Malcom Randall VA Medical Center

Introduction: Fiber-containing (FC) enteral nutrition (EN) has been shown to decrease diarrhea and gastrointestinal complications in patients who are hemodynamically stable. However, in hemodynamically unstable patients requiring vasopressors, fiber may increase the risk of gastrointestinal mucosal injury and bowel ischemia. The purpose of this study was to assess EN tolerance and the incidence of adverse events in patients receiving either FC or fiber-free (FF) EN while on vasopressors. Methods: This was a single-center, retrospective cohort study of patients admitted to the intensive care unit from January 1, 2022, through December 31, 2024, who received EN and concomitant vasopressors. Patients who received FC EN were compared to those who received FF EN. Outcomes included doses of nutrition provided, incidence of bowel ischemia, feeding intolerance, and other adverse events. Results: A total of 35 patients were included, with 19 patients in the FC group and 16 patients in the FF group. All patients received norepinephrine, with 6 patients (31.6%) in the FC group and 2 patients (12.5%) in the FF group receiving additional vasopressors. In the FC group, 5 patients (26.3%) experienced abdominal distention compared to 4 patients (25%) in the FF group (OR 0.93, 95% CI 0.20 to 4.29, p >.9). Five patients (26.3%) in the FC group had diarrhea or constipation compared to 3 patients (18.8%) in the FF group (OR 0.65, 95% CI 0.13 to 3.26, p =.7). Four patients (21.1%) in the FC group developed aspiration compared to 2 patients (12.5%) in the FF group (OR 0.54, 95% CI 0.08 to 3.40, p =.7). Three patients (15.8%) in the FC group developed an ileus compared to no patients in the FF group (OR 0.14, 95% CI 0.01 to 2.99, p =.2). One patient (5.3%) in the FC group experienced bowel ischemia compared to no patients in the FF group (OR 0.37, 95% CI 0.01 to 9.82, p >.9). There were no significant differences in the number of calories or amount of protein provided to each group. Conclusions: While limitations must be considered, this study did not indicate harm associated with fiber in patients receiving EN while on vasopressors. These results may help generate hypotheses for future studies for a more comprehensive evaluation.

Background:Peripheral artery disease (PAD) and its severe form, chronic limb-threatening ischemia (CLTI), significantly impair blood flow to the lower extremities, affecting millions of adults globally. Intramuscular adipose tissue (IMAT) and fibrosis accumulation distinguish patients with CLTI from those with mild PAD, suggesting a role in CLTI pathobiology. However, the functional consequences of IMAT in CLTI remain unclear.Methods:We compared gastrocnemius muscle samples from patients with PAD/CLTI, intermittent claudication, and non-PAD individuals. We analyzed bulk RNA sequencing, proteomic, lipidomic, and single-cell/nucleus RNA sequencing datasets. Additionally, we used murine models of hindlimb ischemia (HLI) with genetic manipulation of Pparγ, a key adipogenic transcription factor, specifically in fibro-adipogenic progenitor cells (FAPs), the cellular source of IMAT, to modulate IMAT formation and assessed the impact on limb function and pathology.Results:Patients with CLTI exhibited significantly elevated expression of adipogenic genes and proteins in muscle specimens when compared to non-PAD controls. Murine models showed that increasing IMAT formation significantly worsened ischemic limb muscle strength and work output. In contrast, preventing IMAT formation significantly improved ischemic limb muscle strength and work output. These findings were consistent across both male and female mice, although females had greater tendency to form IMAT compared with male mice.Conclusions:IMAT accumulation is a key determinant of limb function in PAD/CLTI. Our studies demonstrate that targeting IMAT formation could improve limb function in mice with experimental PAD. Together, these findings suggest that developing strategies to limit or reduce IMAT may improve limb function and walking performance in patients with PAD/CLTI, providing a novel therapeutic avenue to address a critical unmet need.

Abstract INTRODUCTION One of the challenges of monitoring response to treatment in malignant glioma is detecting subtle changes in MR imaging that may indicate disease progression or therapeutic response. This is particularly difficult in the clinical trial setting, given small sample sizes, image registration variability, and heterogenous or novel radiographic morphology. Topological Data Analysis (TDA) and persistent homology can be used to quantify complex tumor shapes and heterogeneities from MRI data in this population. These tools provide robust geometric summaries that capture topological features like connected components and voids, enabling the identification of key radiological markers that may otherwise go undetected. METHODS We used persistent homology to extract topological features from T2 and FLAIR weighted MR images in the KR158 model of glioblastoma (GBM), pet dogs with canine glioma, and human GBM patients treated with RNA lipid particle aggregates (RNA-LPAs) (NCT06389591). These features were then compared to untreated controls. Results and Future Directions: There are clear differences in topological features of images from treated and untreated cohorts across species, despite small sample sizes and variability in image acquisition and registration. This data is rapidly translatable and applicable to monitoring of patients with malignant glioma undergoing treatment with novel therapeutics, particularly within immunotherapy clinical trials.

Walking on uneven terrain becomes more difficult as we age, and gait becomes less automatic. Using mobile brain imaging via high-density electroencephalography (EEG) can provide insight into the neural mechanisms contributing to reduced mobility capability with aging. The objective of this study was to quantify age differences in electrocortical dynamics during uneven terrain walking, both averaged across many strides and variations within a stride. We included 31 young adults and 71 older adults for analysis. All participants walked on an uneven terrain treadmill with four levels of terrain difficulty at their self-selected speed. Compared with younger adults, older adults exhibited a greater increase in step duration variability and mediolateral sacral excursion variability as the terrain became more uneven. We identified multiple brain regions involved during walking on uneven terrain. Regardless of age group, walking on uneven terrain compared with flat terrain led to a widespread change of electrocortical dynamics in the brain, especially in the alpha (8–13 Hz) and beta (13–30 Hz) band power. In the parieto-occipital region, younger adults experienced a greater reduction in alpha and beta power with increasing terrain unevenness than older adults. We also assessed how intra-stride power fluctuations changed with terrain unevenness and age group. Greater intra-stride power spectral fluctuations in the occipital area were associated with greater terrain unevenness for younger adults, but not for older adults. In summary, older adults showed a greater increase in gait variability than younger adults as the terrain became more uneven, but exhibited a lack of modulation of parieto-occipital activity in response to terrain unevenness. The lack of task-related power modulation may suggest reduced cortical network flexibility in older adults. The absence of increased parieto-occipital activity when walking on uneven versus flat surfaces in older adults may also indicate that, unlike younger adults, older adults already heavily rely on visual processes during flat surface walking and may, therefore, have reduced occipital modulation range remaining to cope with the visuomotor processing demands of walking on uneven surfaces.

ABSTRACTLandmark trials of sotatercept in pulmonary arterial hypertension (PAH) excluded patients with significant cardiopulmonary comorbidities. To evaluate the real‐world effectiveness and safety of sotatercept in patients with Group I PAH and cardiopulmonary comorbidities. We conducted a single‐center prospective observational study of adults with PAH on stable background therapy who initiated sotatercept between August 2024 and April 2025. Clinical, echocardiographic, and adverse event data were collected at baseline, 3 months, and 6 months. Forty‐five patients (mean age 59.1 years old; 88.8% female) were included. Common comorbidities include CAD (44.7%), HTN (40.4%), ILD (23.4%), and COPD (12.7%). Most patients were on triple background pulmonary vasodilator therapy (63.8%). At 6‐month follow‐up, oxygen requirement at rest improved from 4.64 to 3.20 L/min (p = 0.001), 6MWD increased by 20 meters (310.5 ± 142.4 m to 330.4 ± 132.3 m, p = 0.01). REVEAL Lite 2 scores improved, with over half the cohort achieving or maintaining low risk status. Adverse effects were mild, including epistaxis and increased hematocrit. Sotatercept appears safe and clinically beneficial in PAH patients with cardiopulmonary comorbidities.

Telehealth has expanded access to psychotherapy for veterans, yet little is known about how art therapy is experienced in remote formats. In this paper, we describe a thematic analysis that involved male and female veterans with PTSD and TBI (aside from one participant without a TBI) in individual telehealth art therapy. This paper explores the similarities and differences in male and female veterans’ engagement in art therapy. Nine veterans (6 male, 3 female) diagnosed with PTSD (with most also having TBI) participated in eight sessions of individual telehealth art therapy. Clinical notes, session summaries, and artwork were analyzed using thematic analysis to identify key patterns in veterans’ therapeutic experiences. Three primary themes emerged from the data: a) Striving to manage self and emotions; b) Diverse relationships with artmaking and media; and c) Seeking to improve interpersonal connection. Telehealth art therapy supported emotional expression, trauma processing, and relational insight in veterans with PTSD and TBI. The findings underscore the value of flexible, personalized approaches in remote care and demonstrate how art therapy can be meaningfully adapted for telehealth delivery and meet the needs of diverse participants. Future research should explore hybrid models, individualized interventions, and the influence of identity and environment on therapeutic engagement and outcomes, as well as the possibly unique experiences of male and female veterans.

Individuals who have chronic pain experience reductions in physical activity (PA), quality of life, and physical capabilities, creating a debilitating cycle where decreased PA and increased weight exacerbate pain. This study aimed to examine associations between weight status, PA, and time spent in pain using a nationally representative sample, accounting for demographic factors. Using data from the 2011-2012 NHANES cycle, a comparison of pain groups with weight status and PA (total and type) and a mediation analysis using PA (total and type) as a mediator between weight status and time spent in pain were conducted. Total PA groups differed in pain levels with those engaging in vigorous activity having the lowest prevalence in the "pain always" category (5.4%), and those with obesity had a higher prevalence of "pain always" (49.6%) compared to those with normal weight (19.5%) and those with overweight (30.9%). Total PA mediated the relationship between people with obesity and the amount of time spent in pain (effect:1.141; CI:0.456-1.837), that is, compared to those who have normal weight, those who have obesity were less likely to meet the total PA guideline, and subsequently likely to spend more days in pain. Breaking down PA by types, travel PA (effect:0.071; CI:0.024-0.152), moderate recreational PA (effect:0.041; CI:0.018-0.079), and vigorous recreational PA (effect:0.135; CI:0.035-0.279) significantly mediated the relationships between people with obesity and days spent in pain. Findings suggest that vigorous PA is linked to lower pain prevalence. Additionally, PA significantly mediates the relationship between people with obesity and days spent in pain. While people with overweight alone was not associated with the number of days spent in pain, engaging in vigorous recreational activities was linked to reductions in days spent in pain for individuals with overweight, highlighting the importance of staying active to manage pain.

The relationship between the gut microbiome and overall human health is increasingly recognized. This review discusses new research that outlines pathways and intermediaries that may mediate the interaction between the gut microbiome and cardiac arrhythmias. Gut microbial constituents and their products have been shown to influence human physiology, including the cardiovascular system, cardiac arrhythmia, and other disease processes. The effect of the human gut microbiome on cardiovascular diseases may improve understanding of disease pathophysiologic mechanisms and presents opportunities for therapeutic modification of the gut microbiome to positively affect disease outcomes. Research into the gut microbiome and its overarching impact on the human body is still in its early stages. Continued investigation of its complex relationships may lead to the development of novel therapies and strategies to enhance patient safety.

Abstract Background and purpose: Veterans exhibit higher lung cancer detection rates as compared to the general U.S. population. In response, the U.S. Department of Veterans Affairs (VA) has implemented nationwide lung cancer screening programs aimed at early detection of population at risk; 50-80year old veterans with significant smoking histories. However, many lung nodules in veterans are incidentally discovered while undergoing imaging for other health conditions or while undergoing pre-existing cancer surveillance monitoring. As such, this study aimed to assess differences in nodule characteristics between veterans who underwent lung cancer screening (LCS) versus those with incidental and cancer surveillance-detected lung nodules. Methods: This retrospective review included 362 adult veterans who underwent diagnostic procedures using Robot-Assisted Bronchoscopy (RAB) for abnormal lung findings detected via Computed Tomography (CT) scans, either incidental/cancer surveillance (n=184, 50.8%) or through LCS (n=178, 49.2%). The sample was predominantly male (93.6%, 339/362), with an equal proportion of males and females in both groups (p=0.799). Results: Veterans who underwent RAB following LCS were older (72.77 ± 8.32 years vs. 70.88 ± 6.89 years; p=0.019) and their primary nodules were smaller (19.16 ± 11.74 mm vs. 21.65 ± 13.65 mm; p=0.032). However, they were not more likely to have positive lymph nodes (25% vs. 12.3%; p=0.075) and there was no difference between groups in the size of the secondary target (11.97 ± 5.60 mm vs. 14.47 ± 9.92 mm; p=0.121). The overall prevalence of malignant nodules was 69.4%, with similar distributions between the LCS group (66.7%) and the incidental group (72.9%, p=0.365). Additionally, there were no significant differences between groups regarding the location of primary (p=0.129) or secondary (p=0.363) nodules, nor in the diagnosis of cancer type (p=0.548). Conclusion: The malignancy rates between the LCS versus incidental and cancer surveillance groups indicate that while both are useful tools in detection of lung cancer, smaller primary targets in the screening group suggest that LCS maybe identifying nodules earlier. The success of the LCS and RAB programs at the North Florida-South Georgia VHA has allowed the screening of 15,000+ veterans annually, with resultant 700 RAB procedures performed since launch in past 24 months. Future work includes enrolling the remainder of 30,000 estimated veterans within the North Florida-South Georgia VHA system into our lung cancer screening program, to shift the stage at diagnosis and identifying and diagnosing lung cancer in veterans sooner.