North Texas Health Care System Research Articles

Impact of VA Hematology/Oncology Clinical Pharmacy Practitioners in the Review of Community Prescriptions for Specialty Medications.

Within the US Department of Veterans Affairs (VA), eligible veterans can receive covered health care through the community care network. Many prescriptions for specialty medications made by community care prescribers are filled by outpatient VA pharmacies. Trained hematology/oncology clinical pharmacy practitioners (CPPs) review specialty medication prescriptions from community-based prescribers. This study's primary objective was to evaluate clinical interventions initiated by hematology/oncology CPPs at the Veterans Affairs North Texas Health Care System (VANTHCS) during their review of hematology/oncology specialty prescriptions from community care prescribers. A retrospective chart review of VANTHCS patients enrolled in the community care program with a specialty hematology/oncology prescription received and reviewed by a VA clinical hematology/oncology CPP was conducted for records from January 1, 2015, to June 30, 2023. The primary outcome was the number and types of clinical interventions. Secondary outcomes include the number of interventions accepted and/or denied by the prescriber and the financial implications of these interventions. Two hundred twenty-one specialty hematology/oncology prescriptions met the study inclusion criteria. VANTHCS hematology/oncology CPPs completed clinical interventions for 82 prescriptions (37%). Among those prescriptions, CPPs documented 97 clinical interventions. The most commonly documented interventions included managing/preventing a drug interaction (26%) and dose adjustment requests (25%). Hematology/oncology CPPs at VANTHCS are essential in reviewing anticancer medication prescriptions from community-based practitioners ; CPPs completed clinical interventions for more than one-third of the prescriptions and prescribers approved most of these interventions.

Effect of pregabalin initiation on diuretic requirements in patients with chronic heart failure

BackgroundLiterature on pregabalin use in patients with heart failure is largely limited to patient case reports and cohort studies. ObjectiveThis study aimed to evaluate the effect of pregabalin initiation on diuretic requirements in patients with heart failure. MethodsA retrospective analysis of patients with heart failure who were started on pregabalin between January 1, 2014, and September 1, 2021, at the Veterans Affairs North Texas Health Care System was used. The primary objective was to determine the median change in loop diuretic dose, in furosemide dose equivalents, 6 months after pregabalin initiation. ResultsOf 58 patients analyzed, there was no statistically significant difference in the primary outcome (P = 0.162). The secondary outcomes were found to be nonstatistically significant, and there was no correlation between pregabalin dose and outcomes. ConclusionThis represents the largest analysis of diuretic dose requirements in patients with heart failure after initiation of pregabalin. Although there was no difference in the median change of diuretic dose prescribed, pregabalin should still be used with caution.

Cardiovascular Safety of Amphetamine/Dextroamphetamine versus Methylphenidate in Older Adults

Background: Recent epidemiological data has shown a sharp increase in stimulant use among older adults, which is notable as older adults may be especially vulnerable to their cardiovascular effects. Results of recent studies have shown an increase in cardiovascular events among older adults using stimulants; however, little data exists comparing cardiovascular safety of these agents head-to-head. Objective: To determine if the incidence of serious cardiovascular events, including myocardial infarction (MI), stroke/transient ischemic attack (TIA), or arrhythmia, are different in patients taking amphetamine/dextroamphetamine compared with patients taking methylphenidate. Methods: Retrospective chart review of veterans 50 years and older at the Veterans Affairs North Texas Health Care System (VANTHCS) who were first prescribed a stimulant between 2015 and 2021. The primary outcome was the difference in composite cardiovascular events between amphetamine/dextroamphetamine and methylphenidate. Secondary outcomes were the composite cardiovascular endpoints compared individually (MI, stroke/TIA, or arrhythmia). Hazard ratios were calculated based off of a time-to-event analysis displayed using a Kaplan-Meier curve for primary and secondary outcomes. Results: 466 veterans were screened for inclusion, 30 were excluded, and 436 were included. There was no difference found in composite cardiovascular events between the 241 veterans in the amphetamine/dextroamphetamine group and the 195 veterans in the methylphenidate group with 12 (5%) vs 8 (4.1%) events respectively (P = .6635). There was also no difference in time-to-event analysis (P = .4966). Conclusion: In elderly veterans, there was no difference found in incidence of major cardiovascular events with the use of amphetamine/dextroamphetamine compared with methylphenidate.

Editorial introductions.

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Matthew A. CiorbaMatthew A. CiorbaDr Matthew Ciorba is a gastroenterologist and biomedical researcher dedicated to advancing care in the Inflammatory Bowel Diseases (IBD) and Colon Cancer. His clinical expertise is in caring for patients with Crohn's and ulcerative colitis and preventing colon cancer. He is Director of the IBD Center at Washington University, USA, and leads one of the largest clinical teams in the USA dedicated to providing comprehensive and cutting-edge clinical care to more than 8000 patients affected by IBD. His basic-translational research program is dedicated to defining pathways and mechanisms of intestinal inflammation and the transition to colon cancer. His lab has developed methods to study intestinal organoids and tumoroids to facilitate studies of the epithelial response to inflammation, injury and repair. His lab investigations have spawned four ground-breaking Bench-to-Bedside clinical trials addressing unmet patient needs in colitis, enteritis and rectal cancer using probiotics, novel immunotherapies and manipulating bile acids. In addition to his own lab, Dr Ciorba is also Director of IBD Research at Washington University and use this platform to foster collaborative discovery between the world-class scientific investigators and the robust IBD clinical program. Finally, he is deeply committed to training the next generation of medical investigators who will advance discovery and treatment of digestive diseases. Supporting this mission, he serves as Associate Director of the GI Fellowship's T32 Research Training grant and serves on several training grant review committees for several organizations including the CCF, AGA and NIH. Stuart J. SpechlerStuart J. SpechlerStuart Jon Spechler, MD is Chief of the Division of Gastroenterology and Co-Director of the Center for Esophageal Diseases at Baylor University Medical Center at Dallas, as well as the Co-Director of the Center for Esophageal Research at the Baylor Scott and White Research Institute. Prior to joining Baylor University Medical Center in January 2017, Dr Spechler was the Chief of the Division of Gastroenterology for the VA North Texas Healthcare System, Professor of Medicine, and holder of the Berta M. and Cecil O. Patterson Chair in Gastroenterology at the University of Texas Southwestern Medical Center, and he had been the Director of the Center for Swallowing Disorders at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, Massachusetts. Dr Spechler's research has focused primarily on disorders of the esophagus, especially GERD and its complications, and eosinophilic esophagitis. He has chaired three VA Cooperative Studies on medical and surgical treatments for gastroesophageal reflux disease. He described the condition known as “short-segment Barrett's esophagus” in 1994. Dr. Spechler has published more than 300 scientific reports, editorials, review articles, and book chapters on esophageal disorders. He is best known for his work in the areas of GERD, Barrett's esophagus, and eosinophilic esophagitis. Dr Spechler has served on the editorial boards of numerous journals including Gastroenterology, Gut, Alimentary Pharmacology and Therapeutics, Digestive Diseases and Sciences and Diseases of the Esophagus, and he has served as Chair of the Gastroenterology Teaching Project and the Esophago-Gastro-Duodenal Section of the American Gastroenterological Association.

Incidence of Venous Thromboembolism Among Commonly Prescribed Second-Generation Antipsychotics

Background: Second-generation antipsychotics (SGAs) are commonly prescribed medications used to treat a variety of mental health conditions. Recent data has correlated antipsychotic medications with venous thromboembolism (VTE). SGAs have diverse side effect profiles, which may contribute to differences in incidence of VTE. It is unknown which SGAs confer the most risk, and what the mechanism of increased risk is. Objective: Determine incidence of VTE in Veterans at Veterans Affairs North Texas Health Care System (VA-NTX HCS) between SGAs aripiprazole, olanzapine and risperidone. Methods: Retrospective chart review of adult Veterans at VA-NTX HCS between October 2015 to December 2019 prescribed aripiprazole, olanzapine, or risperidone. Results: Of 823 Veterans, incidence of VTE was lowest in aripiprazole group at .4%, increased to 1.7% in the olanzapine group, and was highest at 2.5% in the risperidone group. However, differences in incidence of VTE between SGAs were not statistically different, indicating no between-group differences. Conclusion: There was no difference in the incidence of VTE between risperidone, olanzapine, or aripiprazole. Given multiple limitations with this study, higher-powered studies should be conducted to investigate the possibility of differences in the incidence of VTE between the SGAs.

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

COVID-19 Is No Longer a Public Health Emergency: Implications for Patients and Clinicians

Effect of serious infectious threat response initiative (SITRI) during the coronavirus disease 2019 (COVID-19) pandemic at the Veterans Affairs North Texas Health Care System

Health care-associated infections (HAIs) increased worldwide as health care facilities struggled through the pandemic. We describe our methods in the implementation of a programmatic initiative called serious infectious threat response initiative (SITRI) that was conceptualized to support our staff, to facilitate day-to-day clinical operations related to COVID-19 and to shield our infection prevention and control program (IPC) from excessive COVID-19 work burden to the extent possible to retain routine prevention focused efforts. Post implementation, we sought to understand and quantify the workload and utility of SITRI, IPC burnout and HAI incidence during the implementation period. We correlated the number of weekly phone calls with inpatient COVID-19 census, assessed types of calls, staff feedback, IPC burnout, pre- and postpandemic HAI incidence, and the cost. There was significant correlation between SITRI calls and the weekly average COVID-19 census (P=.00026). IPC burnout evaluation indicated improvement in scores for exhaustion and reduced achievement and worsening in score for depersonalization. HAI incidence did not increase. SITRI's cost was $360,000. Staff solicited SITRI's support in tandem with the COVID-19 burden. Our HAI during the pandemic did not increase while SITRI was operational in contrast to what is published in literature.

1922. Outbreak and Management of COVID-19 and Infection Prevention Control Practices at a Community Living Center in Veterans Administration Hospital, North Texas

Abstract Background The increase in SARS-CoV-2 cases due to the omicron wave led to significant utilization of healthcare resources and reduced acute care hospital beds at the Veterans Administration Hospital, North Texas Health Care System (VANTHCS). As a result, veterans with non-severe disease were managed at a VANTHCS community living center (CLC) during a COVID-19 outbreak. Methods Veterans residing at the CLC with laboratory-confirmed cases of SARS-CoV-2 (the virus that causes COVID-19) by polymerase chain reaction diagnosed from January 1 to February 15, 2022, were included in the descriptive analysis. We described resident characteristics and outcomes and infection control practices (IPC) implemented to control the outbreak. Resident data was ascertained from the COVID-19 facility dashboard and medical record system. Results From January 1–February 15, 2022, 33 adults residing at the CLC were diagnosed COVID-19. Most infections (93.9%) occurred between January 12–24 (figure 1). The median age was 76 years [interquartile range, 71–80 years] and 30 (90.9%) were men and 25 (75.8%) were white and 5 (15.2%) African American (table 1). Among the total cases, 9 (27.3%) resided in the dementia unit. Nineteen of 33 (57.6%) were asymptomatic. Overall, 28 (84.8%) were documented to be fully vaccinated against SARS-CoV-2 and 24 (72.7%) were boosted. Obesity, ischemic heart disease, chronic obstructive pulmonary disease, and stroke were the most common comorbidities. Residents were cohorted based on COVID-19 results. A multidisciplinary team was convened, and staff were fit tested for appropriate personal protective equipment (PPE) and received refresher training on hand hygiene, donning and doffing of PPE. Most residents were determined to have mild or moderate COVID-19 and managed at the CLC while 7 (21.2%) were hospitalized in the acute care hospital. For management of COVID-19, 11 (33.3%) received dexamethasone and 25 (75.8%) received remdesivir. Overall, 32 (97%) residents survived while one hospice resident was transferred to acute care and died; only 1 resident required ICU admission. Epidemic curve of laboratory-confirmed coronavirus disease 2019 (COVID-19) disease at a Community Living Center, Veterans Administration Hospital, North Texas Health Care System, January–February 2022. Table 1Epidemiological Characteristics, and Outcomes of Laboratory-confirmed COVID-19 cases (N=33)Abbreviation: BMI, body mass index; COPD, Chronic Obstructive Pulmonary Disease; ESRD, end stage renal disease1Other comorbidity (asthma n=1 and chronic liver disease n=2) Conclusion It is feasible to administer COVID-19 therapies to high-risk residents with mild-moderate disease in a CLC with a multidisciplinary team and IPC strategies. Disclosures All Authors: No reported disclosures.

Predictors of One Year Pressure Injury Outcomes in Hospitalized Spinal Cord Injured Veterans

<h3>Research Objectives</h3> To investigate predictors of wound outcomes at 1 year of discharge of Veterans with spinal cord injury (SCI) hospitalized with one stage 3 or 4 pelvic pressure injury (PI). <h3>Design</h3> Retrospective medical record review between 1/1/2013-12/31/2018. <h3>Setting</h3> VA North Texas HealthCare System SCI unit. <h3>Participants</h3> Veterans with SCI admitted with one stage 3 or 4 pelvic PI. Traumatic and atraumatic SCI patients treated medically without flap surgery were included. <h3>Interventions</h3> Wound care. <h3>Main Outcome Measures</h3> Wound status at one year of discharge. A logistic model was built to select the significant predictors of wound healing outcomes. The area under the curve (AUC) was calculated using the leave-one-out cross validation method. P< 0.05 was considered statistically significant. <h3>Results</h3> A total of 62 hospitalizations were included for analyses: 33 healed, and 29 non-healed wounds. Three significant predictors of non-healed wound outcomes include: pressure mapping protocol during hospitalization, wound depth, and usage of alginates dressings. Two significant predictors of healed wound outcomes include: animal-based tissue and hydrocolloid dressings. The AUC of this logistic regression model is 79.98%. <h3>Conclusions</h3> The five wound outcome predictors are the depth of the wound, and clinical decision-making factors regarding seating and wound treatments. Pressure mapping protocol correlated with other variables that could not serve as a predictor by themselves including higher neurological level of injury and lack of manual pressure relief techniques. The clinical decision having a patient pressure mapped predicts that the wound may not heal at one year of discharge. The three wound treatment product predictors may represent characteristics of the wound. Further investigation on these clinical decision-making factors is warranted in utilizing treatment and healthcare recourses for SCI individuals hospitalized with PI. <h3>Author(s) Disclosures</h3> N/A.

Evaluating Weight Loss With Semaglutide in Elderly Patients With Type II Diabetes.

Background: Semaglutide is an effective agent indicated for type II diabetes mellitus (T2DM) treatment and weight management. It is unknown if the magnitude of weight loss differs significantly between nonelderly (18-64 years old) and elderly (≥65 years old) patients diagnosed with T2DM. Objective: To determine whether there is a significant difference in percent weight loss between elderly and nonelderly Veterans diagnosed with T2DM and initiating semaglutide. Methods: This institutional review board-approved retrospective cohort study conducted at the VA North Texas Health Care System included adult Veterans with T2DM initiating semaglutide. Veterans with medications, procedures, or conditions that could significantly affect weight were excluded. The primary endpoint was the difference in percent weight loss 3 months after initiating semaglutide. Secondary endpoints were differences in percent weight loss at 6 months and differences of kilogram weight loss at 3 and 6 months. Safety outcomes were significant adverse drug events (ADEs) associated with semaglutide. Results: In total, 177 Veterans were analyzed (n = 111 elderly, n = 66 nonelderly). For the primary endpoint, elderly Veterans lost a mean of 2.02% body weight versus 2.25% in the nonelderly with a mean difference of 0.23% (95% CI, -1.03% to 1.48%; P = 0.72). Secondary endpoints were also not statistically significant. Significant ADEs were gastrointestinal-related, leading to drug discontinuation or dose reduction. Conclusion: Weight loss differences between elderly and nonelderly Veterans diagnosed with T2DM initiating semaglutide were not statistically significant. Age may not be a robust predictor of semaglutide's influence on weight.

Relationship between sleep apnea and hospital readmission in rural and urban populations.

The aims of this study were to evaluate geographic differences in obstructive sleep apnea (OSA) prevalence, to determine if readmissions were more likely among rural patients with OSA than others, and to model predictors, including diagnosed OSA, of 30, 60, and 90-day acute-care readmissions. This cohort study employed a secondary analysis of data extracted from the electronic health record shared by all hospitals in a north Texas healthcare system. The sample consisted of records associated with 472,503 adult patients admitted to any of the study system's acute-care facilities from 2016 through 2019. Measurements consisted of case-level health information, including admissions, demographic variables, payors, diagnoses, screens, and physician orders. OSA was significantly related to hospital readmission when considered in isolation but did not significantly predict readmission when modeled with plausible covariates. Screening rates for OSA did not vary by geography. Differences in rural/urban-suburban OSA prevalence were not statistically significant. Findings contrast with previous suggestions that OSA plays an independent role in hospital readmissions or that rural resident may be disadvantaged regarding services that support the OSA diagnosis. Prevalence and screening rates were almost identical in urban and rural populations.

Healthcare utilization and outcomes of spinal cord injured veterans with stage 3–4 pressure injuries

Background Pressure injuries (PI) are a significant source of morbidity for individuals with spinal cord injury/disease (SCI/D). They are also associated with significant healthcare resource utilization including prolonged hospitalizations. However, the long-term outcomes in terms of wound recurrence-free survival, hospital readmission rates, and all-cause mortality in this population remain largely unknown. Objective To examine the clinical characteristics, healthcare utilization and outcomes of SCI Veterans hospitalized at the VA North Texas Health Care System (VANTHCS) SCI inpatient unit with stage 3 and 4 PI, and compare these between those who received a myocutaneous flap surgery (flap patients (FP)) and those treated medically (non-flap patients (NFP)). Methods A retrospective chart review was conducted of all adult patients admitted to the VANTHCS SCI/D unit with stage 3 or 4 pelvic PI between 1/1/2013 and 12/31/2018. Healthcare utilization and outcome information was extracted for pre-specified time points. Results 78 patients met criteria (113 hospitalizations; 27 FP; 51 NFP). Average length of stay (LOS) was 122 days; FP had a significantly higher LOS than NFP (P = 0.01). Average number of consults was 24. Estimated cost per hospitalization was $175,198. Readmission rate within 30 days was 12.39%. The mortality rate within 1 year of discharge was 21.57% for NFP, as opposed to 3.70% in the FP group. Only 5.00% of NFP wounds were healed at discharged with sustained healing at 1 year, significantly less than FP wounds (55.26%, P < 0.01). Conclusions Despite the high investment in terms of healthcare utilization, outcomes in terms of wound healing are poor. Additionally, nearly 22% of NFP died within one year of discharge. This calls into question the utility of prolonged hospitalizations for PI in the SCI/D population in terms of wound treatment efficacy, healthcare costs, and patient morbidity/mortality.

Utilization of a neurology specialty service by primary care providers for headache management at a tertiary care hospital.

BackgroundRecent data indicate that the three-month prevalence of severe headaches or migraines in the US general population is close to 25%. Participation of primary care providers will therefore be critical in providing care to affected individuals.ObjectiveTo determine the number of headache disorder consult requests to a neurology outpatient service in a tertiary medical center, the appropriateness of the consult requests, and the effectiveness of a lecture series on headache diagnosis and management in preventing inappropriate consult requests from non-neurology providers.MethodsClinical data on US Veterans is captured and documented in the Veterans Health Information Systems and Technology Architecture (VISTA). The Computerized Patient Record System (CPRS) electronic medical record (EMR) was used for data entry and retrieval. All consult requests for the study period within the VA North Texas Health Care System were identified in VISTA, and the clinical information reviewed in CPRS. Based on a defined algorithm, headache consult request were categorized as appropriate or inappropriate. A board-certified neurologist provided four in-person/virtual lectures to ambulatory care providers, primary care providers, internal medicine residents, and emergency room providers within the VA North Texas Health Care System on the diagnosis and management of headaches. Prior and post the lecture series, the total number of headache consults per day was assessed over 45-day periods.ResultsThe number of daily headache consult requests in the 45-day period prior to the lecture series was 3.6 per day (standard deviation 2.7), and 6.0 per day after the lecture series (standard deviation 2.1). The difference was not statistically significant. There were as many inappropriate headache consult requests after the lecture series as appropriate ones (50% each).ConclusionWe found that a short-term educational initiative that instructed primary care providers on the diagnosis and management of common headache disorders did not reduce the number of consultation requests and, surprisingly, it did not improve the appropriateness of the consults. Given the prevalence of headaches in the general population, better training of all primary care providers in headache management should be pursued.

Low Insertional Torque and Early Dental Implant Failure

There is lack of uniformity regarding the ideal insertional torque with which dental implants need to be placed. The purpose of this retrospective analysis is to compare the incidence of early dental implant failures with an insertional torque less than 30 N-cm to implants placed with an insertional torque 30 N-cm or greater. A retrospective cohort study was conducted to evaluate dental implants placed between 2015 and 2016 at the Veterans Affairs North Texas Health Care System in Dallas. The primary predictor variable was dental implant insertional torque, measured at the time of implant placement as either greater than or equal to 30 N-cm or less than 30 N-cm. The primary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation before prosthesis loading. The study conducted a time-to-event analysis to examine a group difference in time to implant failure between insertional torque group greater than or equal to 30 N-cm and less than 30 N-cm using Kaplan-Meir curves and a frailty model. The time to follow-up was censored at 6months. One hundred three patients had 214 implants placed, with early failures occurring in 14 implants (6.5%). Implants placed with an insertional torque less than 30 N-cm were nearly 14 times more likely to have an early failure compared to implants placed with an insertional torque 30 N-cm or greater (hazard ratio= 13.909; 95% confidence interval, 1.835 to 105.416), which was statistically significant (P=.0108). The results of this retrospective cohort study suggest that insertional torque values less than 30 N-cm are associated with early dental implant failures. Future, prospective studies will be performed to further elucidate the association between insertional torque and early dental implant failure.

Are Lower Insertional Torque Values Associated with Increased Early Dental Implant Failures?

Statement of the problemThe purpose of this retrospective cohort study was to determine whether low insertional torque vales < 30-Ncm were associated with increased early dental implant failures. Materials and methodsA retrospective cohort study was conducted to evaluate dental implants placed in 2015 at the VA North Texas Health Care System in Dallas. The following inclusion criteria were defined: 1) patients who were not lost to follow-up within the first 6 months of implant placement; 2) cases with sufficient medical records, including pre-surgical and post-surgical evaluation. Patients were excluded as study subjects if: 1) they had inadequate medical records; 2) they were a current tobacco smoker or were undergoing treatment for systemic conditions such as bisphosphonate use, head and neck radiation, and chemotherapy. The primary predictor variable was dental implant insertional torque, measured at the time of implant placement as: < 30-Ncm, 30-39-Ncm, 40-49-Ncm, 50-59-Ncm, 60-69-Ncm, and > 60-Ncm. The primary outcome variable was early implant failure, defined chronologically as implant failure necessitating explantation within 6 months of placement.1 Secondary predictor variables were age ≥ 65 years and sex, defined as male or female. Descriptive, bivariate, and multiple logistic regression analyses were performed with P < .05 used to determine statistical significance. Results and outcomesThirty-three subjects and 69 implants met the defined inclusion and exclusion criteria. The average age of the cohort was 65 years. Sixty-two implants were placed in males, and 7 were placed in females. There was a total of 5 early failures (7%). Four occurred in males, and 1 occurred in a female. Four occurred in subjects ≥ 65, and 1 occurred in a subject < 65. Two early failures occurred with an insertional torque < 30-Ncm, 1 occurred with an insertional torque of 30-39-Ncm, and 2 occurred with an insertional torque of 50-59-Ncm. Analysis of the predictor variable and primary outcome variable revealed that decreased insertional torque values resulted in an increase in early dental implant failures and was statistically significant (P = .034). Specifically, insertional torque values below the threshold of 30-Ncm resulted in a 14-fold increase in early failures (OR 14.66; 95% CL 1.74-123.51). Analysis of the secondary predictor variables, age and sex, revealed no statistically significant differences with P = 1.00 and P = .4242, respectively. Discussion and conclusionThe results of this retrospective cohort study suggest that decreased insertional torque values of dental implants below 30-Ncm increase early failure rates within 6 months of dental implant placement. A systematic review by Oliveira et al found that there was not strong enough evidence to conclude that insertional torque < 30-Ncm established enough primary stability between the implant and surrounding bone. They concluded that this decreased primary stability decreased overall implant survival.2 The results of this present study suggest that a low insertional torque value < 30-Ncm decreases the primary stability of the implant in the surrounding bone, thereby increasing the rate of early dental implant failure. Future prospective studies by this group will be performed to further elucidate the association between insertional torque and early dental implant failure.

Are Antidepressant Medications Associated with Increased Dental Implant Failure?

Statement of the problemThe purpose of this study was to determine whether antidepressant medications were associated with a lower dental implant success rate. Materials and methodsA retrospective cohort study was conducted to evaluate dental implants placed in 2015 at the VA North Texas Health Care System. The following inclusion criteria were defined: 1) patients with adequate postoperative follow-up appointments for 5 years; 2) cases with sufficient medical records; 3) patients who had a current diagnosis of depression at the time of implant placement and were taking an antidepressant medication. Patients were excluded as study subjects if: 1) they had inadequate medical records; 2) they were a current tobacco smoker or were undergoing treatment for systemic conditions such as bisphosphonate use, radiation, or chemotherapy. The primary predictor variable was current use of an antidepressant medication. The primary outcome variable was implant success, defined as an implant without pain upon function, no mobility, < 2mm radiographic bone loss from initial surgery, and no history of exudates.1 Secondary predictor variables were age ≥ 65 years and sex, defined as male or female. Descriptive, bivariate, and multiple logistic regression analyses were performed with P < .05 used to determine statistical significance. Results and outcomesThirty-one patients and 67 implants met the defined inclusion and exclusion criteria. The average age was 65 years. Fifty-two implants were placed in patients 65 years and older. Sixty implants were placed in males, and 7 were placed in females. Sixty-one implants met the defined success criteria (91%), with 7 implant failures (7%). Forty-six implants were placed in patients on antidepressant medication. The antidepressant treatment group had 41 implants that met success criteria (89%) and 5 implant failures (11%). Analysis of the predictor variable and primary outcome variable revealed that antidepressant therapy was associated with a nearly 60% decrease in success (OR 0.41; 95% CL 0.04-3.75), but was not statistically significant (P = .6542). Analysis of the secondary variables reveled that age ≥ 65 and female sex were not associated with statistically significant differences in dental implant success (P = 1 and P = .4927, respectively). Discussion and conclusionThe results of this retrospective analysis suggest that antidepressant use does not affect the success rate of dental implants. A systemic review by Silva et al found an increased risk for implant failure in antidepressant users compared to non-users, but cautioned their conclusions due to a lack of methodological rigor and standardization.2 They found an increased rate of dental implant failures in tobacco smokers who also took antidepressants. They hypothesized that tobacco smoke can be a surrogate for dental implant failure in patients taking antidepressants as nicotine can impair new bone formation and impair osseointegration, artificially inflating the rate of implant failure in this cohort. One of the strengths of the current study is strict rule-out criteria for current tobacco smokers, as patients who receive implants at this center have point-of-care nicotine testing prior to implant placement. The results of this present study suggest that antidepressant use does not decrease implant success rates over a 5-year period. Future prospective studies, with larger cohorts, will be performed to further elucidate the association between antidepressant use and dental implant success.

Perinatal Symptoms and Treatment Engagement in Female Veterans.

Women veterans using Veterans Health Care Administration maternity benefits have a high prevalence of mental health disorders, including depression, PTSD, and anxiety. Additionally, women with psychiatric histories often experience a relapse or worsening of symptoms during pregnancy and postpartum. Adequate perinatal mental healthcare engagement is critical to optimizing outcomes for mother and child. This study evaluated psychiatric symptom severity and predictors of women veteran's mental health treatment engagement during pregnancy and postpartum at the VA North Texas Health Care System. Seventy women using Veterans Health Administration were assessed longitudinally via chart review and interviews (including the Edinburgh Postnatal Depression Scale) during pregnancy and postpartum. A Friedman test was used to evaluate the change in symptom severity during (1) the 6 months before pregnancy, (2) pregnancy, and (3) postpartum. Multivariate logistic regressions were used to determine predictors of attending outpatient mental health appointments. Potential predictors examined included sociodemographic factors, symptoms of depression, history of military sexual assault, presence of a pre-pregnancy psychiatric diagnosis, and attendance of mental health appointments before pregnancy. Approximately 40% of participants demonstrated at least mild psychiatric symptoms before pregnancy, and symptom severity did not significantly change across the perinatal period (pre-pregnancy, pregnancy, and postpartum) X2 (2, n = 70) = 3.56, P = .17. Depressive symptoms during the 2nd or 3rd trimester were a significant predictor for attendance of mental health appointments during both pregnancy (OR = 1.18, 95% CI, 1.04 to 1.34) and postpartum (OR = 1.18, 95% CI, 1.02 to 1.36). An active psychiatric diagnosis during the 6months before pregnancy was also a significant predictor of attendance following delivery (OR = 14.63, 95% CI, 1.55 to 138.51). Our results demonstrate that women with prior histories of mental health conditions will continue to be symptomatic, and this is a good predictor of mental health treatment engagement during the perinatal period.

Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty.

Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population. A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation. Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09). Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.

472. The Utility of Infectious Diseases E-consults in the Era of COVID-19

BackgroundDuring the COVID-19 pandemic, rapid Infectious Diseases (ID) consultation has been required to answer novel questions regarding SARS-CoV-2 testing and infection prevention. We sought to evaluate the utility of e-consults to triage and provide rapid ID recommendations to providers.MethodsWe performed a retrospective study reviewing ID e-consults in three institutions in the North Texas region: Clements University Hospital (CUH), Parkland Hospital and Health System (PHHS), and the VA North Texas Health Care System (VA) from March 1, 2020 to May 15, 2020. Variables collected include age, sex, ethnicity, comorbidities, time to completion, reason for consult and outcome of consult (initiation or removal of personal protective equipment (PPE) and recommendation to test or retest for COVID-19).ResultsWe performed all analysis using R studio (Version 1.3.959). Characteristics of 198 patients included: 112(57%) male, 86(43%) female, 86(43%) Caucasian, 71(36%) Hispanic, 42(21%) African American, 6(3%) Asian and mean(sd) age of 55.1(15.9). Patient comorbidities included: 89(45%) with a heart condition, 77(39%) diabetes, 30(15%) asthma and 14(7%) liver disease.Median time to completion for all hospitals was 4 hours(h); ((CUH (4h) vs PHHS (2h), p< 0.05; VA (5.5h) vs PHHS (2h) p< 0.05)). Most common reasons for e-consult included: (63)32% regarding re-testing ((CUH 14(21%) vs PHHS 43(50%), p< 0.05; CUH vs VA 14(27%), p< 0.05; PHHS vs VA, p< 0.05)), (61)31% testing ((CUH 25(37%) vs PHHS 39(45%), p< 0.05; CUH vs VA 7(16%), p< 0.05; PHHS vs VA, p< 0.05)) and 61(31%) infection prevention (IP). Based on the e-consult recommendation, 53(27%) of patients were tested ((CUH 31(45%) vs PHHS 11(13%), p< 0.05, CUH vs VA 11(25%), PHHS vs VA, p< 0.05)), 45(23%) were re-tested, 44(22%) of patients had PPE started on and 19% had PPE removed ((CUH 0(0%) vs PHHS 16(19%), p< 0.05; CUH vs VA 21(48%), p< 0.05; PHHS vs VA, p< 0.05)).Reason for Consult ConclusionE-consult services can provide prompt ID input during the COVID-19 pandemic, minimizing the risk of infection to the patient and health care workers while preserving PPE and testing supplies.Disclosures Roger Bedimo, MD, MS, Gilead Sciences (Consultant)Merck & Co. (Advisor or Review Panel member)ViiV Healthcare (Advisor or Review Panel member, Research Grant or Support)

526: Enabling Goal-Concordant Healthcare Delivery: VHA’s Success Using Engineering Controls in the EMR

1Veterans Affairs Maryland Healthcare System, Baltimore, MD 2University of Maryland School of Medicine, Baltimore, MD 3Veterans Affairs North Texas Health Care System, Dallas, TX