Philadelphia Veterans Affairs Medical Center Research Articles

Machine Learning and Artificial Intelligence: A Web-Based Implant Failure and Peri-implantitis Prediction Model for Clinicians.

To develop a machine learning model that can predict dental implant failure and peri-implantitis as a tool for maximizing implant success. This study used a supervised learning model to retrospectively analyze 398 unique patients receiving a total of 942 dental implants presenting at the Philadelphia Veterans Affairs Medical Center from 2006 to 2013. Logistic regression, random forest classifiers, support vector machines, and ensemble techniques were employed to analyze this dataset. The random forest model possessed the highest predictive performance on test sets, with receiver operating characteristic area under curves (ROC AUC) of 0.872 and 0.840 for dental implant failures and peri-implantitis, respectively. The five most important features correlating with implant failure were amount of local anesthetic, implant length, implant diameter, use of preoperative antibiotics, and frequency of hygiene visits. The five most important features correlating with peri-implantitis were implant length, implant diameter, use of preoperative antibiotics, frequency of hygiene visits, and presence of diabetes mellitus. This study demonstrated the ability of machine learning models to assess demographics, medical history, and surgical plans, as well as the influence of these factors on dental implant failure and peri-implantitis. This model may serve as a resource for clinicians in the treatment of dental implants. Int J Oral Maxillofac Implants 2023;38:576-582. doi: 10.11607/jomi.9852.

On-Site Nurse-Led Cancer Genetics Program Increases Cancer Genetic Testing Completion in Black Veterans.

Telegenetics services can expand access to guideline-recommended cancer genetic testing. However, access is often not distributed equitably to all races and ethnicities. We evaluated the impact of an on-site nurse-led cancer genetics service in a diverse Veterans Affairs Medical Center (VAMC) oncology clinic on likelihood of germline testing (GT) completion. We conducted an observational retrospective cohort study of patients who were referred for cancer genetics services at the Philadelphia VAMC between October 1, 2020, and February 28, 2022. We evaluated the association between genetics service (on-site v telegenetics) and likelihood of GT completion in a subcohort of new consults, excluding patients with prior consults and those referred for known history of germline mutations. A total of 238 Veterans, including 108 (45%) seen on site, were identified for cancer genetics services during the study period, with the majority referred for a personal (65%) or family (26%) history of cancer. In the subcohort of new consults, 121 Veterans (54% self-identified race/ethnicity [SIRE]-Black), including 60 (50%) seen on site, were included in the analysis of germline genetic testing completion. In a univariate analysis, patients who were seen by the on-site genetics service had 3.2-fold higher likelihood of completing GT (relative risk, 3.22; 95% CI, 1.89 to 5.48) compared with the telegenetics service. In multivariable regression analysis, the on-site genetics service was associated with higher likelihood of GT completion, but this association was only statistically significant in SIRE-Black compared with SIRE-White Veterans (adjusted RR, 4.78; 95% CI, 1.53 to 14.96; P < .001; P-interaction of race × genetics service = .016). An on-site nurse-led cancer genetics service embedded in a VAMC Oncology practice was associated with higher likelihood of germline genetic testing completion than a telegenetics service among self-identified Black Veterans.

Outcomes of Resident Performed Hydrus, iStent, and Kahook Glaucoma Procedures in a Predominantly African American Population.

This retrospective study characterized the efficacy and safety of 3 different microinvasive glaucoma surgery (MIGS) procedures in a predominantly African American population at the Philadelphia Veterans Affairs Hospital (Hydrus, Kahook, iStent), demonstrating no significant difference in intraocular pressure (IOP) and medication reduction between the 3 at long-term follow-up. To compare the efficacy and safety of 3 different MIGS procedures in a predominantly African American population. Retrospective cohort study of patients undergoing cataract extraction combined with 1 of 3 MIGS procedures (Hydrus, iStent, Kahook) at the Philadelphia Veterans Affairs Medical Center between January 1, 2015 and November 1, 2020. Analysis of variance and regression models were used to compare reduction in IOP and medication use among 3 MIGS types. A total of 123 eyes of 112 patients were included, including 56 (45.5%) eyes for Hydrus, 40 (32.5%) eyes for iStent, and 27 (22.0%) eyes for Kahook. Adjusted mean IOP reduction was greater for Hydrus at postoperative day 1 (-4.49 vs. -1.76 for iStent and -1.69 for Kahook, P=0.05 and greater for Kahook at postoperative week 1 (-2.53 vs. +0.70 for iStent vs. -1.41 for Hydrus, P=0.02), but did not differ significantly between MIGS types at subsequent postoperative visits (all P>0.05). In multivariable analysis, MIGS type was not significantly associated with reduction in IOP or medication use at 9 to 12 months postoperatively. There were no significant differences in complication rates across MIGS types. In this study, the difference in IOP lowering and medication reduction postoperatively between the Hydrus, iStent, and Kahook was not statistically significant after postoperative day 1. More studies are needed to evaluate outcomes of MIGS surgeries in glaucoma populations of different disease severity.

Is Bone Grafting during Implant Placement a Protective Factor against the Development of Peri-implantitis? A Retrospective Cohort Analysis

This study aims to identify if the use of bone grafting at time of implant placement is a protective factor against the development of peri-implantitis. A retrospective cohort study was conducted at the Philadelphia Veterans Affairs Medical Center from 2006 to 2013. Physician encounter notes within three months of implant placement were used to gather data about patients' health status. Operative report notes were used to assess the use of bone grafting at time of implant placement. Implant status was assessed using dental encounter notes and radiographs from follow-up appointments at one, three, five and 10 years. Peri-implantitis was defined as radiographic evidence of changes in the crestal bone level, clinical evidence of bleeding on probing with or without suppuration. Electronic medical records of 797 implants were retrospectively analyzed. Statistics were computed using the SAS System (SAS Institute Version 9.4, 2002-12, Cary, NC). The primary predictor variable was bone grafting at time of implant placement (xenograft, allograft or autograft). The primary outcome variable was the presence of peri-implantitis. Other study variables assessed were diabetes, smoking, gender and age. Descriptive, univariate and multivariate regression analyses were performed to measure the association between predictive variables and development of peri-implantitis. Of the 797 implants placed, 168 (21%) developed peri-implantitis. Following a multivariate analysis that controlled for diabetes, smoking, gender and age, placement of bone graft at implant placement was shown to be associated with a decreased risk in the presence of peri-implantitis (p = 0.050) when compared to implants that did not receive bone graft. The data from this study show that implants placed with simultaneous bone graft were 44.7 percent less likely to develop peri-implantitis compared to implants placed without bone graft (OR = 0.553, 95 percent Cl 0.303-1.000). To the researchers' knowledge, no existing literature demonstrates this significant, protective relationship. Human studies demonstrate a significant contraction of ridge dimensions following extraction, even when immediately restoring with an implant. However, the placement of bone graft during implant placement was shown to histologically modify the process of bone healing and provide additional hard tissue at the extraction socket when compared to sockets restored with no graft. Therefore, in conjunction with the results, the use of bone graft at the time of implant placement may reinforce the surrounding implant site on a biochemical or structural level and provide protective features against the development of peri-implantitis. Analysis of implants placed at the Philadelphia VA Medical Center revealed an important association between use of bone grafting at implant placement and the development of peri-implantitis. The study shows that the supplemental placement of bone graft may play a role in decreasing the development of peri-implantitis. However, it is important to note that the use of bone grafting is case-specific for areas that may be deficient of peri-implant tissue. As the restoration of edentulous areas with dental implants is becoming the new standard of care, identifying protective factors, such as use of bone grafting during implant placement, will be critical in ensuring successful outcomes. In addition to completing prospective studies, identification of other implant protective and risk factors is a necessity. 1. Lang, NP, et. al: Periimplant diseases: where are we now? consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol, 2011. 2. Alves D, Faria-Almeida R, Azevedo A, Liñares A, Muñoz F, Blanco-Carrion J: Immediate 1-piece zirconia implants with/without xenograft in the buccal gap: a 6-month pre-clinical study. Clin Oral Implants Res, 2021

Is Immunosuppression a Risk Factor for Development of Peri-implantitis? A Retrospective Cohort Analysis

The present study aims to identify if immunosuppression is a risk factor for the development of peri-implantitis. A retrospective cohort study design was conducted on patients presenting to the Philadelphia Veterans Affairs (VA) Medical Center for dental implant placement from 2006 to 2013. Medical encounter notes within 3 months of implant placement were used to collect information about patients’ health status, including evaluations of immune system function. Implant status was assessed using dental encounter notes and radiographs from follow-up appointments at 1, 3, 5, and 10 years. Peri-implantitis was defined as radiographic evidence of change in crestal bone level, clinical evidence of bleeding on probing, with or without suppuration.1Electronic medical records of 884 implants were retrospectively analyzed. Descriptive statistics were calculated using the SAS System (SAS Institute Version 9.4, 2002-2012, Cary, NC). The primary predictor variable was immunosuppression. The primary outcome variable was the presence of peri-implantitis. Other study variables assessed included graft at the time of implant placement, diabetes, smoking, gender, and age over 60. Descriptive, univariate, and multivariate regression analyses were performed to measure the association between predictive variables and development of peri-implantitis.Of the 884 implants placed, 205 (23.1%) developed peri-implantitis. Following a multivariate analysis that controlled for diabetes, smoking, gender, and age over 60, immunosuppression was shown to be significantly associated with an increased risk in the presence of peri-implantitis (P = .0071) when compared to implants placed in immunocompetent subjects. The data from this study show that implants placed in immunosuppressed patients were 29.78% more likely to develop peri-implantitis compared to implants placed in immunocompetent patients (OR = 2.229, 95% CI 1.243-3.996). To the best of the authors’ knowledge, no existing literature has demonstrated this significant risk relationship.Following surgical implant placement, adequate function of the immune system's inflammatory response is imperative to target infections and orchestrates wound healing to allow for successful osseointegration of implants. Few studies, however, have directly investigated this nexus at a mechanistic level. In vivo studies in rabbits have indicated that titanium implant placement may up-regulate the immune system's type 2 inflammatory response to inhibit bone resorption markers and promote healing.2 Therefore, in conjunction with the authors' results, immunosuppression could play a significant role in increasing risk of peri-implantitis.Analysis of implants placed at the Philadelphia VA Medical Center revealed an important association between immunosuppression and the development of peri-implantitis. This study shows that immunosuppression may play a role in increasing the development of peri-implantitis. Along with need for further exploration regarding the pathophysiology of this relationship, additional observational and randomized controlled studies are necessary to validate the authors' findings. As implant restoration of edentulous areas is becoming the new standard of care, identification and understanding of associated risks factors are critical to ensure successful implant outcomes.

Are proton pump inhibitors associated with implant failure and peri-implantitis?

Proton pump inhibitors (PPIs) may be linked to implant failure by affecting bone metabolism and osseointegration. This study evaluated how PPIs influence long-term implant failure and peri-implantitis in PPI users and nonusers. This was a retrospective cohort study of patients treated at the Philadelphia Veterans Affairs Medical Center between 2006 and 2013. The primary predictor variable was PPI use. Outcome variables were long-term implant failure and the presence of peri-implantitis. Data gathered included demographic characteristics, medical comorbidities, implant location, and dimensions. Multivariate regression models measured independent factor associations. The final study cohort contained 933 implants placed in 284 patients. A total of 323 (32.6%) implants were placed in patients with ongoing PPI use. PPI users were less likely to smoke (22.1% vs 31.9%; P < .01) and use illicit drugs (5.0% vs 9.7%; P=.01) and more likely to have undergone prior bone grafting (18.3% vs 12.9%; P=.03). PPI use lost significance after controlling for confounding factors and was not an independent predictor of implant failure (odds ratio [OR], 0.801; 95% confidence interval [CI], 0.56-1.15; P=.24) or peri-implantitis (OR, 0.801; 95% CI, 0.56-1.15; P=.24). Our study found no independent associations between PPI use and implant failure or peri-implantitis. Contrary to published literature, PPIs may not influence implant health.

Does Alcohol Consumption Protect Against Late Dental Implant Failures?

<h3>Purpose</h3> Social factors have been implicated in the development of various peri-implant pathologies, including implant failure. This study aims to investigate whether varying levels of alcohol consumption affects late dental implant failures. <h3>Methods</h3> A retrospective cohort study was performed to evaluate implants placed between 2006 and 2012 at the Philadelphia Veterans Affairs Medical Center. The primary predictor variable was alcohol consumption, measured as nonconsumption or mild, moderate, and heavy consumption. The primary outcome variable was late dental implant failure. Other study variables included age, sex, and the type of implant restoration used. Appropriate univariate, bivariate, and multivariate statistics were applied, with <i>P</i> < .05 used to define statistical significance. <h3>Results</h3> Our retrospective cohort consisted of 103 unique patients and 295 implants with a 5-year minimum follow-up period. Most patients were male (93%) with an average age of 60 at the time of implant placement. Late dental implant failure was associated with 30 implants (10%). Compared to nonconsumption, mild alcohol consumption was associated with a 75% decrease in late implant failure (<i>P</i> = .0494), moderate consumption was associated with a 60% decrease in late implant failure (<i>P</i> = .3826), and heavy consumption was associated with a 200% increase in late implant failure (<i>P</i> < .1782). Compared to mild alcohol consumption, heavy consumption was associated with an 847% increase in late implant failure (<i>P</i> = .0135). <h3>Conclusion</h3> The results from this retrospective cohort analysis suggest mild alcohol consumption is associated with a decrease in late dental implant failures, and heavy consumption is associated with an increase in late dental implant failures.

Hygiene Recall in Diabetic and Nondiabetic Patients: A Periodic Prognostic Factor in the Protection Against Peri-Implantitis?

Diabetes mellitus is associated with an increased risk of poor outcomes with dental implant placement. This study aims to identify if frequency of hygiene visits is a protective factor for the development of peri-implantitis in diabetic patients. A retrospective cohort design was conducted on patients presenting for dental implant placement at the Philadelphia Veterans Affairs (VA) Medical Center from 2006 to 2012. The primary predictor variable was hygiene frequency, recorded as either infrequent, annual (7-12month recall), or biannual (≤6-month recall). The number of months between implant placement and the presence of peri-implantitis was the primary outcome (time-to-peri-implantitis) variable, which was assessed on a subject level and adjusted for clustered, correlated multiple implants on the same subject. Additional variables were greater than or equal to 60years of age, male gender, smokers, short implant length, diabetes, uncontrolled diabetes, and removable prostheses. Descriptive, univariate, and Cox proportional hazards regression statistics were computed to measure associations with peri-implantitis with P≤.05 used to define statistical significance. The study sample was composed of 286 patients. In total, 748 implants were placed. Subjects greater than or equal to 60years of age were 2 times more likely to develop peri-implantitis (hazards ratio (HR)=2.015, 95% Cl (0.985-4.119), P=.0549). Subjects receiving implant-supported removable prostheses were 2.3 times more likely to develop peri-implantitis (HR=2.315, 95% CI (1.006-5.327), P=.0485). With each hygiene visit, patients' risk of developing peri-implantitis decreased 20% (HR=0.805, 95% Cl (0.394-1.647), P=.5528). In addition, diabetic patients were 49% more likely to develop peri-implantitis (HR=1.491, 95% CI (0.758-2.936), P=.2475) than nondiabetic patients. Diabetic patients may be at increased risk for the development of peri-implantitis and an increased frequency of hygiene visits may reduce peri-implant diseases.

Does alcohol consumption protect against late dental implant failures?

Social factors have been implicated in the development of peri-implant pathologies, including implant failure. This study aims to investigate whether alcohol consumption affects late dental implant failures. A retrospective cohort study evaluated implants placed between 2006 and 2012 at the Philadelphia Veterans Affairs Medical Center. The primary predictor variable was alcohol consumption, measured as nonconsumption and mild, moderate, and heavy consumption. The primary outcome variable was late dental implant failure. Univariate, bivariate, and multivariate statistics were applied, with P < .05 used to define statistical significance. Our cohort consisted of 103 patients and 295 implants with a 5-year minimum follow-up. Most patients were male (93%) with an average age of 60 at the time of implant placement. Late implant failure was associated with 30 implants. Compared to nonconsumption, mild consumption was associated with a 75% decrease in late implant failure (P=.0494), moderate consumption was associated with a 60% decrease (P=.3826), and heavy consumption was associated with a 200% increase (P < .1782). Compared to mild consumption, heavy consumption was associated with an 847% increase in late failure (P=.0135). Results from this retrospective cohort analysis suggest that mild alcohol consumption is associated with a decrease in late dental implant failures.

Is Implant Placement in the Operating Room a Risk Factor for the Development of Peri-Implantitis? A Retrospective Cohort Analysis

This study aims to identify if preoperative antibiotic administration is a protective factor for the development of peri-implantitis in implants placed in the operating room vs outpatient clinic. A retrospective cohort study was conducted at the Philadelphia Veterans Affairs Medical Center from 2006 to 2013. Physician encounter notes within 3 months of implant placement were used to gather data about patients’ health status, including the setting of implant placement in the operating room vs outpatient clinic. Operative report notes were used to assess administration of antibiotic prophylaxis, recorded as none, oral, or intravenous administrations. Implant status was assessed using dental encounter notes and radiographs from follow-up appointments at 1, 3, 5, and 10 years. Peri-implantitis was defined as radiographic evidence of changes in the crestal bone level, clinical evidence of bleeding on probing, with or without suppuration.1 Electronic medical records of 942 implants placed in 398 unique patients were retrospectively analyzed. Descriptive statistics were computed using the SAS System (SAS Institute Version 9.4, 2002-2012, Cary, NC). Predictor variables were implant placement in the operating room or outpatient clinic and administration of preoperative antibiotics. The primary outcome variable was the presence of peri-implantitis. Descriptive, bivariate, and multiple logistic regression analyses were performed to measure the association between predictive variables and development of peri-implantitis. Of the 942 implants placed, 205 (22%) developed peri-implantitis. Overall, placement of implants in an operating room was shown to be associated with an increased risk in the presence of peri-implantitis (P ≤ .0001) when compared to implants placed in the outpatient clinic. When controlling for preoperative antibiotics, patients who received implants in the operating room were still found to be at risk for developing peri-implantitis (P = .0015). The data from this study show that implants placed in the operating room were 4 times more likely to develop peri-implantitis compared to implants placed in the outpatient clinic (OR = 4.056, 95% Cl 2.697-6.102). To our knowledge, no existing literature demonstrates this significant relationship. Our data show that preoperative antibiotics are protective against the development of peri-implantitis in patients who receive implants in the operating room. When controlling for preoperative antibiotics, operating room patients’ risk of developing peri-implantitis decreased by nearly 35% (OR = 2.633, 95% Cl 1.448-4.788). Studies have demonstrated that in a peri-implantitis model, antibiotic-treated specimens attenuated natural bone loss. The authors suggest that preoperative antibiotic administration may decrease the occurrence of peri-implantitis by reversing inflammatory responses and decreasing attachment loss via attenuation of pathogenic oral bacteria at the site of implant placement.2 Therefore, the administration of preoperative antibiotics, especially in medically complex patients who cannot tolerate implant placement in an outpatient clinic, may temper the progression of pathological processes around the peri-implant tissues. Analysis of implants placed at the Philadelphia VA Medical Center revealed an important association between the setting of implant placement, use of preoperative antibiotics, and the development of peri-implantitis. Our study shows that a standardized preoperative antibiotic regimen can play an important role in decreasing the development of peri-implantitis in patients who receive implants in an operating room. Administration of preoperative antibiotics in these patients may provide an opportunity to abate inflammatory reactions as a result of an existing complex disease and provide protection against the development of peri-implantitis. In addition to completing prospective studies, identification of other protective factors in this high-risk patient population is a necessity.

Hygiene Frequency in Diabetic Patients: A Simple Factor for Protection Against Peri-implantitis?

This study plans to identify if frequency of hygiene visits is a protective factor for the development of peri-implantitis. A retrospective cohort design was conducted at the Philadelphia Veterans Affairs Medical Center from 2006 to 2012.

Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea.

Despite significant medical sequelae of obstructive sleep apnea (OSA), the condition remains undiagnosed and untreated in many affected individuals. We explored the feasibility of a comprehensive, telemedicine-based OSA management pathway in a community-based Veteran cohort. This prospective, parallel-group randomized pilot study assessed feasibility of a telemedicine-based pathway for OSA evaluation and management in comparison to a more traditional, in-person care model. The study included 60 Veterans at the Philadelphia Veterans Affairs Medical Center and two affiliated community-based outpatient clinics. Telemedicine pathway feasibility, acceptability, and outcomes were assessed through a variety of quantitative (Functional Outcomes of Sleep Questionnaire, dropout rates, positive airway pressure [PAP] adherence rates, participant satisfaction ratings) and qualitative (verbal feedback) metrics. There was no significant difference in functional outcome changes, patient satisfaction, dropout rates, or objectively measured PAP adherence between groups after 3 months of treatment. Telemedicine participants showed greater improvement in mental health scores, and their feedback was overwhelmingly positive. Our pilot study suggests that telemedicine-based management of OSA patients is feasible in terms of patient functional outcomes and overall satisfaction with care. Future studies should include larger populations to further elucidate these findings while assessing provider- and patient-related cost effectiveness.

Quality-improvement initiatives focused on enhancing customer service in the outpatient pharmacy.

The development and implementation of quality-improvement initiatives to enhance customer service in an outpatient pharmacy of a Veterans Affairs (VA) medical center are described. Historically low customer service satisfaction rates with the outpatient pharmacy at the Philadelphia Veterans Affairs Medical Center prompted this quality-improvement project. A three-question survey was designed to be easily and quickly administered to veterans in the outpatient pharmacy waiting area. Using 5-point Likert scale, veterans were asked to rate (1) their overall experience with the outpatient pharmacy service and (2) their satisfaction with the customer service provided by the pharmacy department. They were also asked how they thought the pharmacy department could improve its customer service. After receiving feedback from the survey, several quality-improvement initiatives were developed. The initiatives were categorized as environmental, personnel, communicative, and technological. For each initiative, one or more tasks were developed and the initiatives were subsequently implemented over eight months. After each task was completed, veterans were surveyed to measure the impact of the change. A total of 79 veterans were surveyed before the implementation of the quality-improvement initiatives, and 49% and 68% rated their experience with the outpatient pharmacy and customer service favorably, respectively. Twenty-five veterans were surveyed after the implementation of numerous quality-improvement interventions, with 44% and 72% rating their experience with the outpatient pharmacy and customer service favorably. Customer service satisfaction with an outpatient pharmacy service at a VA medical center was enhanced through the implementation of various quality-improvement initiatives.

Financial incentives for completion of fecal occult blood tests among veterans: a 2-stage, pragmatic, cluster, randomized, controlled trial.

Rates of patient completion of fecal occult blood tests (FOBTs) are often low. To examine whether financial incentives increase rates of FOBT completion. A 2-stage, parallel-design, pragmatic, cluster, randomized, controlled trial with clustering by clinic day (ClinicalTrials.gov: NCT01516489). Primary care clinic of the Philadelphia Veterans Affairs Medical Center. 1549 patients who were prescribed an FOBT (unique samples of 713 patients for stage 1 and 836 patients for stage 2). In stage 1, patients were assigned to usual care or receipt of $5, $10, or $20 for FOBT completion. In stage 2, different patients were assigned to usual care or receipt of $5, a 1 in 10 chance of $50, or entry into a $500 raffle for FOBT completion. Primary outcome was FOBT completion within 30 days. Preplanned subgroup analyses examined 30-day FOBT completion by previous nonadherence to a prescribed FOBT. In stage 1, none of the incentives increased rates of FOBT completion. In stage 2, a 1 in 10 chance of $50 increased FOBT completion compared with usual care (between-group difference, 19.6% [95% CI, 10.7% to 28.6%]; P< 0.001) but a $5 fixed payment and entry into a raffle for $500 did not. None of the incentives were more effective among patients who had previously been nonadherent to an FOBT than among patients who had previously completed an FOBT. Single Veterans Affairs medical center setting, short follow-up, use of 3-sample rather than 1-sample immunochemical FOBTs, limited power to detect small effects of incentives, inability to evaluate cost-effectiveness. A 1 in 10 chance of receiving $50 was effective at increasing rates of FOBT completion, but 5 other tested incentives were not. Veterans Affairs Center for Health Equity Research and Promotion.

Practical guidance and ethical considerations for studies using photo-elicitation interviews.

Photo-elicitation is a qualitative interviewing technique that has gained popularity in recent years. It is the foundation for photovoice projects and is a tool well-suited for community-based participatory research. Photo-elicitation yields rich data, and interview participants say these interviews encourage community awareness and engagement. This article draws on 9 studies, conducted by researchers at 3 institutions (the University of Pennsylvania, the Philadelphia Veterans Affairs Medical Center, and the Geisel School of Medicine at Dartmouth) in partnership with community-based organizations and students, in which 303 participants completed photo-elicitation interviews. We offer 8 practical suggestions for overcoming challenges encountered during photo-elicitation research and for managing ethical concerns about the use of visual data in public health research. Our guidelines can inform study design, protocol development, and institutional review board approval.

C-58 * Using Multimodal Magnetic Resonance Imaging to Explore Biomarkers of Veterans with Post-Traumatic Stress Disorder after Blast Injury

OBJECTIVE: This study aims to compare neuroimaging measures of gray matter thickness and volume in the medial prefrontal and parietal areas of combat veterans with and without Post-Traumatic Stress Disorder (PTSD) and blast exposure. Secondary objectives include investigating the relationship between neuropsychological and imaging data. METHOD: Twenty post-9/11 male combat veterans were recruited from the Philadelphia Veterans Affairs Medical Center. All participants had been deployed, 13 had a history of PTSD and blast exposure, and seven did not endorse PTSD or blast. Veterans completed measures of emotional and neuropsychological functioning and one MRI scan. RESULTS: Volumetric measures of the caudal and rostral anterior cingulate cortex (ACC) and precuneus areas were normalized using total gray matter volume. Group differences in gray matter volume across hemispheres were examined using repeated measures analyses of variance and no significant differences were found. Independent samples t-tests also did not find significant group differences in thickness for these areas. Controls outperformed those with TBI and PTSD on a measure of premorbid intelligence, t(18) = 2.65, p =.02, 95% CI [3.77, 32.47]), but no other significant differences in neuropsychological performance were observed. CONCLUSION(S): These initial findings are unexpected, as previous research has found significantly smaller anterior cingulate cortex volumes in those with PTSD. However, these areas are relatively unexplored in relation to PTSD and blast injury. This study may provide evidence that the medial prefrontal and parietal areas do not serve as biomarkers for the presence of PTSD and blast trauma, but more data are needed to draw firm conclusions. Language: en

Don LaRossa, M.D., 1941 to 2014.

Don LaRossa, M.D., 1941 to 2014.

Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy.

Patient safety and sleep experts advocate a protected sleep period for residents. We examined whether interns scheduled for a protected sleep period during overnight call would have better end-of-rotation assessments of burnout, depression, and empathy scores compared with interns without protected sleep periods and whether the amount of sleep obtained during on call predicted end-of-rotation assessments. We conducted a randomized, controlled trial with internal medicine interns at the Philadelphia Veterans Affairs Medical Center (PVAMC) and the Hospital of the University of Pennsylvania (HUP) in academic year 2009-2010. Four-week blocks were randomly assigned to either overnight call permitted under the 2003 duty hour standards or a protected sleep period from 12:30 am to 5:30 am. Participants wore wrist actigraphs. At the beginning and end of the rotations, they completed the Beck Depression Inventory (BDI-II), Maslach Burnout Inventory (MBI-HSS), and Interpersonal Reactivity Index (IRI). A total of 106 interns participated. There were no significant differences between groups in end-of-rotation BDI-II, MBI-HSS, or IRI scores at either location (P > .05). Amount of sleep while on call significantly predicted lower MBI-Emotional Exhaustion (P < .003), MBI-Depersonalization (P < .003), and IRI-Personal Distress (P < .006) at PVAMC, and higher IRI-Perspective Taking (P < .008) at HUP. A protected sleep period produced few consistent improvements in depression, burnout, or empathy, although depression was already low at baseline. Possibly the amount of protected time was too small to affect these emotional states or sleep may not be directly related to these scores.

Wave reflections and left ventricular mass in aortic stenosis

Wave reflections and left ventricular mass in aortic stenosis Prasad Konda, Payman Zamani, Scott Akers, Prithvi Shiva Kumar, Shivapriya Peddireddy, Sanjal Desai, Amin Vakilipour, Chandrahasa Sarabu, Deepa Rawat, Preston Broderick, Julio A. Chirinos. Hospital of the University of Pennsylvania, Philadelphia, PA, United States; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, United States

A Randomized Trial of a Three-Hour Protected Nap Period in a Medicine Training Program

Protected sleep periods for internal medicine interns have previously resulted in increased amount slept and improved cognitive alertness but required supplemental personnel. The authors evaluated intern and patient outcomes associated with protected nocturnal nap periods of three hours that are personnel neutral. Randomized trial at Philadelphia Veterans Affairs Medical Center (PVAMC) Medical Service and Hospital of the University of Pennsylvania (HUP) Oncology Unit. During 2010-2011, four-week blocks were randomly assigned to a standard intern schedule (extended duty overnight shifts of up to 30 hours), or sequential protected sleep periods (phone sign-out midnight to 3:00 AM [early shift] intern 1; 3:00 to 6:00 AM [late shift] intern 2). Participants wore wrist Actiwatches, completed sleep diaries, and performed daily assessments of behavioral alertness. Between-group comparisons of means and proportions controlled for within-person correlations. HUP interns had significantly longer sleep durations during both early (2.40 hours) and late (2.44 hours) protected periods compared with controls (1.55 hours, P < .0001). At PVAMC sleep duration was longer only for the late shift group (2.40 versus 1.90 hours, P < .036). Interns assigned to either protected period were significantly less likely to have call nights with no sleep and had fewer attentional lapses on the Psychomotor Vigilance Test. Differences in patient outcomes between standard schedule months versus intervention months were not observed. Protected sleep periods of three hours resulted in more sleep during call and reductions in periods of prolonged wakefulness, providing a plausible alternative to 16-hour shifts.