Denver Veterans Affairs Medical Center Research Articles

Tribute to Larry Robbins MD (1950–2021)

Tribute to Larry Robbins MD (1950–2021)

Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans.

Rates of diabetes for veterans who receive health care through the Veterans Health Administration are higher than rates in the general population. Furthermore, many veterans live in rural locations, far from Veterans Affairs (VA) hospitals, thus limiting their ability to readily seek face-to-face endocrinology care for diabetes. Telehealth (TH) technologies present an opportunity to improve access to specialty diabetes care for such patients; however, there is a lack of evidence regarding the ability of TH to improve glycemic control in comparison to traditional face-to-face consultations. This was a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical Center over a 1-year period. A total of 189 patients were included in the analysis. In all, 85 patients had received face-to-face (FTF) endocrinology consultation for diabetes and 104 patients had received TH consultation. Subjects were mostly males (94.7%) and the mean age was 62.8 ± 10.1 years old. HbA1c improved from 9.76% (9.40% to 10.11%) to 8.55% (8.20% to 8.91%) (P < .0001) for the TH group and from 9.56% (9.16% to 9.95%) to 8.62% (8.22% to 9.01%) (P < .0001) for the FTF group after 1 visit. This change in HbA1c was not significantly different in the TH and FTF groups (P = .24). TH visits were associated with a hypothetical savings in median distance traveled of 231.2 miles per trip (which equates to $94.79 saved per trip). Endocrinology TH consultations improved short-term glycemic control as effectively as traditional FTF visits in a veteran population with diabetes.

2016 Carl W. Gottschalk Distinguished Lectureship of the American Physiological Society Renal Section.

Announcements2016 Carl W. Gottschalk Distinguished Lectureship of the American Physiological Society Renal SectionPublished Online:15 Apr 2016https://doi.org/10.1152/ajprenal.00105.2016This is the final version - click for previous versionMoreSectionsPDF (158 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations ShareShare onFacebookTwitterLinkedInWeChat The American Physiological Society (APS) Renal Section has selected David H. Ellison, M.D. as the recipient of the 2016 Carl Gottschalk Distinguished Lectureship. Dr. Ellison is Professor of Medicine and Physiology and Pharmacology, Director of the Oregon Clinical and Translational Research Institute, and Associate Vice President for Clinical and Translational Research at Oregon Health and Science University. Dr. David H. EllisonDownload figureDownload PowerPoint Dr. Ellison graduated from Stanford University with distinction and Departmental Honors in Biology. After receiving his Medical Degree with Alpha Omega Alpha honors from Rush Medical College (Chicago, IL), he trained in Internal Medicine at the University of Oregon Health Sciences Center (Portland, OR) and Nephrology at Yale University. Following a Nephrology Fellowship and postdoctoral training in renal physiology with Dr. Fred Wright, Dr. Ellison joined the faculty at Yale. He then moved to the University of Colorado (Denver, CO), where he was Chief of the Renal Section at the Denver Veterans Affairs Medical Center. Prior to taking his new position, he was Head of the Division of Nephrology and Hypertension at Oregon Health and Science University for the last 13 years.Dr. Ellison's research centers on the molecular target of thiazide diuretics, drugs recommended as first-line antihypertensive agents. A model physician-scientist, all of his work beautifully combines basic and clinical approaches. His early studies showed that the thiazide-sensitive Na-Cl transporter (NCC) is the dominant salt transport pathway along the distal convoluted tubule (DCT) and helped define the physiological and clinical importance of the nephron segment. This work was later translated to provide insights into the mechanisms of loop-diuretic resistance. Dr. Ellison has been a leader in defining how mutations in the NCC cause Gitelman syndrome, a hypokalemic salt-wasting disease in humans and how mutations in the WNK kinase cascade activate the NCC and cause familial hyperkalemic hypertension. His group demonstrated that the immunosuppressive drug tacrolimus causes hyperkalemia and hypertension by activating the NCC. Recently, his studies revealed how the NCC is regulated by dietary potassium, providing new insights to explain the deleterious effects of dietary potassium deficiency on blood pressure. This work also promises to rewrite the textbooks on the mechanisms of altered renal sodium handling in primary aldosteronism and Addison disease.Dr. Ellison has served on many important committees for the American Physiological Society, American Society of Nephrology, and American Heart Association. He was Chair of the Council on the Kidney in Cardiovascular Disease, American Heart Association. He is presently an Associate Editor for the Journal of the American Society of Nephrology. He has also served on numerous national peer review groups. Currently, he is Chair of the Kidney Molecular Biology and Development Study Section for the National Institutes of Health.Dr. Ellison continues to make important contributions to explain the effects of diet on blood pressure, the mechanisms of salt transport by the kidney, the genetic basis of human blood pressure variation, and on diuretic treatment of edema. The Renal Section is honored to have him present the 2016 Carl Gottschalk Distinguished Lecture.This article has no references to display. Download PDF Previous Back to Top Next FiguresReferencesRelatedInformation More from this issue > Volume 310Issue 8April 2016Pages F802-F802 Copyright & PermissionsCopyright © 2016 the American Physiological Societyhttps://doi.org/10.1152/ajprenal.00105.2016PubMed26911847History Published online 15 April 2016 Published in print 15 April 2016 Metrics

Tryptophan supplementation and postoperative delirium--a randomized controlled trial.

To determine whether the postoperative administration of tryptophan would be beneficial for elderly adults undergoing surgery who are at risk of developing postoperative delirium. Randomized, double-blind, placebo-controlled trial. Denver Veterans Affairs Medical Center. Individuals aged 60 and older undergoing major elective operations requiring a postoperative intensive care unit (ICU) admission (n=325). L-tryptophan, 1g orally three times a day or placebo was started after surgery and continued for up to 3days postoperatively. Delirium and its motor subtypes were measured using the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) and the Richmond Agitation and Sedation Scale. The primary outcome for between-group comparison was the incidence of excitatory (mixed and hyperactive) postoperative delirium. The secondary outcomes for comparison were the incidence and duration of overall postoperative delirium. The overall incidence of postoperative delirium was 39% (95% confidence interval=34-44%) (n=116). Seventeen percent of participants in the tryptophan group and 9% in the placebo group had excitatory delirium (P=.18), and the duration of excitatory delirium was 3.3±1.7days for tryptophan and 3.1±1.9days for placebo (P=.74). Forty percent of participants in the tryptophan group and 37% in the placebo group had overall delirium (P=.60), and the duration of overall delirium was 2.9±1.8days for tryptophan and 2.4±1.6days for placebo (P=.17). Postoperative tryptophan supplementation in older adults undergoing major elective operations requiring postoperative ICU admission did not reduce the incidence or duration of postoperative excitatory delirium or overall delirium.

Virtual Rapid Response

The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center’s tele–intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a “virtual handshake” by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19’s medical centers.

Impaired Cognition in Elderly Degrades Postoperative Outcomes

I cognition among older adults who undergo elective surgery is significantly associated with adverse postoperative outcomes, including increased complications, length of stay, and longterm mortality, results from a singlecenter study showed. In addition, delirium was found to be an effect modifier in the relationship between impaired cognition and adverse postoperative outcomes. “The most striking finding is that delirium appears to work as part of a causal pathway between baseline impaired cognition and long-term mortality,” lead investigator Dr. Thomas N. Robinson said in an interview before the annual meeting of the Western Surgical Association, where he presented the work. His team at the University of Colorado, Denver, prospectively evaluated 186 adults aged 65 and older who underwent an elective operation requiring postoperative intensive care. Impaired cognition was defined as a Mini-Cog score of 3 or less. To assess delirium, the researchers used the Confusion Assessment Method for the ICU, a validated tool measuring fluctuation in mental status, inattention, disorganized thinking, and altered level of consciousness. To determine adverse outcomes, they used definitions from the Veterans Affairs Surgical Quality Improvement Program. Dr. Robinson, who holds a surgery appointment at the Denver Veterans Affairs Medical Center, said the mean age of the 186 patients was 73 years and 96% were male. Nearly half (44%) had impaired cognition. Compared with their counterparts who had normal cognition at baseline, those with impaired cognition had a higher rate of one or more complications (41% vs. 24%, respectively), a higher incidence of delirium (78% vs. 37%), longer hospital stays (a mean of 15 vs. 9 days), a higher rate of discharge to an institutional care facility (42% vs. 18%), a higher 30-day readmission rate (21% vs. 10%), and a higher 6-month mortality (11% vs. 5%). All differences were statistically significant. Dr. Robinson also reported that the hazard ratio for death was 2.77 higher among patients with impaired cognition and delirium at baseline compared with patients with normal cognition and delirium. On the other hand, the hazard ratio for death was 1.86 among patients who had impaired cognitive function but no delirium at baseline. The researchers noted limitations of the study including the fact that nearly all patients were male and that a wide variety of operations were included, which “leads to large variability in measurements such as blood loss, operating room time, and length of stay.” They went on to conclude that “recognition of the brain’s function as a relevant marker of postoperative events has implications on the clinician’s ability to counsel their older patients about the anticipated postoperative course. In the future, preoperative risk stratification will likely not be based on physiologic compromise of a single organ system alone. Instead, the sum of compromise across multiple health-related domains (e.g., cognition, function, nutrition, disease burden) will likely be used to forecast postoperative outcomes.” The study received financial support from the National Institute on Aging and the American Geriatrics Society. Dr. Robinson said that he had no relevant financial conflict of interest.

Abstract A36: Breath Biomarkers in the Post NLST-era for the Discrimination between Malignant from Benign Pulmonary Nodules

Abstract Background: The recent National Lung Cancer Screening Trial (NLST) has proven that screening for lung cancer by low dose CT (LDCT) scans reduces the related mortality rate by 20%. However, in this program, the false positive rate was extremely high: 96% out of the 24% positive CT findings were non-cancerous. A high rate of false positives leads to unnecessary invasive procedures, which are both costly and associated with significant morbidity and mortality. It is now widely anticipated that LDCT screening programs will be launched in many countries in the near future. This will lead to a dramatically increased detection of small solitary pulmonary nodules (SPNs) for invasive investigation. Consequently, additional non-invasive biomarker approach to distinguish between benign and cancerous conditions is necessary. For that purpose, we evaluated in this study the role of exhale breath analysis as a potential non-invasive biomarker to discriminate between benign and malignant SPNs in the post NLST-era. Objectives: Developing a signature of volatile organic compounds (VOCs) in the exhaled breath that aids to distinguishes between benign and cancerous SPNs, and therefore also aids in 1) Early detection of lung cancer, 2) Improves the specificity of the NLST screening protocol in high risk cohorts, 3) helps prevent unnecessary invasive procedures, 4) results in the early treatment of lung cancer, and 5) Improves the costeffectiveness of the NLST screening program. Specifically, in this study we report the VOCs signature that discriminates benign from malignant SPNs, between NSCLC and SCLC and between early and advanced NSCLC. Methods: Cross-sectional comparative survey from 74 patients with solitary pulmonary nodules (SPNs) attending the University of Colorado Cancer Center or Denver Veterans Affairs Medical Center; USA. Breath samples were taken and the VOC profiles for malignant and benign lung nodules were determined by gas-chromatography/mass-spectrometry (GCMS), and the corresponding collective VOCs patterns were identified by a nanomaterialbased array of sensors. Results: Among the 74 high risk patients with SPNs on their LDCTs, 53 were malignant and 21 were benign. Age, smoking history, co-morbidity and medications were similar in both groups. Nodule sizes were 2.7±1.7 cm vs. 1.9±1.1 cm accordingly (NS). Within the malignant group, 47 were NSCLC and 6 were SCLC. Thirty had early disease (stage I-II/limited) and 23 had advanced disease (stage III-IV/extensive). GC-MS analysis identified two VOCs in the exhaled breath of nodule positive patients that showed statistically significant differences in concentration for benign and malignant lung nodules (N=11, 28 respectively; Benzene, 1-methyl-4-(1-methylethyl) and 1-Octene). The sensor array could distinguish between the corresponding collective VOCs patterns with an accuracy of 89.4%. Among the malignant SPNs we could further distinguish between SCLC and NSCLC (accuracy 93.9%) and between early and advanced disease (89.7%). Conclusions: An array of nanomaterial-based sensors could discriminate significantly between benign and malignant SPNs in a high-risk cohort with positive LDCTs based on lung cancer related VOCs profiles. Further, it was able to discriminate between NSCLC and SCLC, as well as between early and advanced disease. These results could promote the development of a non-invasive, fast and potentially cost-effective diagnostic tool for the management of nodule-positive patients that could help to eliminate risky invasive procedures in patients with benign nodules in the post NLST-era.

Virtual Rapid Response

The first of its kind in the Veterans Affairs (VA) system, the Denver VA Medical Center's tele-intensive care unit (ICU) program is unique because it is entirely nurse driven. A nontraditional tele-ICU model, the program was tailored to meet the needs of rural veterans by using critical care nursing expertise in Denver, Colorado. An experienced CCRN-certified nurse manages the system 24 hours a day, 7 days a week, from Eastern Colorado Health Care System. The virtual ICU provides rapid response interventions through virtual technology. This tele-ICU technology allows for a "virtual handshake" by nursing staff at the start of the shift and a report on potential patient issues. Clinical relationships have been strengthened between all 5 VA facilities in the Rocky Mountain Region, increasing the likelihood of early consultation at the onset of clinical decline of a patient. In addition, the tele-ICU nurse is available for immediate nursing consultation and support, coordinates point-to-point virtual consultation between physicians at the rural sites and specialists in Denver, and assists in expediting critical care transfers. The primary objectives for the tele-ICU program include improving quality and access of care to critical care services in rural sites, reducing community fee basis costs and frequency of transfers, and increasing collaboration and collegiality among nursing and medical staff in all Region 19's medical centers.

Assessing Neuropsychiatric Disturbances Associated With Post-Stroke Aphasia

Assessing Neuropsychiatric Disturbances Associated With Post-Stroke Aphasia

Screening for cognitive decline following single known stroke using the Mini-Mental State Examination

Background:Progressive cognitive decline develops in a nontrivial minority of stroke survivors. Although commonly used to identify cognitive decline in older stroke survivors, the usefulness of the Mini-Mental State Examination (MMSE) as a screening tool for post-stroke cognitive decline across a wider range of ages is not well established. This study therefore investigated the usefulness of the MMSE for this purpose.Methods:Twenty-seven subjects, aged 18–82 years, with a single known remote stroke were assessed using the MMSE. The frequency of cognitive impairment was determined by comparison of MMSE scores with population-based norms. Relationships between cognitive performance, motor impairments, age, gender, handedness, stroke laterality, and time since stroke also were explored.Results:Age-adjusted MMSE scores identified mild cognitive impairment in 22.2% and moderate-to-severe cognitive impairment in 7.4% of subjects. Raw and age-adjusted MMSE scores were inversely correlated with time since stroke, but not with other patient or stroke characteristics.Conclusion:A relationship between time since single known stroke and MMSE performance was observed in this study. The proportion of subjects identified as cognitively impaired in this group by Z-transformation of MMSE scores using previously published normative data for this measure comports well with the rates of late post-stroke cognitive impairment reported by other investigators. These findings suggest that the MMSE, when normatively interpreted, may identify cognitive decline in the late period following single known stroke. Additionally, the lack of a relationship between MMSE and Fugl-Meyer scores suggests that the severity of post-stroke motor impairments is unlikely to serve as a clinically useful indicator of the need for cognitive assessment. A larger study of stroke survivors is needed to inform more fully on the usefulness of normatively interpreted MMSE scores as a method of screening for post-stroke cognitive decline.

Frailty Markers Predicted Post-Op Mortality in Elderly

Frailty Markers Predicted Post-Op Mortality in Elderly

Predictors of Long-term Mortality After Bariatric Surgery Performed in Veterans Affairs Medical Centers

The purpose of this study was to examine patient factors associated with mortality among veterans who undergo bariatric surgery. Prospective study that uses data from the Veterans Affairs (VA) National Surgical Quality Improvement Program. Group Health Center for Health Studies, the VA North Texas Health Care System, the Denver VA Medical Center, and the Durham VA Medical Center. We identified 856 veterans who had undergone bariatric surgery in 1 of 12 VA bariatric centers from January 1, 2000, through December 31, 2006. The risk of death was estimated via Cox proportional hazards. The 856 veterans had a mean body mass index (BMI) of 48.7, a mean age of 54 years, and a mean DCG score of 0.76; 73.0% were men, 83.9% were white, and 7.0% had an ASA class equal to 4. Fifty-four veterans (6.3%) had died by the end of 2006. In our Cox models, patients with a BMI greater than 50 (superobesity; hazard ratio [HR], 1.8; P = .04) or a DCG score greater than or equal to 2 (HR, 3.4; P < .001) had an increased risk of death. Superobese veterans and those with a greater burden of chronic disease had a greater risk of death after bariatric surgery from 2000 through 2006.

Introduction: Helping Military Personnel and Recent Veterans Manage Stress Reactions

We were pleased when Dr. Rogers asked us if we would be interested in guest-editing a special section of this journal on issues relevant to working with Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) military personnel and veterans. As Veterans Affairs (VA) clinician researchers we face the timeliness of these issues on a daily basis and appreciate the many ways in which the mental health community outside of the VA and the Department of Defense (DoD) can play a role in working with the men and women affected by the current conflicts. We therefore solicited original research, theoretical papers, critical reviews, and case reports from a broad cross section of disciplines. In particular, we sought manuscripts that would provide new ideas or timely reviews directly pertinent to the practice of mental health counseling with those who served in Iraq or Afghanistan. The resulting submissions were reviewed by a group of clinical scholars with expertise in the areas covered. We would like to thank our colleagues from the VA VISN 19 Mental Illness Research Education and Clinical Center and Denver VA Medical Center, Drs. Lawrence Adler, Herbert Nagamoto, Beeta Homaifar, and Jennifer Olson-Madden, and from the Zablocki VA Medical Center in Milwaukee, Dr. Michelle Cornette. We believe the articles selected present a range of ideas and techniques that address the goals of this special section. Application of this information can benefit military personnel, veterans, and their families. The common theme of the three articles selected is deployment-related stress and ways to facilitate coping. Potter and colleagues present data on an in-theater intervention for combat stress control. They also review the types of clinical work being done in the field. Besides informing DoD clinicians about a novel means of service delivery, their article can orient VA and community-based mental health counselors to the types of care their clients may have received in-theater. Corso and colleagues have adapted a range of evidence-based PTSD treatments to use in a primary care setting. Their data suggest that integrating mental health and primary care can be effective and that a behavioral health consultation model can decrease symptoms of PTSD in clients who do not seek traditional mental health services. Finally, from a review of the suicide literature as it relates to members of the military, Martin and colleagues highlight similarities and differences in risk and protective factors for military personnel and veterans compared with the general population. Their material can inform case conceptualization and treatment planning, particularly for counselors new to working with suicidal military personnel and veterans. Readers may be asking why a special section on such topics is necessary. Preliminary evidence suggests that the mental health needs of those who have served or are serving in Iraq and Afghanistan are significant (Lineberry, Bostwick, & Rundell, 2006; Milliken, Auchterlonie, & Hoge, 2007; Seal et al., 2008). As such, increased attention to meeting the needs of these individuals is warranted. Ideally, this will be facilitated via DoD, VA, and community partnerships, and can in part be accomplished by collaboratively pooling resources and sharing information across systems. Based on the clinical literature (Lineberry, Ramaswamy, Bostwick, & Rundell, 2006) we expect that the challenges-both physical and psychological--faced by some individuals will require significant intervention, and that the type of care needed will evolve over time. As individuals return from deployments to Iraq and Afghanistan, clinicians will be seeing clients at differing points in their recovery. Corso et al. (this issue) highlight that many individuals are exhibiting symptoms but do not yet meet the full diagnostic criteria for PTSD. Providing treatments which help these individuals more effectively manage their symptoms may indeed lead to fewer clients developing PTSD. …

Perceived Risks of Endoscopy At the Denver Veterans Affairs Medical Center

Background: Colonoscopy is generally safe but carries with it important finite risks including bleeding, perforation, and adverse reactions to sedation. Open access endoscopy allows providers to order tests without consultation or intimate procedural knowledge. At the Denver Veterans Affairs Medical Center (VAMC) patients (pts) are mailed a brochure in advance of their procedure that outlines indications and risks. The effectiveness of this passive educational approach is unknown. We describe the results of a self-completed survey from the Denver VAMC. Methods: From January 1 to March 31, 2004, 375 consecutive pts underwent colonoscopy in the outpatient endoscopy suite at the Denver VAMC. After IRB approval, all pts were offered participation in a survey study designed to address pre-procedural knowledge pertaining to indications, risks, and compliance with the provided brochure. Subjects were asked to provide minimal demographic data (highest level of education and income), and were asked whether the following were risks of colonoscopy: bleeding, diarrhea, infection, pain, adverse reaction to medicines, perforation, or no significant risks. Data were analyzed in a binary fashion (yes/no) for each risk. Results: Two-hundred ninety five pts (79%) completed the survey. Two-hundred fifty eight reported receiving the informational brochure and 257 read the brochure. Seventy-eight percent perceived some risks and 22% no risks. Risk perception was not statistically different between subjects who did vs. did not read the brochure. Twenty-one percent who read the brochure perceived no risks vs. 32% who did not (p = 0.14). Educational level and income appeared to predict subjects' ability to recognize procedure-related risks overall, however this was statistically significant only for selected risks (adverse reaction to sedation and perforation; p = 0.006 and p = 0.003, respectively for educational level beyond high school and p = 0.28 and p = 0.04, respectively for annual income above $20,000). In multivariate analysis, only educational level remained statistically significant. Conclusion: In a survey study of 295 veterans undergoing colonoscopy, more than 1 in 5 of subjects had the perception that this invasive procedure entailed no significant risks. Passive educational approaches, such as mailed brochures, may not be maximally effective in educating patients prior to colonoscopy. Data from this subject population suggest that future refinements in procedure-related risk education should take socioeconomic status into account with respect to information processing.

Determining whether delayed nonarteritic ischemic optic neuropathy associated with cataract extraction is a true entity

To evaluate cases of delayed nonarteritic anterior and posterior ischemic optic neuropathy after cataract extraction and to evaluate the need for centralized prospective reporting of nonarteritic ischemic optic neuropathy after cataract extraction. Neuro-ophthalmology Clinics, University of Colorado Health Sciences Center and Denver Veterans Affairs Medical Center, Denver, Colorado, USA. A retrospective review of all patients referred to the Neuro-ophthalmology Divisions, University of Colorado Health Sciences Center and Denver Veterans Affairs Medical Center, from January 2001 to October 2005 was performed. All patients with a diagnosis of nonarteritic anterior or posterior ischemic optic neuropathy were identified. Patients with ischemic optic neuropathy that occurred between 2 months and 12 months after cataract extraction were selected for evaluation. Six eyes with nonarteritic ischemic optic neuropathy that occurred 2 to 6 months after cataract extraction in 4 patients (2 bilateral nonarteritic ischemic optic neuropathy) and 1 eye with nonarteritic ischemic optic neuropathy that occurred after 6 months in 1 patient were identified. One patient had nonarteritic ischemic optic neuropathy in 1 eye 3 months after cataract extraction and 4 years later had nonarteritic ischemic optic neuropathy in the fellow eye 5 months after cataract extraction. Follow-up after the last cataract extraction was 1 to 3 years for all patients. Although an association between cataract extraction and delayed nonarteritic anterior and posterior ischemic optic neuropathy has been suggested, current data do not support a causal relationship. In addition, the window of postoperative susceptibility for delayed ischemic optic neuropathy after cataract extraction is unclear.

Interstitial Lung Disease, Lung Cancer, Lung Transplantation, Pulmonary Vascular Disorders, and Sleep-disordered Breathing in AJRCCM in 2004

Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Denver Veterans Affairs Medical Center; Departments of Medicine and Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, Colorado; Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, Michigan; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland, United Kingdom

Excess Body Weight in Critically Ill Patients

Letters21 September 2004Excess Body Weight in Critically Ill PatientsJames M. O'Brien Jr, MD and Carolyn H. Welsh, MDJames M. O'Brien Jr, MDFrom Ohio State University, Columbus, OH 43210, and Denver Veterans Affairs Medical Center, Denver, CO 80220.Search for more papers by this author and Carolyn H. Welsh, MDFrom Ohio State University, Columbus, OH 43210, and Denver Veterans Affairs Medical Center, Denver, CO 80220.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-141-6-200409210-00027 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Drs. Schultz and Wolthuis raise questions about the technique for weight and BMI determination in our study. At study enrollment, study personnel recorded patient weights according to medical records. We presume that weight was most commonly recorded as a part of daily clinical care and that it was determined by using bed scales in the participating centers. Study personnel measured patient height to calculate predicted body weight and, subsequently, tidal volume. Although we acknowledge that the weight assessment was not subject to a rigorous protocol, we contend that any systematic measurement errors are unlikely. There is no reason ...Reference1. Bercault N, Boulain T, Kuteifan K, Wolf M, Runge I, Fleury JC. Obesity-related excess mortality rate in an adult intensive care unit: A risk-adjusted matched cohort study. Crit Care Med. 2004;32:998-1003. [PMID: 15071392] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Ohio State University, Columbus, OH 43210, and Denver Veterans Affairs Medical Center, Denver, CO 80220. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoExcess Body Weight Is Not Independently Associated with Outcome in Mechanically Ventilated Patients with Acute Lung Injury James M. O'Brien Jr. , Carolyn H. Welsh , Ronald H. Fish , Marek Ancukiewicz , Andrew M. Kramer , and Excess Body Weight in Critically Ill Patients Marcus J. Schultz and Esther K. Wolthuis Metrics Cited byAccuracy of weight and height estimation in an intensive care unit: Implications for clinical practice and research* 21 September 2004Volume 141, Issue 6Page: 485-486KeywordsBody mass indexBody weightLungsMortalityOverweightTidal volume ePublished: 21 September 2004 Issue Published: 21 September 2004 Copyright & PermissionsCopyright © 2004 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Factors influencing risk-adjusted patient satisfaction after coronary artery bypass grafting

Factors influencing risk-adjusted patient satisfaction after coronary artery bypass grafting

Principles of Behavioral and Cognitive Neurology, Second Edition

Principles of Behavioral and Cognitive Neurology, Second Edition

Efficient operation of a high-volume anticoagulation clinic.

A pharmacist-operated anticoagulation clinic at a Department of Veterans Affairs (VA) medical center is described. An anticoagulation clinic established by the pharmacy service at the Denver VA Medical Center cares for 600 patients by using 1.35 fulltime-equivalent pharmacists. The pharmacists are privileged by medical staff to write prescriptions for warfarin, adjust warfarin dosages, and conduct appropriate laboratory monitoring. A protocol has been developed to standardize care. Patients referred to the clinic are scheduled for a same-day warfarin class and laboratory so that International Normalized Ratios (INRs) are available for the patient's appointment with the pharmacist; the patient's understanding of the material presented in the class is assessed during this appointment. The pharmacist determines the therapeutic range and duration of treatment and schedules a follow-up appointment. A locally developed computer program imports patient data from the hospitalwide computer system and simplifies scheduling and tracking of patient-related information. At any point in time, approximately 67% of clinic patients are in the therapeutic range, 13% are above range, and 20% are below range. From January to December 1994, 1.1% of clinic patients were admitted to the medical center for bleeding compared with 2.0% of patients receiving usual care, and 0.9% of clinic patients had thromboembolic complications compared with 3.1% of usual care patients. A computer program, clinical privileging of pharmacists, and a clinic protocol have helped a pharmacist-operated anticoagulation clinic to provide efficient care to veterans.