Haley Veterans Research Articles

Improving Fecal Immunochemical Test Collection for Colorectal Cancer Screening During the COVID-19 Pandemic.

Colonoscopy is a first-line method for colorectal cancer (CRC) screening. However, cost-effective noninvasive tests, such as high-sensitivity guaiac-based fecal occult blood test (gFOBT) and fecal immunochemical test (FIT), are also used. The COVID-19 pandemic had a substantial negative impact on CRC screening rates. The James A. Haley Veterans Affairs Hospital (JAHVAH) continued socially distant CRC screening using FITs, but encountered inefficiencies due to high rates of incorrectly collected FIT samples. A quality improvement (QI) project was conducted to increase correctly collected and testable FIT kits upon initial laboratory submission. The ambulatory QI project sought out root causes for incorrectly returned FITs and proposed Plan-Do-Study-Act (PDSA) cycles based on a series of approved action plans. A multidisciplinary team of laboratory, nursing, administrative, and primary care staff worked together to discover 6 major root causes. Our multipronged PDSA cycle attempted to set up redundant patient reminders, centralize the FIT dispersal process, and make the patient-FIT interface more user-friendly. All PDSA solutions were implemented over 4 months. Lack of collection date was the most common reason for incorrectly returned FIT kits and the focus of PDSA improvements. The rate of FITs with missing collection dates dropped from 24% prior to PDSA to 14% in April 2021. The rate of correctly returned FIT kits rose from 38% before the project to 72% afterwards, surpassing the 20% improvement goal. FIT is a useful method for CRC screening that can be particularly helpful when in-person visits are limited, as seen during the COVID-19 pandemic. The increase in demand for FITs during the pandemic revealed process deficiencies and gave JAHVAH an opportunity to improve workflow.

Frequency and features of malignant tumors clinically mimicking cutaneous cysts: A retrospective chart review.

Many cutaneous lesions are clinically suspected as "cyst"; however, following histopathological examination, are found to be more significant lesions. Here, we examine the frequency and features of malignancies with cutaneous cysts in the clinical differential. A retrospective study of surgical pathology specimens at the James A. Haley Veterans' Hospital from January 2018 to December 2022 was conducted. Cutaneous specimens containing the clinical diagnosis of "cyst" were included. The clinicopathological features were summarized. Premalignant or malignant neoplasms accounted for 4.5% of all specimens submitted with cysts in the clinical differential. Most cyst-mimicking cancers were basal cell carcinoma (BCC) or squamous cell carcinoma (SCC); however, cancers with poorer prognoses, such as Merkel cell carcinoma and melanoma, also clinically masqueraded as cysts. The BCCs were predominately nodular, and the SCCs were largely well-differentiated and invasive. Many exhibited clinical signs and symptoms compatible with benign cysts, such as central punctum, pain, and rapid growth. Identified risk factors included history of prior non-melanoma skin cancer diagnosis, previous excision, and immunosuppression. Many lesions clinically concerning cutaneous cysts were found to be malignancies following histopathological review. Accordingly, following biopsy all cyst-like lesions should be examined microscopically, especially in certain clinical contexts in which the incidence of skin cancer is increased.

0666 Need a novel method to reduce anger after combat? Treat sleep apnea

Abstract Introduction Dysregulated anger can result in devastating health and interpersonal consequences for individuals, families, and communities. Compared to civilians, combat veterans and service members (C-V/SM) report higher levels of anger and often have risk factors for anger including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), pain, alcohol use, and impaired sleep. Methods The current study examined the relative contributions of established variables associated with anger (e.g., combat exposure, current PTSD symptoms, history of TBI, pain interference, and hazardous alcohol use) in 1,263 C-V/SM. Sleep impairments, represented by poor sleep quality and obstructive sleep apnea (OSA) risk, were also evaluated as potential mediators of the relationships between established risk factors and anger, and therefore potential modifiable treatment targets. Results Multiple regression model results revealed that PTSD symptoms (β = 0.517, p < .001), OSA risk (β = 0.057, p = .016), pain interference (β = 0.214, p < .001), and hazardous alcohol use (β = 0.054, p = .009) were significantly associated with anger. Results of the mediation models revealed that OSA risk accounted for associations between PTSD and pain interference with anger. Conclusion Treating OSA may be a novel way to reduce anger in C-V/SM who have PTSD and/or pain interference. The current study extends previous literature by simultaneously examining factors associated with anger using a multivariable model in a large sample of C-V/SM. Support (if any) This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense, through the Psychological Health/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium (LIMBIC) Award/W81XWH-18-PH/TBIRP-LIMBIC and with resources and the use of facilities at the James A. Haley Veterans’ Hospital. The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@mail.mil. UNCLASSIFIED

Prevalence of Antibiotic Allergy at a Spinal Cord Injury Center.

Infectious diseases are the most common reason for rehospitalization in patients with spinal cord injury (SCI). Persons with SCI are at high risk for antibiotic over-use and hospital-acquired infection due to chronic bacteriuria, frequent health care exposure, implanted medical devices, and other factors. We aimed to record the percentage of subjects from the local SCI registry with an antibiotic allergy, the most common antibiotic classes responsible for the allergy, and allergic reactions. We conducted a retrospective study at the James A. Haley Veterans' Hospital in Tampa, Florida, of patients in the SCI registry between October 1, 2015, and September 30, 2017. We collected patient demographics and SCI descriptors. The outcomes included antibiotic allergy and adverse drug reactions. Of 1866 patients, 1659 met inclusion criteria; 29.8% of the subjects had a recorded allergy to antibiotics. Penicillin (13.1%), sulfa drugs (9.6%), and fluoroquinolone (4.5%) were the most common allergens. However, only 11.9% of patients with a penicillin allergy had severe reactions. Almost 30% of patients with SCI had a recorded allergy to an antibiotic. There are opportunities to examine whether approaches to confirm true reactions, such as skin testing, would help mitigate unnecessary avoidance of certain antibiotic classes due to mild adverse effects, rather than a true allergy, in the SCI population. Differentiating true allergy is the only clear way to deter unnecessary avoidance of first-line therapies for antibiotic treatment and avoid promotion of antibiotic resistance.

Multi-Phase Veteran Engagement to Develop a Spinal Cord Injury Employment Survey.

Multi-Phase Veteran Engagement to Develop a Spinal Cord Injury Employment Survey Denise C. Fyffe, PhD, Bridget A. Cotner, PhD, Lisa Ottomanelli, PhD, Ashleigh Quinn, BS, Deveney Ching, MA, Conner T. Clark, BA, Paul J. Tobin, MSW, and John O'Neill, PhD What Is the Purpose of this Study/Review? • To adapt an employment survey for veterans living with spinal cord injury (SCI). • To describe the process and outcomes of actively engaging veterans living with SCI in the revision of an employment survey. What Is the Problem? • Seeking, obtaining, and maintaining employment are some of the most difficult economic challenges reported by persons living with an SCI. • Few SCI employment studies have examined striving to work strategies used by veterans with SCI to overcome employment barriers. • Although there are employment surveys for people living with disabilities, none exist for veterans living with an SCI. • This project will adapt an existing employment survey to better understand the employment experiences of veterans living with SCI who are striving to work. What Are the Findings? • Veterans described the following barriers looking for and at work: 1) concern about losing government assistance or benefits; 2) employers assumed you cannot do the job because of your disability; and 3) negative attitudes on the part of supervisors and co-workers. • Veterans described the following ways to overcome barriers: 1) strong social networks; 2) supportive supervisors and co-workers; and 3) strategies to manage and prevent medical complications. • Engaging veterans in multiple phases informed the revisions of an employment survey about the lived experience of veterans seeking, obtaining, and maintaining employment after a SCI. Who Should Care Most? • Veterans living with a SCI. • Employers of veterans living with SCI. • Vocational rehabilitation service employees. • Rehabilitation researchers and clinicians interested in using a veteran-centered approach to improve employment outcomes of veterans living with SCI. [End Page e3] Recommendations for Action • Engage veterans living with SCI throughout the research process, from planning to disseminating, to improve survey tools and other outcomes. • The strategies used in this study to engage veterans living with SCI may be applied to research with other disability groups: 1) involve existing stakeholder groups, 2) create a study-specific engagement group, and 3) collaborate with participants to inform study procedures and materials. [End Page e4] Denise C. Fyffe Kessler Foundation New Jersey Medical School Rutgers, the State University of New Jersey Bridget A. Cotner James A. Haley Veterans' Hospital and Clinics Department of Anthropology, University of South Florida Lisa Ottomanelli James A. Haley Veterans' Hospital and Clinics Rehabilitation and Mental Health Counseling Program, Department of Child and Family Studies, College of Behavioral and Community Sciences, University of South Florida Ashleigh Quinn Kessler Foundation Deveney Ching James A. Haley Veterans' Hospital and Clinics Conner T. Clark Kessler Foundation Paul J. Tobin Quality of Life Advisors John O'Neill Kessler Foundation New Jersey Medical School Rutgers, the State University of New Jersey Copyright © 2023 Johns Hopkins University Press

Principal Component Analysis of the Traumatic Brain Injury Rehabilitation Needs Survey: Comparison of Three Models

<h3>Research Objectives</h3> To examine the higher-order structure of the Rehabilitation Needs Survey (RNS) and explore the internal consistency of the identified components. <h3>Design</h3> Principal Components Analysis; Cohort study. <h3>Setting</h3> Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. <h3>Participants</h3> Persons enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) who completed a five-year post-TBI follow-up interview (N=378; 96% male, age M=34.8; SD=14.0). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> RNS. <h3>Results</h3> The Kaiser Criterion resulted in a four-component solution with only three components containing ≥ 3 items (Cronbach alphas 0.837 to 0.900). The scree plot method resulted in a two-component solution with both containing ≥ 3 items (Cronbach alphas 0.826 to 0.901). Parallel analysis resulted in a three-component solution, all containing ≥ 3 items (Cronbach alphas 0.608 to 0.901). Twenty of the 21 items had acceptable corrected item-total correlations. The average corrected item-total correlations were 0.589 (range 0.224 to 0.715), 0.593 (range 0.434 to 0.712), and 0.602 (range 0.378 to 0.573) across the 4-, 2-, and 3-component solutions, respectively. There were between 7-9 cross-loading items depending on the model. Overall, items loaded on to components representing Activities/Participation and Body Functioning domains consistently and Vocation/Productivity inconsistently. <h3>Conclusions</h3> The three-component solution of the RNS appeared to be the clinically useful model that accounted for all 21 items with at least three items and minimally acceptable internal consistency. Although there were several cross-loading items, they refer to complex rehabilitation needs that are influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination. <h3>Author(s) Disclosures</h3> Funding: GDIT subcontract from DHA (Richardson [HT0014-21-C-0012]) and NIDILRR (O'Neil-Pirozzi, [#90DPTB0011], Walker, [#90DP0033]). This research was conducted with James A. Haley Veterans' Hospital resources and use of facilities. The views and/or findings are those of the authors and not official policy of the U.S. Departments of Defense, Veterans Affairs, Defense Health Agency, or any other federal agency. No official endorsement should be inferred.

Establishing a Hospital Artificial Intelligence Committee to Improve Patient Care.

The use of artificial intelligence (AI) in health care is increasing and has shown utility in many medical specialties, especially pathology, radiology, and oncology. Many barriers exist to successfully implement AI programs in the clinical setting. To address these barriers, a formal governing body, the hospital AI Committee, was created at James A. Haley Veterans' Hospital in Tampa, Florida. The AI committee reviews and assesses AI products based on their success at protecting human autonomy; promoting human well-being and safety and the public interest; ensuring transparency, explainability, and intelligibility; fostering responsibility and accountability; ensuring inclusiveness and equity; and promoting AI that is responsive and sustainable. Through the hospital AI Committee, we may overcome many obstacles to successfully implementing AI applications in the clinical setting.

PTSD Treatment Algorithm Suggests First Targeting Sleep Problems

Back to table of contents Previous article Next article Annual MeetingFull AccessPTSD Treatment Algorithm Suggests First Targeting Sleep ProblemsNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:4 Aug 2022https://doi.org/10.1176/appi.pn.2022.08.8.11AbstractAlmost all people with PTSD have nightmares or underlying sleep problems, which if alleviated can help in the treatment of other symptoms including hyperarousal and avoidance.When it comes to alleviating symptoms of posttraumatic stress disorder (PTSD), physicians should prioritize treating patients’ sleep problems, said members of the Harvard South Shore Psychopharmacology Algorithms Project at this year’s Annual Meeting.“PTSD is intimately associated with sleep disturbances,” said David Osser, M.D., an associate professor of psychiatry at Harvard Medical School. He noted that about 90% of people with PTSD have some co-occurring sleep problems, frequently involving disturbed sleep due to nightmares or night terrors.Osser is the general editor of the Algorithms Project, an effort to speed the adoption of evidence-based pharmacotherapy into routine patient care. Osser and his team periodically conduct systematic reviews of the available evidence on the safety and efficacy of medications used for specific conditions. The most recent PTSD psychopharmacology algorithm developed by Osser and colleagues was finalized in 2021 and replaces an algorithm that was developed in 2011.After screening patients thoroughly for such problems as sleep apnea or a TBI-related sleep problems, physicians should consider starting patients on the antihypertensive medication prazosin, said Laura Bajor, D.O., a psychiatrist with the James A. Haley Veterans' Hospital in Tampa and lead editor of the updated PTSD psychopharmacology algorithm.While a trial of 300 veterans published in 2018 did not find prazosin to be more effective than placebo in reducing nightmares and increasing the quality of sleep (“Study Raises Questions About Effectiveness of Prazosin for PTSD-Related Sleep Disorders”), several smaller trials have found the drug to be effective for some patients, Bajor said. Studies suggest that people with elevated blood pressure are more likely to respond to prazosin, while those who drink alcohol or have suicidal thoughts are less likely, she said.Doses of prazosin may need to be as high as 20 mg/night for males and 10/mg per night for females to be effective, she continued. The updated algorithm includes a 36-day titration guideline to reach these levels from the initial dose of 1 mg per night. Patients should be monitored closely during the first month to keep track of emergent side effects including dizziness, fatigue, or chest pain.If prazosin does not work or is not available, physicians can consider the related hypertensive doxazosin for patients with PTSD who are experiencing nightmares. Though not as effective at crossing the blood-brain barrier as prazosin, Osser said some physicians favor doxazosin since it has a more gradual onset of action, which reduces the risk of severe hypotension following ingestion. Doxazosin also has a longer half-life (17 hours) compared with prazosin (5 hours), which means a dose taken at night might still have some effects the following day and possibly reduce daytime stress.If a patient presents with insomnia but no nightmare disorder or continues to experience insomnia symptoms following the resolution of nightmare symptoms, physicians should consider trazodone or hydroxyzine to help patients fall asleep, Bojar said. She recommended against prescribing tricyclic antidepressants, benzodiazepines, or quetiapine for sleep problems due to their side-effect profiles.Bajor said that improving sleep should be a priority because it can impact all other aspects of PTSD treatment. “We know that psychotherapies are highly effective,” she said, reiterating that the PTSD algorithm only assists with the selection of medications as part of multimodal treatment plan. “But if your patient is only sleeping two or three hours a night, they are not in the ideal state to benefit from these interventions.”Reducing a patient’s sleep problems may ameliorate daytime PTSD symptoms including arousal or irritability without the need of further medications, Bajor said. If not, the algorithm recommends prescribing the antidepressants sertraline or paroxetine, which have been approved by the FDA approved for these symptoms).In cases where a patient with PTSD is experiencing severe psychotic symptoms, both experts recommended these symptoms be treated first with antipsychotics, before addressing sleep issues. The updated algorithm suggests treating such patients with risperidone, as it has the most evidence of benefit in PTSD patients. Another good option is aripiprazole, which may result in fewer side effects for patients. ■ ISSUES NewArchived

Single-center Veterans Hospital Heart Failure Study: Heart Failure Readmissions And New-York Heart Association (NYHA) Class Related To Increased Mortality

Background Currently, more than 6.2 million individuals in the United States are diagnosed with congestive heart failure (CHF). CHF readmission rates are associated with higher mortality rates and economic burden. After a hospitalization for decompensated heart failure, the 30-day, 1-year, and 5-year mortality rates are 10%, 20-30% and 42-50%, respectively. By 2030, the cost for CHF is predicted to be around 70 billion dollars per year. Methods Retrospective chart review was completed on patients admitted at James A. Haley Veterans Hospital in Tampa, Florida for a CHF admission between 1/1/20 to 7/31/20. Predictors of overall survival (OS), including readmission status and comorbid conditions, were assessed using the Cox proportional hazards multivariate regression analysis. Hazard ratio (HR) and 95% confidence intervals (95% CI) were reported. The OS was calculated from first admission to last follow up or death. Patients were stratified into two groups based on CHF readmission status. There was a total of 100 patients in the study. Results The non-readmission group had on average longer OS duration (mean: 275 days, 95% CI: 260 to 290) compared to readmission group (mean: 230 days, 95% CI: 193 to 268) (p value: 0.01). Patients discharged on guide-line directed medical therapy (GDMT) with beta-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker had superior OS (HR: 0.27, 95% CI: 0.10-0.74). In Cox proportional hazards multivariate regression analysis, the patients with higher NYHA class (HR: 2.59, 95% CI: 1.03 to 6.52) and patients who were re-admitted (HR: 0.21, 95% CI: 0.07 to 0.60) experienced poor OS. Conclusions : Readmission and higher NYHA class were related to lower OS. These results highlight the need to implement quality improvement measures to prevent readmissions in addition to utilizing GDMT. Quality improvement measures aimed at identifying these high-risk patients and initiating early intervention may improve overall outcomes. Currently, more than 6.2 million individuals in the United States are diagnosed with congestive heart failure (CHF). CHF readmission rates are associated with higher mortality rates and economic burden. After a hospitalization for decompensated heart failure, the 30-day, 1-year, and 5-year mortality rates are 10%, 20-30% and 42-50%, respectively. By 2030, the cost for CHF is predicted to be around 70 billion dollars per year. Retrospective chart review was completed on patients admitted at James A. Haley Veterans Hospital in Tampa, Florida for a CHF admission between 1/1/20 to 7/31/20. Predictors of overall survival (OS), including readmission status and comorbid conditions, were assessed using the Cox proportional hazards multivariate regression analysis. Hazard ratio (HR) and 95% confidence intervals (95% CI) were reported. The OS was calculated from first admission to last follow up or death. Patients were stratified into two groups based on CHF readmission status. There was a total of 100 patients in the study. The non-readmission group had on average longer OS duration (mean: 275 days, 95% CI: 260 to 290) compared to readmission group (mean: 230 days, 95% CI: 193 to 268) (p value: 0.01). Patients discharged on guide-line directed medical therapy (GDMT) with beta-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker had superior OS (HR: 0.27, 95% CI: 0.10-0.74). In Cox proportional hazards multivariate regression analysis, the patients with higher NYHA class (HR: 2.59, 95% CI: 1.03 to 6.52) and patients who were re-admitted (HR: 0.21, 95% CI: 0.07 to 0.60) experienced poor OS. : Readmission and higher NYHA class were related to lower OS. These results highlight the need to implement quality improvement measures to prevent readmissions in addition to utilizing GDMT. Quality improvement measures aimed at identifying these high-risk patients and initiating early intervention may improve overall outcomes.

Rate of Posterior Capsule Rupture in Phacoemulsification Cataract Surgery by Residents with Institution of a Wet Laboratory Course

Abstract Purpose To determine if a structured surgical wet laboratory curriculum for ophthalmology residents reduced the rate of posterior capsule rupture (PCR) in phacoemulsification cataract surgery. Setting James A. Haley Veterans' Hospital, Tampa, FL. Design Retrospective cohort study. Methods The study assessed resident-performed phacoemulsification cataract cases from 2011 to 2017, after the creation of a wet laboratory course. Primary outcome measure was PCR. If present, timing of complication, dropped lens fragments, and the need for anterior vitrectomies were noted. Self-reported rates of PCR prior to institution of a wet laboratory course (2010–2011) were compared with cases done by residents who completed the course (2011–2017). Results A total of 3,445 cases were reviewed of which 2.44% (84 cases) noted PCR. Of these, 19% (16) had dropped lens fragments, and 60.7% (51) required anterior vitrectomy. Sixty-nine cases documented timing of PCR with the majority, 58%, occurring during phacoemulsification. When comparing rates of PCR in cases done prior to the presence of a wet laboratory course versus after, there was a significant reduction observed (5.20% before vs. 2.44% after). Conclusion In the presence of a wet laboratory curriculum, the rate of PCR decreased dramatically. The average rate was lower than those reported at other training programs (2.6–9.9%). Most PCR occurred during phacoemulsification, suggesting need for further focused instruction in this step.

Development and Evolution of a Comprehensive Mild Traumatic Brain Injury Inpatient Rehabilitation Program: A Nursing Perspective.

The James A. Haley Veterans' Hospital in Tampa, Florida has developed an innovative approach to the unique rehabilitation needs of active duty Special Operations Forces (SOF) and veterans with chronic conditions related to their military service. Tampa's program, the Post-Deployment Rehabilitation and Evaluation Program (PREP), was established in 2008. The interdisciplinary team includes one nurse practitioner and eight staff registered nurses. The Veterans Health Administration (VHA) is using Tampa's established and successful PREP as a model to actively expand the program to other Veterans Administration (VA) Polytrauma Rehabilitation Centers over the next several years. There are several important nursing and rehabilitation team considerations for the successful development of these mild traumatic brain injury (mTBI) inpatient rehabilitation programs.

Using Deep Learning for Whole Slide Image Prostate Cancer Diagnosis and Grading in South Florida Veteran Population

Abstract Introduction/Objective Prostate cancer is the most common non-cutaneous malignancy in veterans, with approximately 11,000 new prostate cancer cases diagnosed in the Veteran’s Affairs system each year. Prostate cancer diagnosis and grading can be challenging even for experienced pathologists. Although large VA medical centers have pathologists that specialize in urologic pathology, the vast majority have not. We hypothesized that the AI-augmented diagnosis and grading may provide the solution for such situations. Methods/Case Report Dataset consisted of 10,000 prostate biopsy whole slide images (WSI) from the Kaggle PANDA challenge, and 6,000 WSI from the James A. Haley Veterans’ Hospital. Two Classification models were trained on the combined Kaggle and VA datasets using whole slide labels, and not annotated slides that resemble semi-supervised training. Two-Class Classification to predict Benign: ISUP [0] / Cancerous: ISUP [1,2,3,4,5] Three-Class Classification to predict Benign: ISUP [0] / Low-grade: ISUP [1,2] / High-grade: ISUP [3,4,5] WSI split into “tiles” were used for training the models to reduce whitespace around samples, manage large images, and normalize dimensions/orientations. Results (if a Case Study enter NA) Models trained purely as binary and 3-class classifiers performed very well. Two-Class Model: Accuracy = 0.937 Precision = 0.965 F1 = 0.94 AUC = 0.979 Three-Class Model: Accuracy 0.89 o Benign: Precision=0.897 f1=0.928 o Low-grade: Precision=0.866 f1=0.841 o High-grade: Precision=0.91 f1=0.878 We plan to develop multi-stage prediction models using these 2-Class and 3-Class classifiers as the first stage and a cancer grade predictor in the second stage. Conclusion We successfully showed that AI can augment pathologist’s diagnosis and grading of prostate cancer.

Outcomes of the Suicidal Ideation Assessment Protocol Decision Tree Responses from the Tampa VA TBI Model Systems Research Study

<h3>Research Objectives</h3> To describe participant outcomes from implementation of the Suicidal Ideation Assessment Protocol (SIAP) as a tool for non-clinical research staff to appropriately assess and respond to suicide risk. <h3>Design</h3> Descriptive. <h3>Setting</h3> James A. Haley Veterans Affairs Polytrauma Rehabilitation Center. <h3>Participants</h3> N=155 participant follow-up interviews. <h3>Interventions</h3> Tampa VA TBIMS data collectors implemented the SIAP decision tree in response to participant endorsements of SI on the Patient Health Questionnaire (PHQ-9), a brief self-report rating scale to screen for depression (e.g. "thoughts that you would be better off dead or hurting yourself in some way"), on the Pain Catastrophizing Scale (PCS), a self-report scale that measures trait pain catastrophizing (e.g. "I feel my life isn't worth living"), or through sporadic comments about death or suicide during remote follow-up telephone interviews. <h3>Main Outcome Measures</h3> SIAP as a tool for non-clinical research staff, percentage of participants who endorsed SI during follow-up interviews, and percentage of participants who accepted VCL resources or declined VCL resources because they already had, or did not want them. <h3>Results</h3> Data collectors conducted 155 interviews. 27 participants (17.42%) endorsed SI and were offered the VCL call and text numbers. 10 participants (37.04%) accepted VCL resources, 17 participants (62.96%) declined VCL resources, and 1 participant was transferred to the VCL. The PCS alone had the highest number of SI endorsements (n=8), followed by the PHQ-9 alone (n=7), and both the PCS and PHQ-9 (n=7). <h3>Conclusions</h3> Implementation of the SIAP and referral to VCL resources demonstrates the feasibility and importance of the decision tree for data collectors involved in research with high risk populations. <h3>Author(s) Disclosures</h3> Financial Disclosures: None. This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans' Hospital. Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@mail.mil.

Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study.

BackgroundOver the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation.ObjectiveThe proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery.MethodsThis study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans’ Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants’ bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome.ResultsThis study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted.ConclusionsOur next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients’ rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people’s own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home.International Registered Report Identifier (IRRID)PRR1-10.2196/26133

Improving Inpatient Tobacco Treatment Measures: Outcomes Through Standardized Treatment, Care Coordination, and Electronic Health Record Optimization.

The Centers for Disease Control and Prevention states that tobacco use is the largest and most preventable cause of disease and mortality in the United States. The Joint Commission implemented inpatient tobacco treatment measures (TTMs) in 2012 to encourage healthcare systems to create processes that help patients quit tobacco use through evidence-based care. A tobacco cessation care delivery system was implemented at James A. Haley Veterans' Hospital and Clinics, which included: standardized pathways within the Veterans Health Administration (VHA) electronic health record system to improve nicotine replacement therapy ordering; evidence-based tobacco cessation counseling; and improved care coordination for tobacco cessation treatment through the use of technological innovation. Outcomes were obtained from the VHA quality metric reporting system known as Strategic Analytics for Improvement and Learning (SAIL). TOB-2 and TOB-3 (two Joint Commission inpatient TTMs) equivalent to tob20 and tob40 within SAIL improved by greater than 300% after implementation at James A. Haley Veterans' Hospital and Clinics. Implementation of a tobacco cessation care system at James A. Haley Veterans' Hospital and Clinics enhanced interdisciplinary coordination of tobacco cessation care and resulted in improvements of The Joint Commission inpatient TTMs by greater than threefold.

Impact of Comorbid PTSD on Outcome of Repetitive Transcranial Magnetic Stimulation (TMS) for Veterans With Depression.

A recent randomized controlled trial of repetitive transcranial magnetic stimulation (TMS) for major depressive disorder (MDD) in veterans raised the question of whether comorbid posttraumatic stress disorder (PTSD) negatively impacted the outcome of TMS in veterans. To address this, a quality database was analyzed to compare outcomes of MDD treated with TMS in veterans with and without comorbid PTSD. The clinical outcomes of all consecutive veterans with MDD treated with TMS at the James A. Haley Veterans' Hospital as outpatients from October 2013 through September 2018 were included. Patients were initially evaluated by an experienced psychiatrist, and the diagnosis of MDD was made by clinical evaluation per DSM-IV-TR/DSM-5 criteria. At the start of treatment, after every 5 treatments, and at the end of treatment, patients were assessed with self-report and clinician-rated scales of depression. All data were abstracted from an existing quality database. Among the 118 patients treated with TMS for depression, 55 (47%) had comorbid PTSD and 63 (53%) had no comorbid PTSD. Response and remission rates by score on the Montgomery-Asberg Depression Rating Scale were similar between patients with PTSD (52.5% and 40.9%, respectively) and without PTSD (53.8% and 35.6%, respectively). No seizures or persistent adverse effects were observed or reported in either group. Comorbid PTSD did not impact the outcome of TMS for depression in this sample of veterans. Future studies should include formal ratings of PTSD to determine if the severity of PTSD affects the outcome.

0667 Positive Airway Pressure Non-Adherence Interacts With Post-Traumatic Stress Disorder to Increase Risk of Back Pain

Abstract Introduction Altered sleep, as is associated with obstructive sleep apnea (OSA), may increase the risk of back pain (BP). However, little to no evidence regarding the effect of OSA on musculoskeletal pain is currently available, let alone the effect of positive airway pressure (PAP) treatment non-adherence. The purpose of this analysis is to investigate the effect of PAP non-adherence on future BP diagnosis. Methods A sample of 1,662 veterans who had a sleep study between January 2003 and October 2006 and receiving PAP treatment for OSA were used for analysis. Measures at baseline included demographic and OSA symptom severity data. Up to 3 weeks of PAP adherence data were collected and patient chart data was collected through May 2010 to determine outcomes. Time was calculated from PAP treatment start to BP diagnosis or censoring, which occurred at date of death or last recorded encounter. Survival analysis was conducted to obtain the hazard ratios (HR) for the effect of PAP non-adherence on BP diagnosis and to investigate whether post-traumatic stress disorder (PTSD) is an effect modifier of this relationship. Results PAP treatment non-adherence significantly increased the risk of BP diagnosis (HR 1.88 [95% CI: 1.08, 3.27]) among veterans with PTSD, while non-adherence among veterans without PTSD was not a statistically significant risk factor. Relative excess risk due to interaction (RERI) was 0.97 (95% CI: -0.07, 2.02; p-value=0.068). These estimates are independent of age, sex, race, body mass index, apnea severity (based on Apnea-Hypopnea Index), PTSD diagnosis, income level, and marital status. Conclusion PAP treatment non-adherence among veterans with PTSD appears to result in a significant increase in risk of future BP diagnosis. The interaction between PAP non-adherence and PTSD appears to be borderline synergistic. Therefore, improving PAP adherence among veterans with PTSD may decrease risk of future BP diagnosis. Support This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

0806 Prescription Correlates of Nightmare Disorder Among Veterans

Abstract Introduction In the James A. Haley Veterans Administration (JAHVA) Vista database, the ICD-9 code 307.47 for Nightmare disorder (ND) is infrequently used and appears independently of codes for PTSD. We wanted to determine if certain drugs that may affect sleep are associated with ND. Methods All patients with ND visiting JAHVA between 2007 and 2011 were selected along with control patients who visited JAHVA on one of 20 random days, one day each quarter year. Controls were assigned an index date reflecting their selection quarter. Associations with prescriptions for opioids, antidepressants (SSRI’s, SSNI’s, Tricyclics), antihistamines and benzodiazepine/Z-drugs were initially investigated. Two analyses were performed: risk factor analysis- patients with ND diagnosis dates (cases) or index dates (controls) prior to 2008 were excluded and only prescription dates that preceded the ND diagnosis or index date were considered; treatment analysis- cases and controls with a ND diagnosis date or index date after 2010 were excluded and only prescription dates that were subsequent to the ND diagnosis or index date respectively were considered. Logistic regression adjusting for age, gender, race and Hispanic ethnicity was used to determine the association between drug groups and ND. Results In risk factor analysis (667 cases, 14,739 controls), opioids and antihistamines were significantly less prevalent among would-be ND patients than controls (OR=0.627 and 0.610 respectively); no drug group was predictive of ND. In contrast, all drug groups were significantly associated with ND in treatment analysis (803 cases, 15,530 controls). The strongest associations were seen with benzodiazepine (OR=3.026; 95% CI: 2.472, 3.703) and SSRI (OR=2.789; 95% CI=2.316, 3.358) prescriptions. Conclusion Our data suggest that some JAHVA providers may be treating ND with medication, most notably with benzodiazepines/Z-drugs and antidepressants. The role of anti-histamine and opioid prescriptions needs further elucidation. The ramifications of these treatment decisions should be explored. Support This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

0816 Sleep Correlates Of Nightmares Among Veterans

Abstract Introduction There is an increased prevalence of Nightmare disorder (ND) among patients with obstructive sleep apnea (OSA). A further investigation of objectively measured sleep parameters among patients with and without ND could inform on potential comorbidities. We hypothesize ND correlates with Epworth sleepiness scale (ESS), apnea hypopnea index (AHI), Trough 02% (Sp02 nadir), and periodic limb movement (PLM) index. Methods Data presented herein are interim results from an IRB approved study to determine correlates and sequelae of nightmares. A cohort of all patients with ND visiting James A Haley Veterans Hospital between 2007 and 2011 was defined along with a random cohort of control patients. Demographic and outpatient visit data between January 2006 and April 2016 was pulled from VISTA for both the ND and control cohorts, and patients who had undergone a sleep study were identified. To date, sleep summary data has been individually extracted for 111 ND patients and 835 control patients. Logistic regression (SAS 9.4) was used to compare ESS, AHI, Sp02 nadir, and PLM Index. Results Mean age for ND was significantly lower at 49.7 ± 14, compared to 58.4 ± 12 for controls. Other demographic measures were similar including gender, race, and marital status. PLM index was significantly lower in ND compared to controls, however this relationship disappeared after adjusting for age. There were neither significant differences between other polysomnographic (PSG) variables, specifically AHI and Sp02 nadir, nor did OSA severity significantly different between ND and controls. Conclusion Among veterans undergoing a PSG, there were no significant differences between measured sleep parameters. Our results contradict our hypothesis that ND correlates with ESS, AHI, Sp02 nadir, and PLM index. Support This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans’ Hospital.

A virtual reality intervention for fear of movement for Veterans with chronic pain: protocol for a feasibility study

BackgroundA key concern for people with chronic pain is experiencing increased pain and/or re-injury. Consequently, individuals with chronic pain can develop a maladaptive fear of movement that leads to adverse functional consequences. A primary goal of chronic pain rehabilitation is re-engagement in feared movements through exposure. This is often challenging since safe movement can be uncomfortable. Virtual environments provide a promising opportunity to safely and gradually expose Veterans to movements that are avoided in the real world. The current study will utilize multiple virtual reality (VR) applications (APPs) of varying the intensity levels ranging from passive distraction from pain to active exposure to feared movement. The primary aims of this pilot are to examine VR as an adjunctive nonpharmacological intervention to assist with the adoption and implementation of skills to decrease fear of movement and increase overall functioning among Veterans with chronic pain. Second, to build a hierarchy of VR APPs to assist in gradual exposure to feared movements.MethodsThis study will be conducted in the Chronic Pain Rehabilitation Program (CPRP) at the James A. Haley Veterans Hospital, a unique inpatient program within the VA system. Participants will include up to 20 Veterans who receive a VR intervention as part of their physical therapy. A rating form containing qualitative and quantitative experiences will be administered following each VR session to assess feasibility and to provide descriptive information for the proposed hierarchy. Effect sizes will be calculated from intake and discharge measures for the primary outcome fear of movement and secondary pain and functional outcomes.DiscussionThis study will inform the feasibility of a randomized controlled trial examining the clinical utility of using VR to reduce fear of movement and increase function among Veterans with chronic pain. VR has the advantage of being easily implemented both within VA healthcare settings as well as in Veterans’ own residences, where engagement in ongoing self-management approaches is often most challenging. Presumably, VR that is matched to patient needs, progresses in intensity, immerses Veterans in the applications, and is perceived positively by Veterans, will result in positive functional outcomes.