Administration Medical Center Research Articles

The use of telehealth-supported stewardship activities in acute-care and long-term care settings: An implementation effectiveness trial.

We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. The study included inpatient providers at participating sites who prescribe antibiotics. During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. The telehealth program reviewed 502 unique patients and made 681 recommendations to 24 providers; 77% of recommendations were accepted. After program initiation, antibiotic DOT immediately decreased in the LTC units (-30%; P < .01) without a significant immediate change in the acute-care units (+16%; P = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.

157. A Survey of the Mid-South VA Healthcare Network on Ordering Practices and Interpretation of Procalcitonin

Abstract Background Procalcitonin (PCT) is an inflammatory biomarker that can be helpful for early detection of certain types of infections and can be a useful tool to decrease unnecessary antibiotic (abx ) exposure. However, its use among clinicians remains variable. The aim of this study was to elucidate current practices at a selection of Veteran’s Administration medical centers. Methods The VISN-9 Antimicrobial Stewardship Collaborative distributed a 15-question survey electronically to providers at all five VA medical centers in VISN-9 between 1/15/22 to 3/31/22 to clinicians practicing in the acute care, ICU and ED settings. Information on level of training, primary site as well as current practices and beliefs about PCT were collected. Responses were tabulated as percentages for this cross-sectional study. Results 99 providers completed the survey with two centers comprising 83% of responses. 44% of respondents were attendings. The Figures illustrate some interesting variability in the use of PCT. Figure 1 reveals more than half of residents but less than a quarter of attendings ordered PCT on admission for patients with suspected infection. Figure 2 shows similar use of PCT by attendings and residents to initiate abx, however, residents used PCT much more than attendings to justify continuation of abx, and residents used PCT somewhat more than attendings to de-escalate abx. Only one clinician ordered PCT daily. Figure 3, ordering practices by disease state, shows similar trends between the two groups. 44% of all respondents felt somewhat comfortable whereas 22% felt somewhat uncomfortable interpreting PCT results. Some of the interesting comments from respondents included: “PCT is “ordered too often and indiscriminately”; “I never know what to do with it”; and “I usually allow my patients to complete their abx courses rather than discontinuing abx earlier”. Conclusion Using PCT to help guide abx use can help minimize unnecessary abx exposure which may help to stem the increase in antimicrobial resistance. This survey indicates that many clinicians are unsure of when to use PCT, how often to order it, and whether it is a reliable enough tool on which to base treatment decisions. Further education will be necessary to help inform best practices. Disclosures All Authors: No reported disclosures.

Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital.

Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran’s Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2–6 days) vs. 7 days (6–9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61–104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.

Abstract 11367: Chronic Kidney Disease and 6-12 Month Outcomes After Transcatheter Aortic Valve Replacement

Introduction: Chronic kidney disease (CKD) is known to accelerate the progression of aortic stenosis (AS) and portends adverse outcomes in patients treated with surgical valve replacement. Long-term outcomes in CKD patients after transcatheter aortic valve replacement (TAVR) have been less studied. The purpose of this study is to examine outcomes after TAVR in CKD patients as stratified by glomerular filtration rate (GFR). Hypothesis: CKD is associated with poorer outcomes after TAVR. Methods: Retrospective electronic medical record review from March 2018-June 2020 at the University of Illinois, Chicago and Jesse Brown Veteran’s Administration Medical Center (Chicago, Illinois) identified TAVR patients, who were included if they followed-up within 6 and 12 months of procedure. Patients were stratified into 4 classes by baseline GFR (mL/min): &gt;90, 60-89, 30-59, &lt;30 with the latter 3 groups comprising CKD patients. Outcomes were expressed as event rates and included 6 and 12-month MACE (all-cause mortality, MI, or CVA) and 30-day rehospitalization. Chi-square analysis was used to compare differences across GFR groups. Results: 118 patients (age 76±10 years, 79% male, 46% white) followed up at 6-months and 112 did so at 12-months. There were no statistically significant differences in baseline demographics or comorbidities between CKD and non-CKD patients. CKD patients were more likely to experience MACE compared to non-CKD patients at 6 (p=0.04) and 12-months (p=0.009, Fig. 1). CKD patients also had a higher rate of 30-day rehospitalization (p=0.003). Conclusion: Our results demonstrate that CKD portends adverse outcomes after TAVR with CKD patients experiencing an increased risk of 6 + 12-month MACE and 30-day re-hospitalization. Decreasing GFR correlated with higher rates of MACE at 6 and 12 months.

Is MRI Overutilized for Evaluation of Knee Pain in Veterans?

MRI is an essential diagnostic imaging modality for many knee conditions; however, it is not indicated in the setting of advanced knee arthritis. Inappropriate MRI imaging adds to health care costs and may delay definitive management for many patients. The primary purpose of this study was to ascertain the frequency of inappropriate MRI scans performed at one Veterans' Administration Medical Center (VAMC). We performed a retrospective chart review of all knee MRIs ordered over a 6-month period. Inappropriate MRI was defined as MRI performed prior to radiographs (XRs), or in the presence of XRs demonstrating severe osteoarthritis, without leading to a nonarthroplasty procedure of the knee. Of the 304 cases reviewed, 36.8% (112) of the MRIs were deemed inappropriate, 33 were ordered by orthopedists, and 79 were ordered by other health care providers. Of the 33 ordered by orthopedists, 25 were ordered by retired/nonsurgical orthopedists. Obtaining an MRI delayed care by an average of 29.2 days. Of the 252 cases that had XR prior to MRI, none included all four views in the standard knee XR series and only four had weightbearing images. Over a third of knee MRIs performed at this VAMC were inappropriate and delayed care. Additionally, no XRs in our study contained all the necessary views to properly assess knee arthritis. These concerning findings signify a potential opportunity for education in diagnostic strategies, to better patient care and resource utilization in the VAMC.

Computerized Intervention in Primary Care for Women Veterans with Sexual Assault Histories and Psychosocial Health Risks: a Randomized Clinical Trial

ImportanceSexual assault is a public health concern for women and is associated with subsequent psychosocial health risks of posttraumatic stress disorder (PTSD), hazardous drinking, and intimate partner violence (IPV). Sexual assault is associated with social stigma and other barriers shown to inhibit one from seeking mental health care. Digital health technologies may overcome these barriers.ObjectiveTo test the impact of a brief computerized intervention delivered in primary care to reduce health risks and increase mental health treatment utilization among women with histories of sexual assault and current health risks.Design, Setting, and ParticipantsThe Safe and Healthy Experiences (SHE) program was tested in a randomized controlled trial with N = 153 women veterans at a Veterans Health Administration (VHA) medical center, and they completed assessments at baseline, 2 months, and 4 months.InterventionSHE is a brief motivational interviewing and psychoeducation-based computerized intervention. SHE was compared to a screen and referral-only control condition.Main MeasuresHealth risks were measured via validated self-report instruments. Treatment initiation and utilization were measured via self-report and chart review.ResultsSHE did not impact women’s number of health risks (all p’s > .05). However, women randomized to SHE showed significantly greater increases in treatment use compared to women in the control group, as measured by chart review (χ2 (1, n = 153) = 4.38, p = .036, rs = .16), and self-report (χ2 (1, n = 130) = 5.89, p = .015, rs = .21). SHE was found to be an acceptable intervention.ConclusionsSHE was effective in improving mental health treatment initiation and utilization compared to a control group. Computer-based interventions to address sexual trauma and its consequences are acceptable, are highly scalable, and can add value to primary care with little cost or increase in provider time.Trial RegistrationClinicaltrials.gov identifier NCT02957747.

Abstract WP242: Using Systems Redesign in the Development, Implementation, and Evaluation of a Care Transitions and Hypertension (catch) Management Program for Veterans With Ischemic Stroke

Introduction: Systems Redesign approaches have the potential to be used to develop, implement, and evaluate the implementation of post-ischemic stroke hypertension quality improvement initiatives. Methods: The CAre Transitions and Hypertension (CATcH) management program is a bundled, multi-faceted, provider- and healthcare-systems level pilot-intervention designed to enhance care coordination using infrastructure routinely available within a Veterans Health Administration (VHA) medical center delivering suboptimal post-stroke hypertension care. A rapid process improvement workshop with local personnel from internal medicine, neurology, clinical pharmacy, and facility leadership. The team process mapped out the current state of post-stroke blood pressure (BP) control from the hospitalization period to outpatient follow-up, and conceptualized a future state where there was enhanced care coordination between inpatient and outpatient providers, generalists and specialists, and increased engagement of underutilized talent within clinical pharmacy and telehealth. The CATcH bundle also included a Transition in Care note to improve communication between providers. The team decided to meet weekly to determine newly identified and ongoing needs for patients. Chart review was conducted to determine healthcare utilization. Results: In the six-months prior to the implementation of CATcH, facility-level pass rate for BP control (i.e., obtaining BP &lt; 140/90 mmHg) was 50% (18/36). Stroke survivors were neither discharged with telehealth for BP monitoring nor received clinical pharmacy appointments. In the six-months after CATcH implementation, facility-level pass rate for BP control was 69% (22/32). Nineteen percent were enrolled in telehealth whereas all patients received and attended at least two clinical pharmacy appointments post-discharge. All patients discharged during the intervention period were recipients of the CATcH program. Conclusions: A Systems Redesign approach could be used to eliminate waste and minimize variability in the process of post-stroke hypertension management while using readily available hospital infrastructure to improve hypertension care for stroke survivors.

Early glottic cancer in a veteran population: Impact of race on management and outcomes.

Multiple population studies have shown racial discrepancies in head and neck cancer treatment and outcomes. We sought to characterize the impact of race on clinical outcomes for patients with early glottic squamous cell carcinoma (SCC) in a tertiary institution which provides equivalent access to care. We retrospectively reviewed all early glottic (T1-T2) squamous cell carcinoma at a single institution, the Michael E. DeBakey Veterans' Administration Medical Center (MEDVAMC). Data collected included demographic information, primary and adjuvant treatment modalities, time to diagnosis, time to treatment, recurrences, recurrence treatment modality, secondary malignancies, recurrence-free survival (RFS), and overall survival (OS). One hundred seventeen patients with a primary diagnosis of T1-T2 glottic squamous cell carcinoma were included. Black and white patients demonstrated equivalent rates of recurrence, RFS, and OS. There was no significant difference in treatment delivery by race for all recorded parameters. T1b tumors were associated with an increased risk of recurrence which did not translate into a statistically significant decrease in RFS or OS. Surgical treatment was associated with increased recurrence but similar RFS and OS compared to radiation-based treatment. Secondary malignancies were common; 12% of patients were diagnosed with a second primary lung cancer during the study period. At our institution, race did not impact survival when access to care, treatment selection, and delivery are equivalent for early glottic SCC. Secondary lung cancer is a critical risk factor for mortality in this patient group and requires long-term surveillance and monitoring. 4 Laryngoscope, 130:1733-1739, 2020.

Intravenous Fluid Therapy Is Associated with a Reduced Incidence of Contrast-Induced Nephropathy but not with a Reduced Long-Term Incidence of Renal Dysfunction After Cardiac Catheterization.

Intravenous fluid (IVF) administration for the prevention of contrast-induced nephropathy (CIN) is considered standard of care, but the effect of IVF therapy on longer-term outcomes after radiocontrast dye administration is not well known. We studied 4367 patients undergoing coronary and peripheral angiography and intervention at a veterans' administration medical center. 2653 patients (61%) received IVF prior to the procedure and 1714 (39%) did not. Of the 4367 subjects 1962 (45%) had repeat creatinine values at 72 h and 3100 (70%) had repeat creatinine values at 3 months. CIN at 72 h occurred in 68 (6.7%) patients in the IVF group and in 87 patients (9.8%) in the group receiving no IVF (odds ratio [OR] 0.97; 95% confidence interval [CI] 0.94-0.99; p = 0.004). At 3 months, renal dysfunction was seen in 224 (11.5%) patients of the IVF group versus 152 (13.1%) of the group receiving no IVF (OR 0.98, CI 0.96-1.01; p = 0.18). In adjusted analyses using a propensity score, IVF therapy was associated with a significant reduction in CIN occurrence at 72 h (OR = 0.97, (95% CI 0.94-0.99, p = 0.01) but was not associated with a change in the incidence of renal dysfunction at 3 months (OR 0.98, 95% CI 0.96-1.01. p = 0.18). In this cohort of US veterans, IVF administration was associated with a decreased incidence of CIN at 72 h but was not associated with a decreased incidence of renal dysfunction at 3 months.

Design and Implementation of a Comprehensive Surveillance System for Venous Thromboembolism in a Defined Region Using Electronic and Manual Approaches.

Systematic surveillance for venous thromboembolism (VTE) in the United States has been recommended by several organizations. Despite adoption of electronic medical records (EMRs) by most health care providers and facilities, however, systematic surveillance for VTE is not available. This article develops a comprehensive, population-based surveillance strategy for VTE in a defined geographical region. The primary surveillance strategy combined computerized searches of the EMR with a manual review of imaging data at the Duke University Health System in Durham County, North Carolina, United States. Different strategies of searching the EMR were explored. Consolidation of results with autopsy reports (nonsearchable in the EMR) and with results from the Durham Veterans' Administration Medical Center was performed to provide a comprehensive report of new VTE from the defined region over a 2-year timeframe. Monthly searches of the primary EMR missed a significant number of patients with new VTE who were identified by a separate manual search of radiology records, apparently related to delays in data entry and coding into the EMR. Comprehensive searches incorporating a location-restricted strategy were incomplete due to the assigned residence reflecting the current address and not the address at the time of event. The most comprehensive strategy omitted the geographic restriction step and identified all patients with VTE followed by manual review of individual records to remove incorrect entries (e.g., outside the surveillance time period or geographic location; no evidence for VTE). Consolidation of results from the EMR searches with results from autopsy reports and the separate facility identified additional patients not diagnosed within the Duke system. We identified several challenges with implementing a comprehensive VTE surveillance program that could limit accuracy of the results. Improved electronic strategies are needed to cross-reference patients across multiple health systems and to minimize the need for manual review and confirmation of results.

Use of the brief Confusion Assessment Method in a veteran palliative care population: A pilot validation study.

Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample. This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans' Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other. We enrolled 36 patients who were a median of 67 years (interquartile range 63-73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96). Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.

Neutrophil to Lymphocyte Ratio (NLR) at the Time of Transurethral Resection of Bladder Tumor: A Large Retrospective Study and Analysis of Racial Differences.

Introduction: Neutrophil/lymphocyte ratio (NLR) is an indicator of systemic inflammation and has been proven to be associated with an increased risk of extravesical disease, decreased cancer specific survival and overall survival in bladder cancer patients. A large proportion of healthy African Americans have a WBC count that is persistently lower than the normal range defined for individuals of European ancestry, this condition has been called “benign ethnic neutropenia”. The purpose of our study was to determine if NLR was different in patients of African ancestry (AA) vs European ancestry (EA) across different tumor grades and stages at the time of transurethral resection of bladder tumor(s) (TURBT).Materials and Methods: The records of consecutive patients who underwent TURBT were reviewed from the University of Wisconsin and the Atlanta Veterans’ Administration Medical Center (2000–2012). NLR was compared across tumor stage, tumor grade and ethnicity.Results: 297 consecutive patients met study criteria. 89% and 86%, were males and of European ancestry (EA) respectively. NLRs were different across T-stages (Ta-2.5, T1-3.9, T2-3.8; p = 0.001). but not across tumor grades in Ta (LG-2.5 vs HG-3.9, p = 0.57). EA had higher NLRs than AA (3.4 vs 1.9; p < 0.001).Conclusions: Higher NLRs appear to be associated with more advanced tumor stage at the time of TURBT. Patients of African ancestry have lower NLRs across all tumor stages compared to patients of European ancestry. Ethnicity should be taken into account when interpreting the NLR in patients with bladder cancer.

Albuminuria and masked uncontrolled hypertension in chronic kidney disease.

Masked uncontrolled hypertension (MUCH) is associated with greater target organ damage such as left ventricular hypertrophy, increased arterial stiffness and albuminuria. Whether MUCH independently associates with greater cardiovascular end-organ damage or kidney damage is unclear. The objective of this study was to assess the strength of the relationship of MUCH (awake ambulatory blood pressure ≥135/85 mmHg and clinic blood pressure <140/90 mmHg) with target organ damage. In a cross-sectional study at a veterans' administration medical center, clinically normotensive veterans without chronic kidney disease (CKD) (n = 29) and 287 patients with CKD and controlled hypertension (CH, n = 193), MUCH (n = 67) and uncontrolled hypertension (UCH, n = 27) had evaluation of target organ damage. Target organ damage was measured by echocardiography [left ventricular mass index (LVMI)], arterial ultrasonography [aortic pulse wave velocity (PWV)] and 24-h urine collection [albuminuria (urine albumin to creatinine ratio)] in all participants. Compared to that of controls, LVMI was higher by 21.8 g/m2 (CI, 4.0-39.7 g/m2) in CH, 27.9 (CI, 8-47.8) in MUCH and 39.5 (CI, 15.7-63.2) in UCH (P < 0.01 for group differences, P < 0.01 for linear trend). Although differences persisted after adjustment for age, sex and race, they lost significance after adjustments for cardiovascular risk factors and their treatment. Compared to that of controls, PWV was different among CH, MUCH and UCH (P = 0.04 for group differences, P = 0.02 for linear trend). However, differences lost significance after adjustments for age, sex and race. Compared to that of controls, log2 UACR was higher by 2.40 mg/mg (CI, 1.28-3.52) in CH, 4.94 (CI, 3.70-6.18) in MUCH and 6.01 (CI, 4.49-7.53) in UCH (P < 0.0001 for group difference, P < 0.0001 for linear trend). Differences persisted after adjustment for age, sex and race, cardiovascular risk factors and their treatment and cardiovascular disease (P < 0.0001 for group difference, P < 0.0001 for linear trend). MUCH is more strongly related to albuminuria compared with cardiovascular damage as assessed by left ventricular mass and PWV. A graded and an independent relationship of blood pressure classification status with albuminuria is consistent with the hypothesis that renal mechanisms may be more important than cardiovascular disease in mediating the pathogenesis of MUCH.

The development and validation of a novel outcome measure to quantify mobility in the dysvascular lower extremity amputee: the amputee single item mobility measure

Objective: This study describes the development and psychometric evaluation of a novel patient-reported single-item mobility measure. Design: Prospective cohort study. Setting: Four Veteran’s Administration Medical Centers. Subjects: Individuals undergoing their first major unilateral lower extremity amputation; 198 met inclusion criteria; of these, 113 (57%) enrolled. Interventions: None. Main measures: The Amputee Single Item Mobility Measure, a single item measure with scores ranging from 0 to 6, was developed by an expert panel, and concurrently administered with the Locomotor Capabilities Index-5 (LCI-5) and other outcome measures at six weeks, four months, and 12 months post-amputation. Criterion and construct validity, responsiveness, and floor/ceiling effects were evaluated. Responsiveness was assessed using the standardized response mean. Results: The overall mean 12-month Amputee Single Item Mobility Measure score was 3.39 ±1.4. Scores for transmetatarsal, transtibial, and transfemoral amputees were 4.2 (±1.3), 3.2 (±1.5), and 2.9 (±1.1), respectively. Amputee Single Item Mobility Measure scores demonstrated “large” and statistically significant correlations with the LCI-5 scores at six weeks (r = 0.72), four months (r = 0.81), and 12 months (r = 0.86). At four months and 12 months, the correlation between Amputee Single Item Mobility Measure scores and hours of prosthetic use were r = 0.69 and r = 0.66, respectively, and between Amputee Single Item Mobility Measure scores and Trinity Amputation and Prosthesis Experience Scales functional restriction scores were r = 0.45 and r = 0.67, respectively. Amputee Single Item Mobility Measure scores increased significantly from six weeks to 12 months post-amputation. Minimal floor/ceiling effects were demonstrated. Conclusions: In the unilateral dysvascular amputee, the Amputee Single Item Mobility Measure has strong criterion and construct validity, excellent responsiveness, and does not exhibit floor/ceiling effects.

Abstract 211: Long-Term Mortality in Diabetic Patients with Non-Obstructive Coronary Disease Undergoing Coronary Angiography/Cardiac Catheterization

Background: Diabetes mellitus is associated with poorer outcomes in patients with cardiovascular disease and patients with diabetes are at increased risk of death. Several studies with coronary computed tomography have shown that, for equal numbers of severely diseased coronary arteries, the outcomes of patients with diabetes is worse compared to patients without diabetes. However, it is unclear if the outcomes of diabetic patients with non-obstructive coronary disease is different than the outcomes of patients without diabetes and non-obstructive disease. Methods and Results: We studied 901 consecutive, predominantly (98%) male patients undergoing coronary angiography/cardiac catheterization at a veterans’ administration medical center who had normal coronaries or non-obstructive coronary artery disease and we assessed the association between diabetic status and mortality. The mean age of the patients was 64.4 years. One third of the patients (n=311, 34.5%) were diabetic. Diabetic patients were the same age, and had the same baseline creatinine, but were more often hypertensive, and were more often on statins, angiotensin receptor blockers, angiotensin conversion enzyme inhibitors, calcium channel blockers and aspirin therapy compared to the non-diabetic patients. Contrast-induced nephropathy (CIN) occurred in 8 (2.57%) diabetic patients and in 11 (1.86%) non-diabetic patients at 72 hours after the procedure (odds ratio [OR] 1.39; 95% confidence interval [CI] 0.55 - 3.49; P= 0.48). At 3 months, renal dysfunction was seen in 34 (10.93%) diabetic patients versus 32 (5.42%) of the non-diabetic group (OR 2.14, CI 1.29 - 3.54; P=0.0032). After a median follow up of 67 months 59 patients (18.97 %) of the diabetic group had died versus 72 (12.20 %) of the non-diabetic group (OR 1.68, CI 1.16 - 2.45; P=0.0007). On multivariate analysis, after adjustment for age, comorbidities, medical therapy, baseline creatinine and the incidence of CIN, the presence of diabetes was significantly associated with the 5 year mortality (OR= 2.10, 95% CI 1.44 - 3.85, P=0.0006). Conclusion: In this cohort of patients undergoing coronary angiography who had normal coronaries or non-obstructive coronary disease, diabetes was associated with an increased mortality.

Review of Integrated Psychological Services in Primary Care.

Reviews the book, Integrated Psychological Services in Primary Care edited by William Scott Craig (see record 2016-01850-000). This book opens with an article by the editor, in which he outlines the behavioral health needs of primary care patients and the rationale behind integrating mental health services in primary care settings. Subsequent chapters address basic and practical information for a variety of practice locations, such as Patient Centered Medical Home clinics, the Veteran's Administration medical centers, and primary care settings where the concept of integrated health is new. This is an excellent primer for anyone planning to implement an integrated care program or for those considering moving from an independent practice, agency, or traditional health care/hospital environment into an integrated primary care environment. The authors' writing styles made difficult concepts easy to understand and their knowledge of the utility of integration was evident. (PsycINFO Database Record

Venous Thromboembolism (VTE) Surveillance: Incidence, Characteristics, and Initial Treatment of VTE Patients

Introduction: Venous thromboembolism (VTE), defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both, has been estimated to affect 300,000 to 600,000 individuals in the US each year. Incidence estimates suggest that African Americans have similar, or slightly higher, rates of VTE compared to Whites, while Asians appear to have a lower rate (Beckman, et al., Am J Prev Med, 2010;38:S495-S501). Acquired risk factors for VTE can be identified in ~50% of cases. Using a population-based approach, we used multiple case finding techniques to improve estimates of VTE occurrence in a geographically defined, racially diverse population.Methods: Durham County, NC, has a population of ~280,000 individuals, characterized as: 52.4% female; 53% White, 38.8% African American, 4.9% Asian, 1% American Indian, and 2.2% ≥2 races; and 13.5% Hispanic (US Census Data, 2012). The County is served by three hospitals, two in the Duke University Health System (DUHS) that share an electronic medical record, and the Durham Veterans’ Administration Medical Center (VAMC). We used a combination of methods to systematically identify patients living in Durham County with a new diagnosis of VTE. These included direct review of imaging data in the Duke Picture Archive and Communication System (PACS); automated review of ICD9 diagnosis codes for VTE and CPT codes for imaging procedures used for diagnosing DVT and PE stored in the Duke Medicine Enterprise Data Warehouse via the Duke Enterprise Data Unified Content Explorer (DEDUCE); direct review of Duke autopsy reports; and review of Veterans Health Information Systems and Technology Architecture (VISTA) to identify cases at the VAMC. Individual patients and events were cross-referenced to avoid duplicate entries, and demographic, risk factor, and treatment data were collected by record review and entered into a REDCap database. Data for the 9 month period from March through November 2013 collected at the DUHS hospitals are included in this abstract.Results: During the study period, we identified a total of 273 unique individuals with VTE, resulting in an estimated annual incidence of 1.3 per 1,000 individuals in Durham County. The mean age of the patients was 61.6 years (range, 19 to 99 years), and 153 (56%) were female. Mean BMI was 29.5±8.4. Racial distribution of VTE and estimated annual incidence is shown in the table below. Table 1RacePatients, n (%)Estimated annual incidence per 1,000 populationAsian2 (0.73%)0.19African American164 (60%)2.01White104 (38%)0.93Other3 (1.1%)0.45Characteristics of some of the events and risk factors comparing African American and White patients are shown in the table below. Abstract 4256. Table 2Total (total n=273)African American (total n=164)White (total n=104)Pulmonary emboli141/271 (52%)91/163 (55.8%)48/103 (46.6%)History of prior VTE63/273 (23%)38/162 (23.2%)25/103 (24%)Surgery within the preceding 90 days103/238 (43%)55/151 (36.4%)34/92 (38.0%)Active cancer57/246 (23%)38/153 (24.8%)18/89 (20.2%)Catheter-related17/250 (7%)11/148 (7.4%)6/88 (6.8%)None of these comparisons were statistically significant. Three African American patients had sickle cell disease. Hypertension (p=0.0392) and end-stage renal disease (p=0.0038) occurred more frequently in African American VTE patients compared to White VTE patients.Most patients were treated with anticoagulant therapy at the time of diagnosis (n=236; 87%), including low-molecular weight heparin (n=167; 70.8%), unfractionated heparin (n=78; 33.1%), and rivaroxaban (n=21; 8.9%); some patients received more than 1 agent. 129 patients (54.7%) were started on warfarin at the time of diagnosis. A minority of patients were treated with thrombolytic therapy (n=7; 2.6%), thrombectomy/embolectomy (n=3; 1.1%), or placement of an IVC filter (n=19; 7%). Major bleeding occurred in 6 patients (2.2%).These estimates are subject to limitations. They do not include Durham County residents who were diagnosed and treated completely outside the county, and cases from the Durham VAMC are pending.Conclusions: Our VTE surveillance case finding approach resulted in an estimated annual VTE incidence of ~1.3 persons per 1,000 per year, with an incidence in African Americans that is approximately twice the incidence in Whites. Common risk factors were similar for African Americans and Whites, but hypertension and end-stage renal disease were more common comorbid conditions in African Americans. DisclosuresNo relevant conflicts of interest to declare.

Autopsy-Proven Venous Thromboembolism (VTE): Incidence and Characteristics of Patients Correlated with Clinical Management Prior to Death

Introduction: Venous thromboembolism (VTE), defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both, is an important cause of morbidity and mortality among hospitalized patients, with PE ranking among the most frequent undiagnosed acute diseases in medical practice (Adv Orthop,2010;2(1):8–14).Methods: Durham County, NC, has a population of ~280,000 individuals and is served by three hospitals, Duke University Medical Center (DUMC) and Duke Regional Hospital (DRH) that share an electronic medical record, and the Durham Veterans’ Administration Medical Center (VAMC). Autopsy service is performed primarily at DUMC and, much less frequently, at the Durham VAMC. We performed a retrospective review of all autopsies performed at DUMC during a two year period (April 1st 2012 through March 31st 2014). Individuals living outside of Durham County were excluded. We also excluded autopsies performed on fetuses and neonates less than one month of age, as well as autopsies that were limited to examination of the brain only. Autopsies at DUMC are generally limited to the chest, abdomen and pelvis, and the limbs are typically not examined. VTE identified at autopsy, therefore, included PE and DVT involving the inferior vena cava and the abdominal, iliac, brachiocephalic, subclavian, and/or internal jugular veins. For Durham county patients with autopsy-proven VTE, we reviewed the medical records for the clinical characteristics of these individuals, including whether VTE was clinically suspected (or known) prior to death. To evaluate the total number of deaths in Durham county residents within the same time period, we obtained data from the Durham county Register of Deeds office and the NC Vital Records office.Results: During the two year study period, a total of 677 autopsies were performed at DUMC as shown in the figure below. [Display omitted] Of the 97 autopsies on patients from Durham county, VTE was diagnosed at autopsy in 19 cases (19.6%). The mean age of patients diagnosed with VTE at autopsy was 54 years (range 21-82 years). Ten were male (53%). Characteristics of the events are summarized in the table below. Table 1Type of eventHospitalization at the time of death.Thromboprophylaxis prior to death.VTE diagnosed antemortemSubsegmental PE only (n=6) Segmental PE only (n=2) Both (n=4)5 2 33 2 21 0 0DVT* (n=6)531PE and DVT* (n=1)100Total (n=19)16102* DVT involved the following veins: hepatic vein (2), left common iliac (1), internal jugular vein (1), inferior vena cava (1), “central” venous (1), and the mesenteric and pelvic veins (1)Slightly more than half the patients who were hospitalized at the time of death were receiving some type of thromboprophylaxis, and two of the patients had been diagnosed with VTE prior to their death.According to the pathologist’s report, PE was the direct cause of death in 4 cases. All patients had one or more risk factors for VTE as shown in table below. Table 2Predisposing FactorOccurrence, n (%)Hospitalization16 (84%)Age >4012 (63%)Surgery6 (32%)Obesity6 (32%)Cancer6 (32%)Diabetes mellitus5 (26%)Central venous catheter3 (16%)Prior known VTE1 (5%)One of the limitations of this analysis is the small number of autopsies that are currently performed in the US. During the two year period, a total of 3918 residents of Durham county died within the state of NC. The rate of autopsy for Durham County residents who died during the study period, therefore, was only 2.5% of all deaths during this period.Conclusions: The frequency of VTE identified at autopsy in our retrospective study is 19.6% (19 of 97). The majority of these patients were not suspected to have VTE prior to death. Although most were hospitalized, more than a third were not receiving thromboprophylaxis at the time of death. Hospitalization is a common risk factor for VTE, and VTE remains an important cause of death in hospitalized patients. DisclosuresNo relevant conflicts of interest to declare.

Parkinson&amp;rsquo;s disease psychosis

Parkinson&rsquo;s disease psychosis Rebekah J Jakel,1,2 Mark Stacy31Department of Psychiatry, Duke University, Durham, NC, USA; 2Durham Veteran&#39;s Administration Medical Center, Durham, NC, USA; 3Department of Neurology, Duke University, Durham, NC, USAAbstract: Parkinson&rsquo;s disease is a progressive neurodegenerative disease characterized by loss of nigral dopaminergic neurons associated with rigidity, resting tremor, bradykinesia, and postural instability. In addition to the above motor symptoms, nonmotor manifestations are increasingly recognized as part of Parkinson&#39;s disease pathology and contribute to overall symptom burden, morbidity, and mortality. Such nonmotor symptoms include autonomic dysfunction, impaired olfaction, gastrointestinal disturbances, and a variety of psychiatric symptoms including psychosis. Psychiatric symptoms may be inherent to the disease process itself, secondary to treatments aimed at restoring dopamine, or related to comorbid mental illness. Given that traditional medications used to treat psychosis are dopaminergic antagonists, pharmacologic treatment of these symptoms carries the risk of worsening the movement disorder, creating a challenge for providers. This review examines current literature regarding psychosis in the context of Parkinson&rsquo;s disease including risk factors for psychosis, prognosis, and management of these challenging symptoms.Keywords: antipsychotics, delusions, hallucinations, non-motor symptoms, paranoia

Neuropsychological Assessment and Treatment Following a Spinal Cord Injury and Alcohol Withdrawal

Mr. Wellington, a 61-year-old veteran, was referred for a neuropsychological assessment and mental health treatment by his attending physician and psychologist following a spinal cord injury (SCI) and alcohol withdrawal. According to the referral, Mr. Wellington had been experiencing anxiety and depressive symptoms, as well as diminished cognitive functioning. These symptoms were considered to be interfering with his participation in SCI rehabilitation. Prior to the assessment, Mr. Wellington had sustained a tetraplegic injury due to a syrinx and partial L5 injury caused by an uncontrolled chronic bone infection and was receiving treatment at a Veteran’s Administration medical center. Results of the assessment, the related challenges in identifying the etiology of the patient’s diminished neurocognitive functioning, and mental health treatment are discussed.