Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BackgroundPhysician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.ObjectiveTo examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.DesignPatient self-report surveys at treatment initiation linked to medical records.SettingVeterans Health Administration (VA) clinics nationally, 2018–2020.ParticipantsA total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White)Main MeasuresPatient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.Key ResultsMore patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.ConclusionsMismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07136-2.KEY WORDS: major depression, treatment preferences, treatment adherence, Veterans     

Rab3 Proteins and SNAP-25, Essential Components of the Exocytosis Machinery in Conventional Synapses, are Absent from Ribbon Synapses of the Mouse Retina

GTP-binding rab proteins, present in synaptic vesicles and endocrine secretory granules, have been shown to be involved in the control of regulated exocytosis. We found rab3 proteins in immunoblots of diverse areas of the mouse central nervous system (spinal cord, olfactory bulb, hippocampus, cerebellum and neocortex). Immunohistochemical observations at light- and electron-microscopical levels in the hippocampus and other areas revealed rab3 proteins in virtually all synaptic fields and terminals of the areas investigated. In the retina, rab3A immunoreactivity was confined to the inner and outer plexiform layers. Ultrastructural examination revealed that rab3A was present in conventional terminals in the inner plexiform layer and in horizontal cell processes of the outer plexiform layer. In contrast ribbon synapses, which play a key role in transferring information from the photoreceptor cells to the central nervous system, were immunonegative. We also tested whether other proteins of the rab3 family are present in ribbon synapses. However, using an antibody recognizing rab3B and rab3C in addition to rab3A, we found no immunoreactivity in these synapses. Interestingly, we observed also no immunoreactivity for synaptosomal-associated protein 25 (SNAP-25) in ribbon synapses, but conventional synapses and horizontal cell processes were heavily stained. Our data show that the known rab3 and SNAP-25 isoforms, which are components of the secretory apparatus of conventional synapses, are absent from ribbon synapses of the retina. Our observations suggest different mechanisms of transmitter exocytosis in conventional and ribbon terminals.     

Differential distributions of cholecystokinin in hamster and rat forebrain

Rats and golden hamsters show a differential feeding response to intracranial injections of cholecystokinin (CCK). Rats, but not hamsters reduce food intake after CCK injections into the hypothalamic paraventricular nucleus. In view of this species difference, we undertook an immunohistochemical study of the distribution of CCK-immunoreactivity in the hamster hypothalamus and remaining forebrain. CCK-immunoreactive perikarya were abundant in the neocortex, claustrum, hippocampal formation, amygdaloid complex, bed nucleus of the stria terminalis, nucleus of the lateral olfactory tract and in the magnocellular basal nucleus. CCK-immunoreactive neurons had a more restricted distribution in the diencephalon and were relatively rare in the preoptic area-hypothalamus. The only exception was the suprachiasmatic nucleus and adjacent medial anterior hypothalamus, in which CCK-immunoreactive neurons were numerous. CCK-containing perikarya were not observed in the hamster hypothalamic paraventricular and supraoptic nuclei, where they have been reported to occur in the rat. Groups of CCK-positive perikarya were also noted in the hamster thalamic paratenial and parafascicular nuclei. CCK-immunoreactive fibers/terminals were localized in the caudate and putamen, periventricular zones, dorsolateral geniculate, thalamic reticular nucleus and the superficial layer of the optic tectum. Fiber/terminal labeling was also present in those regions associated with CCK-immunoreactive perikarya. Our results indicate that the telencephalic distribution of CCK-containing neurons in the hamster appears to be similar to that reported in the rat. However, several differences occur in the diencephalon. Perhaps the most striking is that the hamster differs from the rat in having a large group of CCK-containing neurons in the suprachiasmatic nucleus, and in lacking the CCK-containing perikarya observed in the rat paraventricular and supraoptic nuclei. These differences may underly species differences in feeding responses to intracranial CCK injections and gonadal responses to short photoperiods. Our data further suggest that the distribution of neuropeptides and other neuroactive substances may not always be conserved during evolution.     

Indocyanine Green Tissue Angiography Can Reduce Extended Bowel Resections in Acute Mesenteric Ischemia

Purpose

Surgical exploration and bowel resection are frequently required for treating non-occlusive mesenteric ischemia. Intraoperative evaluation of intestinal perfusion is subjective and challenging. In this feasibility study, ICG fluorescence angiography was performed in order to evaluate intestinal perfusion in patients with acute mesenteric ischemia.

Methods

This is a retrospective analysis of 52 patients who were operated for acute mesenteric ischemia using ICG fluorescence angiography. Patients with occlusive disease requiring recanalization were excluded. The SPY and PinPoint imaging systems were used for open and laparoscopic surgery, respectively. Intraoperative macroscopic assessment of perfusion was compared with the ICG angiography results.

Results

Surgical exploration was performed for ischemia of the colon (n?=?12), the small bowel (n?=?23), or both (n?=?16). One patient had ischemia of the esophagus and stomach. All patients had a preoperative CT angiography to rule out stenosis or occlusion of the mesenteric vessels. In 18 cases (34.6%), ICG fluorescence angiography provided information that was supplemental to macroscopic evaluation, but most patients did not survive the postoperative course. However, in six of those cases (11.5%), ICG angiography led to a major change in operative strategy resulting in a significant clinical benefit for those patients. For two cases, ICG fluorescence produced false negative results.

Discussion

ICG tissue angiography is feasible and technically reliable for evaluating intestinal perfusion in acute mesenteric ischemia and led to a significant clinical benefit in 11% of our patients. A relevant discrepancy between surgical visual assessment and fluorescence angiography was found in 35% of the cases, which may help to define resection margins more accurately and thus support surgical decision-making.

     

Bone disease after orthotopic liver transplantation

After orthotopic liver transplantation (OLT), not infrequently a deterioration of bone disease leading to compression fractures of vertebrae is seen. In a consecutive series of 36 adult OLT patients, we studied, clinically and radiologically, the incidence and degree of bone disease before and after OLT; we also studied whether clinical, radiological and laboratory findings were related to the event of postoperative vertebral collapse. Before OLT, radiological signs of mostly slight osteoporosis were seen in a minority of patients. After OLT, 38% of patients developed vertebral collapse, mainly in the second trimester. Collapse occurred in both previously normal and abnormal vertebrae. Of the preoperative parameters sex, age, menopause, intake of prednisolone, duration and diagnosis of liver disease, duration and degree of cholestasis, bone radiology and urinary calcium, only a low urinary calcium was related to postoperative collapse. Of the postoperative parameters duration of cholestasis, urinary calcium, duration of hospital stay, prednisolone dose and outcome in terms of life and death, none was related to collapse. We conclude that vertebral collapse after OLT occurs frequently and is not easily predicted. Early prevention of bone disease in patients with chronic liver disease before OLT and a low steroid-containing immunosuppressive regimen after OLT are advocated.     

Snacking habits in dutch adolescents

The longitudinal and multidisciplinary study “Growth and Health of Teen- agers” was carried out in the Netherlands at two secondary schools. In this article the snacking habits of 13 1 girls and 102 boys of 12–17 years of age are reported as well as the nutrient values and the methods applied. For the whole age range about 20% of the total daily energy intake was supplied by snacks. Snacksprovided 10% of the protein intake, 18–29% of the fat intake, 25–30% of the total carbohydrate intake and about 10% of calcium and iron intake. The consumption of alcoholic beverages increased strongly with age (5–65% “users,” from 1 to about 15 g alcohol per “user”) and is the most important source of “empty” energy.