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Receipt of Pain Management Information Preoperatively Is Associated With Improved Functional Gain After Elective Total Joint Arthroplasty

Wed, 05/03/2017 - 9:52am

BACKGROUND: Poorly controlled postoperative pain may adversely affect total joint arthroplasty (TJA) patients' outcomes and associated healthcare cost. Understanding effective pain management after surgery is important to patients, surgeons, and hospitals. We evaluated patient-reported receipt of preoperative pain management information in a national prospective cohort evaluating postoperative pain and function following elective TJA.

METHODS: Preoperative and 2-week and 6-month postoperative survey data of 1609 TJA patients collected between June 2013 and December 2014 were analyzed. Data included demographics, medical and musculoskeletal comorbidity, operative joint pain, physical function, and mental health. At 2 weeks postoperative, patients were asked if they had received pain management information prior to surgery, the content of that education, and pain management strategies. Descriptive statistics were performed.

RESULTS: At 2 weeks post-TJA, one-third of patients reported not receiving information about pain management; an additional 11% did not find the information helpful. There were no differences preoperatively in demographics or clinical profiles between those who received pain information and those who did not. Patients who received pain information reported less pain 2 weeks postoperatively, greater use of non-narcotic pain care strategies, and better physical function scores at 6 months postoperatively. No differences in operative joint pain were identified at 6 months between education and noneducation groups.

CONCLUSION: Forty-four percent of the patients reported that they did not receive/received unhelpful information regarding postoperative pain management, highlighting a need for improved patient education. In this sample, the lack of pain management information was associated with poorer 6-month postoperative function.

Duration of the menopausal transition is longer in women with young age at onset: the multiethnic Study of Women's Health Across the Nation

Wed, 05/03/2017 - 9:52am

OBJECTIVE: The menopausal transition (MT) is a critical period associated with physiologic changes that influence women's long-term health and longevity. Information is, however, limited regarding factors that influence age at the onset of the MT and its duration (ie, time from MT onset to the final menstrual period).

METHODS: We analyzed data for 1,145 women from four sites of the Study of Women's Health Across the Nation who participated in the menstrual calendar substudy, had the start of the MT identified, and had no missing covariate information. Participants included from four racial/ethnic groups: African American, white, Chinese, and Japanese. Women completed daily menstrual calendars from 1996 to 2006 and questions on hormone therapy use monthly. Baseline measures included education, economic strain, and menstrual cycle characteristics. Annual measures included height, weight, and smoking status. Cox proportional hazards models were used to analyze the data.

RESULTS: The adjusted median duration of the MT ranged from 4.37 years among the oldest age-at-onset quartile to 8.57 years among the youngest age-at-onset quartile (P < 0.001). Cigarette smoking was associated with an earlier onset (P < 0.001) and a shorter duration (P < 0.001). African American women had a longer duration (P = 0.012) than white women. Body mass index was associated with a later onset of the MT (P = 0.001) but not its duration.

CONCLUSIONS: The duration of the MT was largely influenced by the age at which it began: earlier onset was associated with a longer transition. This finding provides a strong rationale for developing improved markers of the onset of the early MT.

Warfarin in Complex Older Patients: Have we Reached a Tipping Point

Wed, 05/03/2017 - 9:52am

Two papers in this issue of JAGS explore the use of warfarin among older persons with atrial fibrillation.

Research Priorities for Optimal Use of Patient-reported Outcomes in Quality and Outcome Improvement for Total Knee Arthroplasty

Wed, 05/03/2017 - 9:52am

The national Functional and Outcomes Research for Comparative Effectiveness in Total Joint Replacement program routinely collects pre- and postoperative patient-reported outcomes for clinicians to use when making individual patient treatment decisions and monitoring aggregate quality of care and outcomes. When the pre-post gains in pain or function at one site vary from the national norms, the next question is, "how do we improve?" This paper will use the traditional quality management's framework of inputs (patients), processes (clinical care), and outcomes to outline priority research questions to learn how clinicians, hospital managers, and patients can interpret patient-reported outcomes to improve total knee arthroplasty care and outcomes. In summary, research should identify best practices to minimize variation in a patient's health status before surgery, tailor peri-total knee arthroplasty care pathways to match individual patient risks to optimize safe care, and implement patient-reported measures to document optimal outcomes.

STING Contributes to Abnormal Bone Formation Induced by Deficiency of DNase II in Mice

Wed, 05/03/2017 - 9:51am

OBJECTIVE: Cytosolic DNA sensors detect microbial DNA and promote type I interferon (IFN) and proinflammatory cytokine production through the adaptor stimulator of IFN genes (STING) to resolve infection. Endogenous DNA also engages the STING pathway, contributing to autoimmune disease. This study sought to identify the role of STING in regulating bone formation and to define the bone phenotype and its pathophysiologic mechanisms in arthritic mice double deficient in DNase II and IFN-alpha/beta/omega receptor (IFNAR) (DNase II-/- /IFNAR-/- double-knockout [DKO] mice) compared with controls.

METHODS: Bone parameters were evaluated by micro-computed tomography and histomorphometry in DKO mice in comparison with mice triple deficient in STING, DNase II, and IFNAR and control mice. Cell culture techniques were employed to determine the parameters of osteoclast and osteoblast differentiation and function. NanoString and Affymetrix array analyses were performed to identify factors promoting ectopic bone formation.

RESULTS: Despite the expression of proinflammatory cytokines that would be expected to induce bone loss in the skeleton of DKO mice, the results, paradoxically, demonstrated an accumulation of bone in the long bones and spleens, sites of erythropoiesis and robust DNA accrual. In addition, factors promoting osteoblast recruitment and function were induced. Deficiency of STING significantly inhibited bone accrual.

CONCLUSION: These data reveal a novel role for cytosolic DNA sensor pathways in bone in the setting of autoimmune disease. The results demonstrate the requirement of an intact STING pathway for bone formation in this model, a finding that may have relevance to autoimmune diseases in which DNA plays a pathogenic role. Identification of pathways linking innate immunity and bone could reveal novel targets for the treatment of bone abnormalities in human autoimmune diseases.

Supported Education for Individuals With Psychiatric Disabilities: State of the Practice and Policy Implications

Wed, 05/03/2017 - 9:51am

OBJECTIVE: Supported education (SEd) is a promising practice that supports and encourages educational goals and attainment among individuals with psychiatric disabilities. This paper provides insights into how SEd objectives are pursued in different settings, assesses the evidence base, and discusses policy implications.

METHOD: Insights from 3 data sources were synthesized: published literature, an environmental scan, and 3 site visits to programs that support the education goals of individuals with psychiatric disabilities.

RESULTS: While setting, target populations, level of coordination with supported employment, and financing strategies varied, common SEd components emerged: specialized and dedicated staffing, one-on-one and group skill-building activities, assistance with navigating the academic setting and coordinating different services, and linkages with mental health counseling. The evidence base is growing; however, many published studies to date do not employ rigorous methodology.

Conclusions and Implications for Policy and Practice: Continued specification, operationalization, and testing of SEd core components are needed. The components of the evolving SEd model would benefit from rigorous testing to evaluate impact on degree completion and other key impacts such as employment; health, mental health, or recovery; and community participation. In addition to funding streams from special education and Medicaid, new opportunities for increasing the availability of SEd include the Workforce Innovation and Opportunities Act (WIOA) reauthorization, which requires state vocational rehabilitation agencies to fund preemployment services for transition-age individuals. New "set-aside" requirements for the Mental Health Services Block Grant will increase funding for early intervention services for individuals with serious mental illness, potentially including SEd.

Antiemetic use among pregnant women in the United States: the escalating use of ondansetron

Wed, 05/03/2017 - 9:51am

PURPOSE: To examine ondansetron use in pregnancy in the context of other antiemetic use among a large insured United States population of women delivering live births. METHODS: We assessed ondansetron and other antiemetic use among pregnant women delivering live births between 2001 and 2015 in 15 data partners contributing data to the Mini-Sentinel Distributed Database. We identified live birth pregnancies using a validated algorithm, and all forms of ondansetron and other available antiemetics were identified using National Drug Codes or procedure codes. We assessed the prevalence of antiemetic use by trimester, calendar year, and formulation. RESULTS: In over 2.3 million pregnancies, the prevalence of ondansetron, promethazine, metoclopramide, or doxylamine/pyridoxine use anytime in pregnancy was 15.2, 10.3, 4.0, and 0.4%, respectively. Ondansetron use increased from <1% of pregnancies in 2001 to 22.2% in 2014, with much of the increase attributable to oral ondansetron beginning in 2006. Promethazine and metoclopramide use increased modestly between 2001 (13.8%, 3.2%) and 2006 (16.0%, 6.0%) but decreased annually through 2014 (8.0%, 3.2%). Doxylamine/pyridoxine, approved for management of nausea and vomiting in pregnancy in 2013, was used in 1.8% of pregnancies in 2014. For all antiemetics, use was highest in the first trimester. CONCLUSIONS: We observed a marked increase in ondansetron use by study year, prescribed to nearly one-quarter of insured pregnant women in 2014, occurring in conjunction with decreased use of promethazine and metoclopramide. Given the widespread use of ondansetron in pregnancy, data establishing product efficacy and methodologically rigorous evaluation of post-marketing safety are needed.

Synovium-Derived MicroRNAs Regulate Bone Pathways in Rheumatoid Arthritis

Wed, 05/03/2017 - 9:51am

Articular bone erosion in rheumatoid arthritis (RA) is mediated by the interaction between inflammation and pathways regulating bone metabolism. Inflammation promotes osteoclastogenesis and also inhibits osteoblast function, further contributing to the persistence of erosions. MicroRNAs (miRNAs) are important regulators of skeletal remodeling and play a role in RA pathogenesis. We therefore determined the expression of miRNAs in inflamed synovial tissue and the role they play in pathways regulating osteoblast and osteoclast function. Using the serum transfer mouse model of RA in C57BL/6 mice, we performed Fluidigm high-throughput qPCR-based screening of miRNAs from nonarthritic and arthritic mice. Global gene expression profiling was also performed on Affymetrix microarrays from these same synovial samples. miRNA and mRNA expression profiles were subjected to comparative bioinformatics. A total of 536 upregulated genes and 417 downregulated genes were identified that are predicted targets of miRNAs with reciprocal expression changes. Gene ontology analysis of these genes revealed significant enrichment in skeletal pathways. Of the 22 miRNAs whose expression was most significantly changed (p < 0.01) between nonarthritic and arthritic mice, we identified their targets that both inhibit and promote bone formation. These miRNAs are predicted to target Wnt and BMP signaling pathway components. We validated miRNA array findings and demonstrated that secretion of miR-221-3p in exosomes was upregulated by synovial fibroblasts treated with the proinflammatory cytokine TNF. Overexpression of miR-221-3p suppressed calvarial osteoblast differentiation and mineralization in vitro. These results suggest that miRNAs derived from inflamed synovial tissues may regulate signaling pathways at erosion sites that affect bone loss and potentially also compensatory bone formation.

Harms of cervical cancer screening in the United States and the Netherlands

Wed, 05/03/2017 - 9:51am

We studied harms related to cervical cancer screening and management of screen-positive women in the United States (US) and the Netherlands. We utilized data from four US integrated health care systems (SEARCH), the US National Health Interview Survey, New Mexico state, the Netherlands national histopathology registry, and included studies on adverse health effects of cervical screening. We compared the number of Papanicolaou (Pap) smear tests, abnormal test results, punch biopsies, treatments, health problems (anxiety, pain, bleeding and discharge) and preterm births associated with excisional treatments. Results were age-standardized to the 2007 US population. Based on SEARCH, an estimated 36 million Pap tests were performed in 2007 for 91 million US women aged 21-65 years, leading to 2.3 million abnormal Pap tests, 1.5 million punch biopsies, 0.3 million treatments for precancerous lesions, 5 thousand preterm births and over 8 million health problems. Under the Netherlands screening practice, fewer Pap tests (58%), abnormal test results (64%), punch biopsies (75%), treatment procedures (40%), preterm births (60%) and health problems (63%) would have occurred. The SEARCH data did not differ much from other US data for 2007 or from more recent data up to 2013. Thus compared to the less intensive screening practice in the Netherlands, US practice of cervical cancer screening may have resulted in two- to threefold higher harms, while the effects on cervical cancer incidence and mortality are similar. The results are also of high relevance in making recommendations for HPV screening. Systematic collection of harms data is needed for monitoring and for better incorporation of harms in making screening recommendations.

The safety of emerging biosimilar drugs for the treatment of rheumatoid arthritis

Wed, 05/03/2017 - 9:51am

INTRODUCTION: Biological disease-modifying anti-rheumatic drugs (bDMARDs), often administered in combination with methotrexate, target specific inflammatory mediators and have transformed the treatment of rheumatic diseases, especially rheumatoid arthritis (RA) but also the spondyloarthritides. However, the high cost of these drugs in many countries restricts patient access. As many bDMARDs have reached or are near to patent expiration, numerous biosimilar drugs are in development and some have already been approved. Biosimilars are generally priced lower than their reference products (RPs), or bio-originators, and as prices come down it is hoped that patient access to these drugs will increase, making the safety of these drugs an area of major interest. Areas covered: This article reviews publicly available safety data on biosimilars in RA. Expert opinion: Most available data for biosimilars in RA relate to tumor necrosis factor inhibitors (TNFi) and rituximab (an anti-CD20 monoclonal antibody). As biosimilar use around the world increases, evidence supporting the clinical safety of the biosimilars compared with their RPs also grows. To date, no new safety concerns have been raised in studies with TNFi or rituximab biosimilars for the treatment of RA; safety profiles have been consistent with those of their RPs. However, careful post-marketing pharmacovigilance remains necessary.

Introduction to Graphic Medicine

Tue, 05/02/2017 - 4:10pm

This webinar, taught by Matthew Noe from the Lamar Soutter Library at UMass Medical School, will introduce the emerging field of graphic medicine, or, the use of comics in healthcare. We will begin with a brief overview of the field’s emergence, and then switch directions to highlight the role that comics can play in two key areas of librarianship: health literacy and medical education. The webinar will conclude with suggestions for collection development and programming to kickstart graphic medicine in your library.

Educational Games & Health Sciences

Tue, 05/02/2017 - 4:09pm

This webinar will begin with an overview of educational games and their benefits. Rina Wehbe, University of Waterloo, will speak about her research and recent game “Above Water” which informs people about strategies for coping with anxiety. Zeb Mathews, University of Tennessee, will speak about his game, “PubWizard” which quizzes graduate level informatics students' knowledge of primary and secondary sources. This will be followed by an interactive exercise of exploring some of the National Institutes of Health (NIH) & National Library of Medicine (NLM) endorsed games. A Q&A session will follow. Are you interested in creating a game? We’ll have an exit survey to discuss hosting a game creation course.

The learning objectives currently include the following:

- Understand how educational games and gamification are unique - Learn about the possible benefits and advantages of learning with games - Better general understanding of the process of creating an educational game - Become acquainted with 2 educational games that intersect with the health sciences - Understand how basic game design elements are significant in educational games - Become familiar with some NIH & NLM endorsed games

Introduction/Overview: 5-10 min.
Rina Wehbe (Above Water): 20 min.
Zeb Mathews (PubWizard): 20 min.
Game Exercise: 15-20 min.
Q&A & Survey: 5–10 min.

RNA-Sequencing Reveals Direct Targets of Tumor Suppressor miR-203 in Human Mammary Epithelial Cells

Tue, 05/02/2017 - 3:41pm

Background: Breast cancer is the leading cause of cancer-related mortality in women worldwide. Since a significant portion of cases present with or progress to metastatic disease, furthering our understanding of metastasis is critical to develop better treatments. Epithelial cells maintain contact with the extracellular matrix (ECM) predominantly via integrin engagement, a process required for tissue integrity and barrier function. In non-transformed cells, loss of ECM adhesion promotes a specialized form of programmed cell death, anoikis. In order for efficient metastasis to occur, breast tumor cells must evade anoikis. miR-203, known to be down-regulated in several cancers, was found by our lab to be induced ten-fold 24 hours following detachment in breast epithelial cells, but not invasive triple negative breast cancer (TNBC) cells, suggesting that miR-203 may participate in promoting anoikis. Interestingly, more invasive breast cancer cell lines have been shown to express miR-203 at significantly lower levels than those of less invasive lines.

Objectives: Since restoration of miR-203 expression ectopically is not feasible in a clinical setting, we sought to identify and characterize miR-203 target genes in order to provide a pharmaceutical platform for restoration of anoikis sensitivity in metastatic breast cancer.

Methods: We performed traditional RNA-sequencing (RNA-Seq) coupled with immunoprecipitation of the RNA-induced silencing complex (RISC; Ago2 RIP-Seq) in MCF-10A, an immortalized, but non-transformed breast epithelial cell line, overexpressing precursor miR-203 or an empty vector control. MDA-MB-231, triple negative ductal carcinoma cells, were used as our invasive comparison cell line.

Results: Here we show that miR-203 induction in detached MCF-10A cells is due to loss of integrin signaling. Our coupled RNA-Seq and Ago2 RIP-Seq approach revealed 72 potential candidates, 42 of which were predicted miR-203 targets based on the TargetScan algorithm. We subjected the candidates to stringent characterization and found 9 bona-fide miR-203 targets that promote cell death when inhibited. Among these, WDR69, PRKAB1, PRPS2, and HBEGF were significantly elevated in TNBC tumor samples, as determined by RNA-Seq analysis in The Cancer Genome Atlas (TCGA).

Conclusion: Understanding the mechanisms by which cells evade anoikis during tumor dissemination is crucial to developing more effective therapies in breast cancer. miR-203, which is expressed at very low levels in more invasive breast cancers, is a positive regulator of anoikis that is upregulated in response to loss of contact with the ECM. Our combined RNA-sequencing screen revealed 42 direct miR-203 targets. Inhibition of 9 bona-fide targets promoted cell death, suggesting that they are negative regulators of anoikis. WDR69, PRKAB1, PRPS2, and HBEGF were all significantly elevated in TNBC tumor samples relative to less invasive samples, likely a consequence of low miR-203 expression. The identified genes represent potential pharmaceutical targets for novel breast cancer therapies.

Interventional Radiology Readiness Assessment Tool for Global Health

Mon, 05/01/2017 - 4:40pm

The Interventional Radiology Readiness Assessment Tool for Global Health is a new tool to methodically evaluate the environment of a medical institution for interventional radiology services given the existing infrastructure. Global health provides an exciting opportunity for interventional radiology to impact health outcomes in developing countries. A systematic and thoughtful approach to integrating interventional radiology services in the health care institutions of resource poor countries is needed in order to maximize global health efforts and outcomes.

The IR Readiness Assessment Tool is available as on online form and in PDF format under "Additional Files" below.

Collecting Histories of Education and Employment During Recovery (CHEER) Project

Mon, 05/01/2017 - 2:02pm

The Collecting Histories and Employment during Recovery (CHEER) study aims to provide a long-term picture of career development activities of young adults living with serious mental health conditions. From this study, we will better understand the work and education experiences, and the supports and barriers encountered by young adults with serious mental health conditions when trying to achieve their work and/or education goals, as well as how becoming a parent has impacted their work and education experiences.

Recent Trends in Sepsis Mortality, Associations between Initial Source of Sepsis and Hospital Mortality, and Predictors of Sepsis Readmission in Sepsis Survivors

Thu, 04/27/2017 - 3:10pm

Background: Sepsis, a leading cause of US deaths, is associated with high mortality, although advances in early recognition and treatment have increased survivorship. Many aspects of sepsis pathophysiology and epidemiology have not been fully elucidated; the heterogeneous nature of infections that lead to sepsis has made fully characterizing the underlying epidemiology challenging.

Methods: The University HealthSystem Consortium (UHC) from 2011-2014 and the Cerner HealthFacts® database from 2008-2014 were used. We examined associations between infection source and in-hospital mortality in the UHC dataset, stratified by age and presenting sepsis stage. We examined recent temporal trends in present-on-admission (POA) sepsis diagnoses and mortality and predictors of 30-day sepsis readmissions following sepsis hospitalizations using the HealthFacts® dataset.

Results: Patients with sepsis due to genitourinary or skin, soft tissue, or bone sources had lower mortality than patients with sepsis due to respiratory sources regardless of age or presenting sepsis stage. Overall diagnoses of sepsis increased from 2008-2014; however, POA diagnoses and case fatality rates decreased. Factors that predicted re-hospitalization for sepsis included discharge to hospice, admission from or discharge to a skilled nursing facility, and abdominal infection.

Conclusion: Further investigation will reveal more detail to explain the impact of infection source on in-hospital sepsis mortality for all age groups and sepsis stages. Decreasing mortality rates for all POA sepsis stages and all age groups suggest current approaches to sepsis management are having broad impact. Sepsis survivors are at significant risk for re-hospitalization; further studies are needed to understand the post discharge risks and needs of survivors.

A Synthetic Genetic System to Investigate Brain Connectivity and Genetically Manipulate Interacting Cells

Thu, 04/27/2017 - 3:10pm

The underlying goal of neuroscience research is to understand how the nervous system functions to bring about behavior. A detailed map of neural circuits is required for scientists to tackle this question. To this purpose, we developed a synthetic and genetically-encoded system, TRanscellular ACtivation of Transcription (TRACT) to monitor cell-cell contact. Upon ligand-receptor interaction at sites of cell-cell contact, the transmembrane domain of an engineered Notch receptor is cleaved by intramembrane proteolysis and releases a fragment that regulates transcription in the receptor-expressing cell. We demonstrate that in cultured cells, the synthetic receptor can be activated to drive reporter gene expression by co-incubation with ligand-expressing cell or by growth on ligand-coated surfaces. We further show that TRACT can detect interactions between neurons and glia in the Drosophila brain; expressing the ligand in spatially-restricted subsets of neurons leads to transcription of a reporter in the glial cells that interact with those neurons. To optimize TRACT for neural tracing, we attempted to target the synthetic receptor to post-synaptic sites by fusion with the intracellular domain of Drosophila neuroligin2. However, this modification only facilitate the receptor to be localized homogeneously throughout the neurites. The induction data of the modified receptor shows that the new receptor has better sensitivity compared to the original receptor, but the ligand-receptor interaction still happened at non-synaptic sites of membrane contact. To further target the ligand to pre-synaptic sites, we fused the ligand to different pre-synaptic markers. We found the one fused with synaptobrevin is likely located at axon terminals, but only able to trigger moderate induction. Therefore, more examinations are required to further characterize the capability of this ligand. In summary, TRACT is useful for monitoring cell-cell interactions in animals and could also be used to genetically manipulate cells based on contact. Moreover, we believe that proper targeting of the ligand to synaptic sites will improve the specificity of TRACT for synaptic connections in the future.

Intensity of Offending Following State Prison Release Among Persons Treated for Mental Health Problems While Incarcerated

Tue, 04/25/2017 - 10:28pm

OBJECTIVE: This study examined a range of demographic, clinical, and criminal history factors as they relate to the intensity of offending for up to two years postrelease.

METHODS: This study drew on data from 1,438 individuals released from Massachusetts state prisons between 2007 and 2009 who, while incarcerated, received treatment from the prisons' mental health services and were followed for 24 months postrelease. These data were used to explore predictive factors related to the intensity of criminal justice involvement, defined as number of arrests in the two-year follow-up period.

RESULTS: Predictors of subsequent arrests included number of previous incarcerations and black race. Protective factors included older age, supervision by parole, and a drug-related or person-related governing offense on previous arrest. Clinical symptoms were not related to incidence of postrelease arrests.

CONCLUSIONS: This study identified factors related to criminal history, such as type of charge, that were associated with the intensity of subsequent criminal justice involvement. These findings have not been reported in previous studies, perhaps because intensity of offending as opposed to a different dependent variable was used to measure criminal justice involvement. Further investigation should focus on whether the type of previous offense is related to postrelease risk factors for recidivism.

The NITRC image repository

Tue, 04/25/2017 - 10:28pm

The Neuroimaging Informatics Tools and Resources Clearinghouse (NITRC - suite of services include a resources registry, image repository and a cloud computational environment to meet the needs of the neuroimaging researcher. NITRC provides image-sharing functionality through both the NITRC Resource Registry (NITRC-R), where bulk data files can be released through the file release system (FRS), and the NITRC Image Repository (NITRC-IR), a XNAT-based image data management system. Currently hosting 14 projects, 6845 subjects, and 8285 MRI imaging sessions, NITRC-IR provides a large array of structural, diffusion and resting state MRI data. Designed to be flexible about management of data access policy, NITRC provides a simple, free, NIH-funded service to support resource sharing in general, and image sharing in particular.

Is Helplessness Still Helpful in Diagnosing Posttraumatic Stress Disorder

Tue, 04/25/2017 - 10:28pm

Criteria A2, experience of helplessness, fear, or horror at the time of the traumatic event, was removed from the posttraumatic stress disorder diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. We argue that there is empirical support for retention of A2, a criterion that has clinical value and may improve diagnostic accuracy. Specifically, we demonstrate that A2 has high negative predictive power, aids in the prediction of symptom severity, and can be indispensible to detecting the disorder in children. We examine how augmenting A2 with other peritramautic emotions could improve clinical and diagnostic utility. In our opinion, rather than being eliminated, A2 needs to be reconstructed and included as one criterion of PTSD.