) DESIGN/METHODS: This was a double-blind placebo controlled crossover study. Participants received 6 weeks of treatment with either placebo or donepezil, then a month washout, then another 6 weeks of treatment opposite to the first. Inclusion criteria were an MMSE>27 and balance impairment on clinical and posturography assessments (SOT <70). RESULTS: Ten participants’ data was used in the analysis. The mean age, UPDRS motor score, and PD disease duration were 69.6+5.9 years, 24+7, and 10.5+8 years at the initial visit. Mean scores on Stroop conflict time and trails B-A at baseline were 105+48s and 59+32s respectively. The mean composite SOT scores improved from 60+16 to 61+15 during the placebo phase and 59+11 to 62+14 during the donepezil phase. This change was not significant, p=0.7. However, in looking at the single conditions of the SOT, there was a statically significant change seen in condition 4 (Eyes Open, Sway referenced, p<0.03). Out of 10 participants, 4 improved more than 40[percnt], 4 improved mildly (between 15[percnt] and 30[percnt]), and 2 didn’t show improvements in C4 during the active phase of the study. In addition, there was a significant correlation between improvement in cognitive performance and balance, r=0.8, p=0.001. CONCLUSION:In this pilot study there was statistically significant improvement in one component of the SOT. A subset of patients appeared to have an improvement in balance. It appears that improvements in balance and executive functions are related.

Patient simulation is an effective clinical nursing experience and debriefing is recognized as the most crucial phase for students to internalize learning. The Neuman systems model is an excellent organizing framework for simulation debriefing to maximize learning. However, due to the model's complexity, metaphor may be useful to help students to link simulation events with the model's concepts. A medieval metaphorical adaptation of the Neuman systems model was created as an educational debriefing tool to help students bridge this gap. Neuman's concepts are represented as medieval figures encountering and dealing with stressor dragons, with assistance (nursing intervention) as necessary. The companion questionnaire allows recording of student insights and becomes an evaluation tool for student comprehension.

HISTORY This subject is a 13-year-old middle school athlete who began to experience LBP while playing football in September 2005. He had played over 55 baseball games this last summer without incidence. He didn't attribute the LBP to any particular event, although he was 'sore' in his back snowboarding last winter. PHYSICAL EXAMINATION (9/26/05) PATIENT DESCRIPTION OF PAIN AND SYMPTOMS: He was having LBP and wrap around pain into the right upper thigh with running, jumping and any extension activity or lifting. He was comfortable at the time of our evaluation. Oswestry score was 20%. TESTS AND MEASUREMENTS (impairments) He has pes planus and he wears Nike shoes with coil heels that appear to have increased heel height. Active lumbar ranges of motion were grossly ½ to ¾ of normal with limitation of flexion (to ankles) with hamstring tightness. He was initially more painful in flexion, but also reported discomfort in extension. Testing of 2 legged standing extension was equally painful with 1 legged extension. Deep tendon reflexes were deferred. Manual muscle testing of his lower quarter was grossly WNL for myotomes. Trunk endurance times (without the brace): Flexion=127 secs., Extension deferred. Tension testing: His straight leg raises (SLRs) were limited at 50–55 o, with no LBP. DIFFERENTIAL DIAGNOSIS Spondylolysis Discogenic pain Lumbar paraspinal muscle strain Lumbar ligament sprain TESTS AND RESULTS Radiographs demonstrated a unilateral pars articularis fracture at L5 & disc height at L5-S1. MRI was positive for bilateral pars fractures of the L5. FINAL WORKING DIAGNOSIS diagnosis: bilateral spondylolysis. Treatment-based classification: Stabilization Treatment & Outcomes Restriction of sports activity for the Fall 2005. He was placed in a body brace for 6 weeks. Discussion with parents pros & cons of brace. Initiation of stabilization training. Rx # 1. (9/22/05) He was instructed in low level stabilization exercises in his brace and hamstring stretches. Orthotics. Rx # 2. (10/3/05) Active lumbar ROM are ½ of normal with more pain in extension. Progression of ball stability exercises. Rx #3. No complaints of LBP. Progression of ball exercises with increased intensity. Rx # 4 (10/20/05) He reports flattening his back (i.e. flexion) increased his LBP, as with riding a mountain bike with jarring. Rx: stabilization exercise, brace on with dumbbell lifting, weight bearing and non-weightbearing (ball). Oswestry score was 12% at Rx #4. Trunk endurance times (without the brace): Flexion= 148 secs, Extension=137 secs.

The use of sodium bisulfate for field preservation of soil samples collected for the analysis of volatile organics (VOCs) can result in the formation of acetone. The work was performed at Camp Edwards, Massachusetts, as part of a multi-year investigation of the effects of training activities on the local environment. Preservation with sodium bisulfate was initiated in 1999 under regulatory mandate. The frequency of acetone detection and the quantities reported increased immediately thereafter. Correlation of duplicate sample results and a side-by-side comparison of six sample handling methods involving two analytical laboratories suggest the interaction of sodium bisulfate with naturally occurring organic matter in samples from Camp Edwards cause the formation of acetone. The data also indicate that a higher content of natural organic matter results in a greater production of acetone, and more acetone is formed the longer the sodium bisulfate is in contact with the soil.