City Veterans Affairs Medical Center Research Articles

Adapting the multifamily group model to the Veterans Affairs system: The REACH Program.

The Oklahoma City Veterans Affairs (VA) Medical Center modified an evidence-based model offamily psychoeducation (the multifamily group model; McFarlane, 2002) and implemented it for thefirst time in a VA setting and with veterans living with posttraumatic stress disorder (PTSD). Namedthe REACH Program (Reaching out to Educate and Assist Caring, Healthy Families), the 3-phaseprogram begins with 4 weekly “joining sessions” with the individual veteran and his/her familyfocused on rapport building, assessment, and goal setting. Phase II consists of 6 weekly diagnosis-specific educational/support sessions for cohorts of 4 to 6 veterans and their families. In Phase III,veterans/families attend 6 monthly multifamily groups to support the maintenance of gains. Thisarticle describes the rationale for modifying the original Multifamily Group Program (MFG) for aunique setting (the VA) and the needs of families of veterans in a new diagnostic group (PTSD). Thechanges to the MFG curriculum are specifically described, and details of the new REACHintervention are explained. Attendance, retention, and satisfaction data for 2 diagnostic cohorts,PTSD and affective disorders, are also presented.Keywords: family psychoeducation, PTSD, affective disorders, family therapy, multifamily group

Usefulness of Adjusting for Clinical Covariates to Improve the Ability of B-Type Natriuretic Peptide to Distinguish Cardiac from Noncardiac Dyspnea

Certain clinical characteristics affect brain natriuretic peptide (BNP) levels independently of clinical heart failure (HF). However, it is unclear how to adjust the diagnostic cutoffs of BNP for these variables. We hypothesized that adjusting for important covariates would improve the diagnostic accuracy of BNP for HF in the emergency room setting. We included patients presenting with dyspnea at the Salt Lake City Veterans Affairs Medical Center. Physicians unaware of the BNP values adjudicated the outcome as dyspnea due to HF or noncardiac dyspnea. Subgroup analyses and logistic regression analysis were used to adjust the BNP cutoffs. The mean age of the study population (n = 335) was 72 +/- 11 years. A BNP of 100 pg/ml had a sensitivity of 91%, and a BNP of 400 pg/ml had a specificity of 92%. The covariates age, history of atrial fibrillation, creatinine, and body mass index affected BNP levels independently of HF. The subgroup-specific BNP cutoff that maintained 91% sensitivity was 184 pg/ml for patients > or =75 years, 150 pg/ml for those with atrial fibrillation, and 449 pg/ml for patients with a creatinine > or =2 mg/dl. These subgroup-specific cutoffs improved specificity compared to a cutoff of 100 pg/ml. The regression model that adjusted BNP improved the reclassification of patients as having cardiac or noncardiac dyspnea compared to the conventional BNP cutoffs. Of the patients without HF, 11% were correctly reclassified as having noncardiac dyspnea (p = 0.003). In conclusion, adjusting BNP levels for clinical covariates improves its diagnostic performance.

NEW ROUTE TO TREAT DEPRESSION

A NEW TARGET for treating depression, discovered by researchers in Iowa, may offer an alternative to current antidepressants, which target other mechanisms to treat the condition. “The mechanism issue is important because if a patient doesn’t respond to one drug, the chances of them responding to another drug that works through the same mechanism are low,” says John A. Wemmie, who led the research team. Wemmie is an associate professor of psychiatry and neurosurgery at the University of Iowa and a staff physician and researcher at the Iowa City Veterans Affairs Medical Center. Wemmie’s team focused on a biochemical pathway involving acid-sensing ion channel (ASIC) proteins expressed by neurons. ASICs are activated by protons that are believed to act as neurotransmitters (C&EN, Jan. 14, 2008, page 10). Wemmie and his colleagues concentrated on the ASIC1a class of these ion channels, which are abundant in regions of the brain associated with mood. The research group had ...

Copper Deficiency After Gastric Surgery: A Reason for Caution

BackgroundAcquired copper deficiency in adults leads to hematological and neurological manifestations that mimic vitamin B12 deficiency. A significant number of patients with copper deficiency syndrome have a history of gastric surgery, often remote. We sought to determine whether copper deficiency is present in a population of individuals with longstanding partial gastric resection. MethodsSerum copper, ceruloplasmin, and zinc levels were determined in 20 patients with a history of partial gastric resection and 50 controls, randomly selected from the Oklahoma City Veterans Affairs Medical Center electronic database. ResultsHypocupremia and symptoms of copper deficiency were detected in patients with partial gastric resection in contrast to controls (3/20 versus 0/50, P=0.02). Serum copper and ceruloplasmin levels were significantly lower in individuals with partial gastric resection than in controls (P=0.04 and P=0.001, respectively). The mean interval between gastric surgery and testing was 20.7 years. ConclusionsOur results indicate that a significant number of individuals with longstanding history of partial gastric resection have undiagnosed hypocupremia. Screening for copper deficiency after gastric surgery may prevent the development of hematological and neurological complications in these patients.

Recognition of surface mucosal and vascular patterns of colon polyps by using narrow-band imaging: interobserver and intraobserver agreement and prediction of polyp histology

The 2 main types of colon polyps are adenomas and hyperplastic. Pit patterns on the surface of polyps have been described by using magnification chromoendoscopy, which can help differentiate between polyp types. Narrow band imaging (NBI) is a novel technology that enhances the visualization of surface mucosal and vascular patterns on the polyp surface. Earlier we described, in a pilot study, patterns seen on the polyp surface with NBI that can help differentiate between adenomas and hyperplastic polyps with a high degree of accuracy. The aim of this study was to evaluate the interobserver and intraobserver agreement (among endoscopists) for the NBI surface mucosal and vascular patterns and prediction of polyp histology and the accuracy of the investigators to predict polyp histology based on these patterns. Kansas City Veterans Affairs Medical Center. NBI images of the polyp surface mucosal and vascular patterns obtained in our pilot trial were retrieved. A teaching set of 20 images was selected to educate and demonstrate the polyp patterns to 4 endoscopists. Subsequently, the test set of images was evaluated by the 4 endoscopists for quality, polyp pattern, and prediction of polyp type. Interobserver agreement (k value) was calculated among the 4 assessors for the polyp patterns and predicted histology. By using the final histology as the criterion standard, the accuracy of polyp-type prediction was calculated for each assessor. After a period of 2 months, all polyp images were reevaluated by the assessors (as before), and all findings were recorded in a similar fashion. These results were used for calculation of intraobserver agreement (k value) and the accuracy of the assessors in predicting polyp type. Photographs of 65 polyps were included in the test set and were evaluated by the 4 assessors. Thirty-eight polyps were adenomatous, and 27 were hyperplastic. The kappa value for the interobserver agreement for polyp surface pattern was 0.57 (moderate) and for prediction of polyp type was 0.63 (substantial). The kappa value for the intraobserver agreement of the 4 assessors for the surface patterns was 0.70, 0.65, 0.60, and 0.79, and for the prediction of polyp type was 0.87, 0.71, 0.61, 0.81. The accuracy to predict polyp type ranged from 80% to 86% for the 4 assessors in the first reading and from 85% to 91% in the second reading, with every assessor showing an improvement in accuracy in the second reading. A single-center study, with a limited number of polyps. This initial evaluation showed that the NBI polyp patterns described in our pilot study are reproducible, easy to learn, reasonably accurate, and have the potential for use in daily clinical practice for the real-time differentiation of colon polyps.

A New Engagement Strategy in a VA-Based Family Psychoeducation Program

This brief report describes the engagement strategy used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a nine-month family psychoeducation program for veterans with serious mental illness or posttraumatic stress disorder (PTSD). A motivational interviewing-based strategy was created and implemented in a Veterans Affairs hospital to engage providers and veterans and their families into the intervention. Of the 1,539 veterans told about the program, 41% had a family member living nearby and were willing to meet with a provider to learn more. REACH providers met with 505 veterans for a motivational-interviewing session to explore family participation. Of the 436 veterans who were eligible to participate in REACH, 28% of veterans with PTSD, 34% of veterans with an affective disorder, and 25% of veterans with a schizophrenia spectrum disorder went on to participate in at least one session of the REACH program with a family member; these rates compare favorably with those for programs requiring a much shorter commitment. This engagement strategy shows promise as an effective tool in recruiting veterans and their families into family psychoeducation.

Underutilization of Warfarin Therapy in Elderly Patients with Atrial Fibrillation - Fear or False Sense of Security!

Background: Under utilization of warfarin in elderly patients with atrial fibrillation (AF) has been recognized as a significant health care issue. This study examines the rate and reasons for warfarin underutilization in elderly patients with AF at the Kansas City Veterans Affairs Medical Center. Methods: Retrospective study reviewing electronic medical records of all patients aged 65 and older with the diagnosis of atrial fibrillation. Patients on warfarin were excluded. Reasons for not using warfarin were extracted by reviewing the electronic medical record. Anticoagulation indications for these patients were determined based on the ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation. Results: Warfarin was not used by 407 patients (25%) with known AF. Average age was 79+6.2 years. 60% of patients had persistent or permanent AF. Prevalence of risk factors for thromboembolism included hypertension (74%), heart failure or ejection fraction of <40% (21%), diabetes (27%) and coronary artery disease (48%). CHADS (2) scores were documented in the charts less than 1% of the times. Only 11 patients had CHADS (2) score of 0 and 70 had a score of 1. A class I or IIa indication for warfarin therapy was present in 298 (73%) of patients. Return to sinus rhythm (37%) was the most common reason for not using warfarin. In 30% of cases the reason not to use warfarin was not addressed. Other reasons not to use warfarin included fear of falls (7%), prior head or GI bleed (14%), patient refusal & noncompliance (12%). History of CVA or TIA was documented in 12% of patients. Conclusions: Underutilization of warfarin in elderly patients with atrial fibrillation remains a common problem despite their high risk for thromboembolic events. A false sense of security about the paroxysmal nature of AF, lack of proper insight about stroke risk (CHADS (2)), and fear of bleeding are the most common reasons for non use of warfarin.

Impact of Screening for Hepatocellular Carcinoma on Survival

Purpose: Screening for hepatocellular carcinoma (HCC) in patients with chronic liver disease has been based on expert opinion since randomized controlled trials are lacking in the United States. Methods: We retrospectively reviewed patients diagnosed with HCC in the past seven years within the Oklahoma City Veterans Affairs Medical Center. Parameters examined were: cause of liver disease, if screened or not, the stage/size of lesions when initially detected, the forms of treatment, and outcome. Results: Forty-seven patients were diagnosed from 2000 through 2006 with HCC having biopsy proven or multi-phased CT of diagnostic appearance with supportive alpha-fetoprotein (AFP). A rising incidence of HCC has been noted in this short period of time from three in 2000 to twelve in 2006. Co-existent chronic hepatitis C and alcohol consumption were the leading etiologies. On initial imaging, at least 33/47 (70%) had lesions that were too large for transplantation (OLT). Screened patients included 14/47. Nine of the fourteen screened patients (64%) had lesions less than 3.5 cm in greatest dimension on initial discovery allowing 7/14 to undergo treatment with OLT, radio-frequency ablation, chemoembolization, or systemic chemotherapy. One year survival in those screened was 57% compared to 9% in those who were not screened. The median survival in those screened was 425 days compared to 75.5 days in the patients who were not screened (T-test, P= 0.0012; Mann-Whitney, P= 0.000049). Three patients underwent OLT with median survival of 1321 days, all of whom were living at the time of the analysis. Conclusion: Screening for HCC in our population appears to have resulted in improved survival. The gentler slope in survival curve of screened patients suggests that lead time bias was not an important factor. The difference in survival seen in our patient population is probably the result of OLT. There were not enough patients to confirm the survival benefit of other treatment modalities.Figure

Narrow-band imaging colonoscopy—a pilot feasibility study for the detection of polyps and correlation of surface patterns with polyp histologic diagnosis

Colonoscopy is the preferred screening method for colorectal cancer. However, it has a substantial miss rate for colon polyps, and several techniques have been attempted to improve this limitation. Narrow-band imaging (NBI) is a novel technology that enhances the visualization of surface mucosal and vascular patterns. The aim of this study was to determine the detection rate of additional polyps by NBI after removal of polyps visualized by standard white light colonoscopy (WLC) and to correlate the surface mucosal and vascular patterns with polyp histologic diagnosis. This was a prospective pilot feasibility study. Kansas City Veterans Affairs Medical Center. Subjects referred for screening colonoscopy were prospectively enrolled. Subjects underwent colonoscopy after enrollment. After intubation of the cecum, colonic segments were sequentially examined, initially with WLC with removal of polyps followed by re-examination of the same segment with NBI. Additional polyps seen with NBI were photographed for their surface patterns and then removed. The total number of polyps visualized by WLC and NBI was calculated and the surface patterns were then correlated with polyp histologic features. Forty patients were enrolled in the study, all men, 32 white. The mean age was 62 years. A total of 72 polyps were detected by WLC (43 tubular adenoma, 28 hyperplastic polyps), whereas NBI detected an additional 51 polyps, of which 29 were tubular adenomas and 22 were hyperplastic. Five different surface/vascular patterns were observed: fine capillary network with absent mucosal pattern, circular pattern with dots, round/oval pattern, tubular pattern, and gyrus pattern. The sensitivity, specificity, and overall accuracy of the first two patterns for hyperplastic polyps were 86%, 96%, and 92%, respectively, and of the latter three patterns for tubular adenomas were 96%, 86%, and 92%, respectively. This pilot study demonstrates the feasibility of polyp detection and histologic correlation with NBI. These findings need to be confirmed in future randomized controlled trials.

Use of National Surgical Quality Improvement Program Data as a Catalyst for Quality Improvement

Semiannually, the National Surgical Quality Improvement Program (NSQIP) provides its participating sites with observed-to-expected (O/E) ratios for 30-day postoperative mortality and morbidity. At each reporting period, there is typically a small group of hospitals with statistically significantly high O/E ratios, meaning that their patients have experienced more adverse events than would be expected on the basis of the population characteristics. An important issue is to determine which actions a surgical service should take in the presence of a high O/E ratio. This article reviews case studies of how some of the Department of Veterans Affairs and private-sector NSQIP participating sites used the clinically rich NSQIP database for local quality improvement efforts. Data on postoperative adverse events before and after these local quality improvement efforts are presented. After local quality improvement efforts, wound complication rates were reduced at the Salt Lake City Veterans Affairs medical center by 47%, surgical site infections in patients undergoing intraabdominal surgery were reduced at the University of Virginia by 36%, and urinary tract infections in vascular patients were reduced at the Massachusetts General Hospital by 74%. At some sites participating in the NSQIP, notably the Massachusetts General Hospital and the University of Virginia, the NSQIP has served as the basis for surgical service-wide outcomes research and quality improvement programs. The NSQIP not only provides participating sites with risk-adjusted surgical mortality and morbidity outcomes semiannually, but the clinically rich NSQIP database can also serve as a catalyst for local quality improvement programs to significantly reduce postoperative adverse event rates.

Anesthesia monitoring by registered nurses during cataract surgery: Assessment of need for intraoperative anesthesia consultation

To assess the frequency and risk factors for intraoperative anesthesia consultation when performing cataract surgery monitored by registered nurses. Iowa City Veterans Affairs Medical Center, Iowa City, Iowa, USA. This retrospective review was of 270 cataract surgeries performed under local anesthesia from April 1, 2002, to April 1, 2003. The American Society of Anesthesiologists (ASA) classification of each patient was determined: 1 patient was classified as ASA 1. One hundred fifty patients were classified as ASA 2. One hundred nineteen patients were classified as ASA 3. The anesthesiology department was consulted 24 times. Nineteen consultations involved patients who were ASA 3, and 5 consultations involved patients who were ASA 2 (P<.001). In most cases (23 of 24), the anesthesia service provided a consultation (eg, increase oxygen flow rate, clarification of electrocardiogram, start intravenous line, equipment repair) and left the nurses to continue to monitor the patient. In only 1 case (ASA 3), the anesthesia service converted the case to monitored anesthesia care and relieved the nurse to monitor the patient. In this study, monitoring of routine cataract surgery by registered nurses was associated with a low rate of intraoperative anesthesia consultation. Most consultations resulted in little intervention. The ASA classification appears predictive of the need for intraoperative anesthesia consultation.

The Support and Family Education (SAFE) program: mental health facts for families.

Although more than half of adults who have a serious and persistent mental illness live with their families (1), less than 10 percent of families of outpatients with schizophrenia receive support or education (2). Such services fail to be provided despite the fact that family participation in well-designed psychoeducational programs has been documented as reducing relapse and readmission rates, improving involvement and adherence to treatment (3,4), and producing positive outcomes for caregivers, including improved morale, better knowledge of mental illness, enhanced feelings of empowerment, and reduced worry and displeasure about their loved ones (5,6). Moreover, the vast majority of mental health providers believe that educating families about mental illness and its treatment is very important (7). Why, then, do so few clinicians commit the requisite time and energy to providing these effective and much appreciated services? There are four sources of obstacles to the adoption of a psychosocial treatment innovation such as family psychoeducation. The obstacles stem from the psychoeducational program itself (for example, its unfamiliarity and conflicts with the existing treatment ideology); the clinicians (lack of training, experience, and competence in functioning as "teachers" with families); the host agency or institution (countervailing priorities and lack of administrative support); and the process of dissemination (lack of knowledgeable consultants or enthusiastic "champions" or advocates for family psychoeducation and lack of user-friendly curricula or program manuals). These obstacles can be overcome when practitioners and family members work together as stakeholders in the benefits that accrue from ongoing psychoeducation (8). In this month's column, Michelle Sherman, Ph.D., presents the family psychoeducation program she created at the Oklahoma City Veterans Affairs (VA) Medical Center. Dr. Sherman describes how she tailored the intervention to the VA population, thus generating the support not only of the clients and their families but also of her fellow clinicians and the VA administration. Her work demonstrates that when mental health clinicians devote time, energy, and expertise to supporting and educating caregivers, significant benefits emerge for both clients and their families.

Hepatitis G virus slows HIV

Coinfection with an apparently harmless virus could explain why HIV infection progresses more slowly in some people than in others. Recent clinical trials and cell culture studies support earlier findings suggesting that GBV-C (also known as hepatitis G) retards the progression of HIV infection. Following a 12-year study, researchers from the University of Iowa College of Medicine and the Iowa City Veterans Affairs Medical Center, report that patients infected with HIV alone were 3.68 times more likely to die than those who were also infected with GBV-C. Like HIV, GBV-C infects T helper cells, and in in vitro coinfection, HIV production was reduced by 30–40%. Although the results are promising, the researchers are warning HIV patients not to infect themselves with GBV-C intentionally; the long-term effects of GBV-C infection are unknown. AVhttp://www.cbc.ca/cgi-bin/templates/view.cgi?category=Canada&story=/news/2001/09/06/hiv_hepg010906

Mortality in male alcoholics after ten to fourteen years.

Alcoholics frequently die prematurely. The purpose of this study was to determine: (1) whether subjects in a sample of 360 male alcoholics, followed over a period of 10-14 years, died prematurely: (2) if so, from what causes; and (3) whether such deaths are predictable from characteristics present at initial assessment. Subjects were male veterans (N = 360) with a diagnosis of alcoholism admitted to an inpatient substance abuse treatment program at the Kansas City Veterans Affairs (VA) Medical Center during 1980-1984 who consented to participate in intake evaluations and subsequent follow-ups at 1 year and 10-14 years later. Of the 357 (99.2%) men located at the 10-14 year follow-up, 96 (26.6%) were confirmed as deceased, 255 survivors agreed to be reassessed and 6 subjects refused reassessment. Information regarding cause of death was obtained from death certificates, VA records and other sources. At intake, the subsequently deceased men were older, had less education, lower psychosocial functioning, more medical problems and greater psychiatric severity. Their overall death rate was 2.5 times greater than that of a reference group of men. Men in the 35-44 year age group were 5.5 times as likely to die. A statistical model utilizing measures of alcohol dependence to predict mortality from intake to 10-14 year follow-up indicated that alcoholics who limited drinking were half as likely to die whereas those who engaged in morning drinking were 2.5 times more likely to die. Alcoholic men, especially those in the group aged 35 to 44 years, have a significantly higher risk of premature death than a reference group of men. Men who engaged in morning drinking and could not limit drinking appeared to be at higher risk of mortality 10 years later.

Development of an interdisciplinary, telephone-based care program.

An interdisciplinary, telephone-based care program at a Veterans Affairs medical center (VAMC) is described. Patients telephoning the Oklahoma City VAMC complained that they were transferred multiple times and that they had difficulty contacting their provider between scheduled visits. Some went to the walk-in urgent care clinic with nonurgent problems. The average waiting time in the clinic exceeded three hours. An interdisciplinary, telephone-based care program was begun in 1995 to allow efficient problem resolution over the telephone; provide clinical consultations, interventions, and referrals as necessary; and reduce use of the urgent care clinic for nonurgent problems. A team consisting of a patient service representative, a pharmacist, and a nurse was established to handle calls. Policies and procedures were designed to respond appropriately to patients' problems and document the telephone "visits." The pharmacist was given practice privileges, including prescribing authority. A questionnaire indicated patient satisfaction with the new service. Mean waiting times in the urgent care clinic were reduced to less than two hours, and an estimated annual net cost avoidance of $677,671 was achieved by the program's averting unnecessary visits to the urgent care clinic. An interdisciplinary, telephone-based care program at a VAMC successfully responded to patients' concerns, improved their access to care, and conserved urgent care resources.

Correlation of the Medication Management Evaluation Instrument with Compliance in Geriatric Patients

Objective: To assess the Medication Management Evaluation Instrument (MMEI), which has been shown to detect patient difficulties in compliance but has never been correlated with actual compliance. The goal was to determine the value of this instrument as a predictor of compliance difficulties. Methods: Volunteer patients in the Kansas City Veterans Affairs Medical Center currently enrolled in the Geriatric Evaluation and Management Clinic participated in this study. The MMEI, the Jacob's Cognitive Capacity Screening Examination (CCSE), and a pill count (at enrollment and at 6 wk) were conducted on all patients with medications meeting the inclusion criteria. Results: Twenty-two patients participated in the study, with eight compliance data dropouts. Follow-up averaged 44.7 days (range 32–62). The mean age was 71.3 years (range 66–81). The CCSE score was significantly lower in those who had problems defining how to take a medication four times daily than in those who did not (p = 0.002). Compliance ranged from 27.1% to 189% (&gt;100% indicates overcompliance). The CCSE average score was 25.1/30 (range 17–30). Other measures in the MMEI were not statistically significant. Conclusions: Higher cognitive function was found to correlate with better management of complex regimens. On the basis of these data, the MMEI score does not appear to correlate with compliance. Changes in study design and increased power may provide better assessment of correlation.

Using beepers to keep family members involved in the patient's care.

The 1994 Veterans Health Administration (VHA) National Customer Feedback Survey of 43,594 recently discharged inpatients revealed that problems relating to emotional support were reported two to three more frequently by VHA patients than by patients in the private sector. The scores related to emotional support that were reported by 130 Oklahoma City Veterans Affairs Medical Center surgery respondents were the facility's least favorable scores in benchmark comparisons with all VHA surgery patients and with surgery patients at Picker Institute, a nonprofit, private sector research and education organization. These scores prompted the initiation of a successful program to loan radio and digital beepers to patients' family members.

Pilot phase II and toxicity trial of ifosfamide (IFF)/Mesna (M), protracted oral etoposide (VP) and cisplatinum (CP) chemotherapy in advanced non-small cell lung cancer (NSCLC) : S.K. Williamson, S.A. Taylor, R.L. Stephens, R. Sadasivan, R. McKittrick, P. Van Veldhuizen and J. Turner, Kansas City Veterans Affairs Medical Center, Kansas City, MO. and University of Kansas Medical Center, Kansas City, KS

Pilot phase II and toxicity trial of ifosfamide (IFF)/Mesna (M), protracted oral etoposide (VP) and cisplatinum (CP) chemotherapy in advanced non-small cell lung cancer (NSCLC) : S.K. Williamson, S.A. Taylor, R.L. Stephens, R. Sadasivan, R. McKittrick, P. Van Veldhuizen and J. Turner, Kansas City Veterans Affairs Medical Center, Kansas City, MO. and University of Kansas Medical Center, Kansas City, KS

Atypical mitotic figures in basal cell carcinoma. A review of 208 cases.

A retrospective review of 208 cases of basal cell carcinoma (BCC) from the Johnson City Veterans Affairs Medical Center (VAMC) and University Physician's Practice Group Clinic was made to ascertain the percentage of BCCs having mitoses and to evaluate the possible occurrence of abnormal mitotic figures. One of the authors had observed in a limited cytologic sample that the detection of atypical mitotic figures in a lesion suspected of being a BCC could be a helpful indicator pointing toward a nonbasal cell carcinoma diagnosis. The present study demonstrated abnormal-appearing mitotic figures in 121 of 208 cases. However, definite tripolar or tetrapolar forms were present in only a small number of cases. Thus, the presence of these forms in an "equivocal" basal cell carcinoma may suggest an alternate diagnosis but does not totally exclude a diagnosis of BCC.

State of the art immunosuppressive regimens

From the Division of Cardiology, University of Utah Medical Center and the Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT, USA