Puget Sound Health Care System Research Articles

Cumulative Blast Impulse Is Predictive for Changes in Chronic Neurobehavioral Symptoms Following Low Level Blast Exposure during Military Training.

Cumulative low-level blast exposure during military training may be a significant occupational hazard, increasing the risk of poor long-term outcomes in brain function. US Public Law 116-92 section717 mandates that US Department of Defense agencies document the blast exposure of each Service member to help inform later disability and health care decisions. However, which empirical measures of training blast exposure, such as the number of incidents, peak overpressure, or impulse, best inform changes in the neurobehavioral symptoms reflecting brain health have not been established. This study was approved by the US Army Special Operations Command, the University of North Carolina at Chapel Hill, and the VA Puget Sound Health Care System. Using methods easily deployable across different organizational structures, this study sought to identify and measure candidate risk factors related to career occupational blast exposure predictive of changes in neurobehavioral symptom burden. Blast dosimetry-symptom relationships were first evaluated in mice and then tested in a military training environment. In mice, the righting time neurobehavioral response was measured after exposure to a repetitive low-level blast paradigm modeled after Special Operations training. In the military training environment, 23 trainees enrolled in a 6-week explosive breaching training course, 13 instructors, and 10 Service member controls without blast exposure participated in the study (46 total). All participants provided weekly Neurobehavioral Symptom Inventory (NSI) surveys. Peak blast overpressure, impulse, total number of blasts, Time in Low-Level Blast Occupation, and Time in Service were analyzed by Bayesian analysis of regression modeling to determine their probability of influence on the post-training symptoms reported by participants. We tested the hypothesis that cumulative measures of low-level blast exposure were predictive of changes in neurobehavioral symptoms. In mice, repetitive blast resulted in reduced righting times correlated with cumulative blast impulse. In Service members, peak blast overpressure, impulse, total number of blasts, Time in Low-Level Blast Occupation, and Time in Service all showed strong evidence of influence on NSI scores after blast exposure. However, only models including baseline NSI scores and cumulative blast impulse provided significant predictive value following validation. These results indicate that measures of cumulative blast impulse may have utility in predicting changes in NSI scores. Such paired dosimetry-symptom measures are expected to be an important tool in safely guiding Service members' occupational exposure and optimizing force readiness and lethality.

0285 Sleep health in veteran population with and without mild traumatic brain injury

Abstract Introduction Sleep duration is frequently observed in military and Veteran populations. Some of this effect may result from exposure to traumatic brain injury (TBI) during military service. However, other features of combat deployment, circadian disruption, and chronic stress may contribute to poor sleep independent of the effects of TBI. In this study we tested whether combat deployment with or without TBI exposure was associated with poor sleep compared to civilian controls. Methods In a prospective study of Operation Enduring Freedom/Iraqi Freedom/ New Dawn Veterans with repeated blast mild TBI (mTBI) conducted at the VA Puget Sound Healthcare System, self-reported sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Age-matched civilians (CONciv) non-TBI deployed Veterans (CONdep) were included in the study for comparison. The outcomes of interest included the PSQI sum score and its key components scored as 0-3. One way ANOVA and paired comparison with Bonferroni adjustment for each component were performed . Results A total of 104 mTBI, 36 CONdep and 15 CONciv participants were included. Poor overall sleep quality (PSQI sum>5) was most frequently reported by mTBI participants, followed by CONdep and CONciv participants (80 % vs. 50 vs. 11, p< 0.0001). Across virtually every sleep feature, sleep impairment was most pronounced in mTBI participants followed by CONdep: PSQI sum (mTBI VS. CONdep vs. CONvic= 11.6 vs. 6.5 vs. 3, p< 0.0001), sleep duration (5.5 hrs vs. 6.6 vs. 7.1, p< 0.0001), sleep onset insomnia (2.1 vs. 1.3 vs. 0.3, p< 0.0001) , sleep maintenance insomnia (2.5 vs. 1.4 vs. 0.7, p< 0.0001), daytime sleepiness (1.3 vs. 0.6 vs. 0.4, p< 0.0001), daytime function (1.8 vs. 0.9 vs. 0.3, p< 0.0001) and sleep disturbance by pain (1.5 vs. 0.7 vs. 0.1, p< 0.0001). Both mTBI and CONdep groups had significantly worse sleep quality than the CONciv group. Conclusion Veterans with repetitive mTBI exhibited overall poor sleep quality and impaired sleep in multiple sleep domains. Deployed Veterans without TBI, but exhibited similar, but less severe sleep disruption. Future studies should explore how poor sleep quality may be related to the long-term effects of TBI and military deployment. Support (if any)

S261 Effect of a Patient Navigator on Colonoscopy Completion in FIT Positive Patients Refractory to Initial Scheduling Attempts

Introduction: Decreased time from positive fecal immunochemical test (FIT) to colonoscopy is associated with decreased morbidity and mortality from colorectal cancer. However, colonoscopy is often delayed or forgone for a variety of reasons. Prior studies have shown that patient navigation for FIT+ patients increases the likelihood of colonoscopy completion. The purpose of this study was to evaluate the impact of a patient navigator on improvement in colonoscopy completion in Veterans who had not completed timely colonoscopy after FIT+. Methods: Patients in the Veterans Affairs Puget Sound Health Care System with FIT+ between 1/1/2020 and 6/30/2021 who had not yet completed colonoscopy were randomized in 11/2021 to: 1) navigation with a mailed letter and phone call from a trained, non-clinical staff member, 2) mailed letter only, or 3) control. The patient navigator provided basic education to the patient, elicited barriers to care, and facilitated seamless interaction with the primary care team. Demographic variables were recorded from the medical record. The Care Assessment Need (CAN) score was used to assess comorbid status. Outcomes were assessed as of 6/1/2022. Binary logistic regression and Kaplan Meier analyses were performed using SPSS. Results: 170 FIT+ patients were identified and 56, 56, and 58 patients were assigned to the Navigator, Mailed Letter, and Control groups, respectively. Patient demographics were similar between cohorts (Table). Colonoscopy completion was significantly increased in the Navigator group (p < 0.05), while the letter alone had no significant impact (Table). Navigation was also associated with improved documentation of reasons for no colonoscopy (p < 0.05). Adjusting for measured covariates, compared to the Navigator group, the odds of colonoscopy completion was significantly lower for the Mailed Letter group (OR 0.31 (CI 0.14-0.67)) and the Control group (OR 0.37 (CI 0.17-0.78)). Kaplan Meier analysis (Figure) revealed statistically significant differences in time to colonoscopy between the three groups. Conclusion: Patient navigation with a trained non-clinical staff member significantly improves colonoscopy completion following FIT+ in patients who are refractory to initial attempts at timely colonoscopy. Mailing a letter alone had no significant benefit. Further efforts are needed to ensure timely and complete diagnostic evaluation of patients with FIT+ screening. This study was sponsored by a grant from the American Cancer Society.Figure 1.: Kaplan Meier for Colonoscopy Completion Following FIT+ (p = 0.05) Table 1. - Demographic Information and Descriptive Results Overall (n = 170) Navigator (n = 56) Mailed Letter Only (n = 56) Control (n = 58) Mean Age (years) 67.3 65.8 68.6 67.5 Sex (% men) 90.1 89.3 91.1 91.4 Race (% white) 80.1 76.8 85.7 79.3 Hispanic Status (% Hispanic) 0.01 0.0 0.02 0.0 Mean CAN Score 60.0 62.2 57.7 60.0 Referral to GI Placed (%) 82.9 87.5 85.7 75.9 Colonoscopy Completed (%) 28.8 41.1 23.2 22.4 Colonoscopy Completed or Appropriate Reason for no Colonoscopy (%) 47.1 66.1 33.9 39.7 Median Days from FIT+ to Colonoscopy 211 230 235 196

Postanesthesia Recovery Unit Optimization for Patients With Postictal Agitation Secondary to Electroconvulsive Therapy.

The occurrence of postictal agitation (PIA) can rapidly alter and intensify the level of care that electroconvulsive therapy (ECT) patients require during their recovery in the postanesthesia care unit (PACU). This operational analysis was undertaken to determine the impact PIA has on phase 1 PACU resources. This operational analysis was undertaken at the Seattle Division of the US Department of Veterans Affairs Puget Sound Health Care System. From August 2019 to April 2020, we prospectively collected data on the recovery from ECT of 61 unique patients who underwent a total of 334 ECT sessions. Utilization of PACU resources was assessed by determining the PACU length of stay (LOS), onset of PIA, severity of PIA, and duration of agitation in encounters complicated by PIA. Seventy-nine occurrences of PIA occurred during the 334 ECT encounters. The mean ± SD PACU LOS was longer in encounters complicated by the occurrence of PIA compared with those not complicated by PIA (72 ± 32 and 59 ± 18 minutes respectively; P -value <0.05). Postanesthesia care unit LOS and mean duration of agitation increased as severity of PIA increased. The occurrence of PIA can rapidly alter and intensify the level of care that ECT patients may require. Postictal agitation has a significant impact on the phase 1 PACU LOS of patients undergoing ECT. Phase 1 PACU staffing models should factor in the acute and prolonged care needs of patients who develop PIA during the recovery from ECT.

Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse

BackgroundThe benefits of removing small (≤6 mm), asymptomatic kidney stones endoscopically is unknown. Current guidelines leave such decisions to the urologist and the patient. A prospective study involving older, nonendoscopic technology and some retrospective studies favor observation. However, published data indicate that about half of small renal stones left in place at the time that larger stones were removed caused other symptomatic events within 5 years after surgery.MethodsWe conducted a multicenter, randomized, controlled trial in which, during the endoscopic removal of ureteral or contralateral kidney stones, remaining small, asymptomatic stones were removed in 38 patients (treatment group) and were not removed in 35 patients (control group). The primary outcome was relapse as measured by future emergency department visits, surgeries, or growth of secondary stones.ResultsAfter a mean follow-up of 4.2 years, the treatment group had a longer time to relapse than the control group (P<0.001 by log-rank test). The restricted mean (±SE) time to relapse was 75% longer in the treatment group than in the control group (1631.6±72.8 days vs. 934.2±121.8 days). The risk of relapse was 82% lower in the treatment group than the control group (hazard ratio, 0.18; 95% confidence interval, 0.07 to 0.44), with 16% of patients in the treatment group having a relapse as compared with 63% of those in the control group. Treatment added a median of 25.6 minutes (interquartile range, 18.5 to 35.2) to the surgery time. Five patients in the treatment group and four in the control group had emergency department visits within 2 weeks after surgery. Eight patients in the treatment group and 10 in the control group reported passing kidney stones.ConclusionsThe removal of small, asymptomatic kidney stones during surgery to remove ureteral or contralateral kidney stones resulted in a lower incidence of relapse than nonremoval and in a similar number of emergency department visits related to the surgery. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Veterans Affairs Puget Sound Health Care System; ClinicalTrials.gov number, NCT02210650.)

Characterizing Veterans Crisis Line callers and regional follow-up efforts

ABSTRACT The Veterans Crisis Line (VCL) is a national resource offering Veterans 24/7 access to crisis responders and follow-up by a licensed mental health clinician at a Veterans Affairs medical center. This quality improvement project aimed to improve local suicide prevention efforts at the VA Puget Sound Health Care System by characterizing 344 VCL calls and outcomes. Data was extracted from documentation by national VCL responders and local Suicide Prevention Team members. Overall, most callers were assessed at low-to-moderate risk. VCL responders were more likely to assess callers reporting suicidal ideation (SI) as high-risk, but less likely to assess those reporting financial issues as high-risk. VCL calls about SI, about physical health, or that occurred on weekends were more likely to end with immediate evaluation (i.e., emergency room, evaluated by first-responders) compared to their respective comparison groups. VCL calls assessed as high-risk were more likely to report SI during local follow-up contact, whereas VCL calls ending in immediate evaluation (i.e., emergency room, evaluated by first-responders) were less likely to report SI during follow-up with the local VA clinician; 17% of VCL calls without SI reported SI at follow-up. Training of local Suicide Prevention Team members should include that SI can change rapidly and requires assessment regardless of SI during the VCL call.

Best Practices for an Equitable Covid-19 Vaccination Program

Summary An array of factors hamper equitable Covid-19 vaccine deployment in the United States along racial, ethnic, age, and geographic lines. The Puget Sound Veterans Affairs facility developed a multidisciplinary vaccine delivery strategy to forestall systematic inequities in receipt of vaccination among veterans using methods that can be used by other health care organizations. The VA Puget Sound Health Care System deployed targeted outreach to individual patients on the basis of a simple score consisting of the sum of risk factors for severe Covid-19 disease and high-risk race or ethnicity. The health system then conducted sequential outreach using multiple communication modalities; worked with trusted community stakeholders to publicize and deploy mobile clinics to underserved areas; and monitored vaccination coverage rates by age, race, sex, and rural status at prespecified intervals and adjusted operations to ensure equity. Vaccination rates were highest in Black, multiracial, and Hispanic veterans compared with white veterans during the vaccine drive, a finding that persisted after the drive.

Preliminary Evaluation of an Order Template to Improve Diagnosis and Testosterone Therapy of Hypogonadism in Veterans.

Testosterone therapy is indicated for the treatment of hypogonadism. Evidence-based guidelines recommend testosterone treatment only for men with symptoms and signs of testosterone deficiency and consistently low serum testosterone concentrations; luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurements and discussion of risks and benefits of testosterone prior to therapy. However, the US Department of Veterans Affairs (VA) Office of the Inspector General (OIG) report found that health care providers were adhering poorly to guideline recommendations for the diagnosis and treatment of men with hypogonadism. A prior authorization drug request (PADR) testosterone order template was implemented at VA Puget Sound Health Care System. A retrospective chart review was conducted in veterans who were prescribed testosterone and had no previous prescription in the prior year. Eligible veterans were evaluated 6 months before (pretemplate) and after (posttemplate) implementation of the template, and 3 months after removal of alternative testosterone ordering pathways (posttemplate/no alternative ordering pathways) that were discovered after PADR template implementation. We assessed the proportion of eligible veterans with documented symptoms of testosterone deficiency; appropriate diagnosis and evaluation of hypogonadism with ≥ 2 low serum testosterone and LH and FSH levels; and discussion of risks and benefits of testosterone treatment. In the pretemplate period, only 20 of 80 eligible veterans (25%) had a completed PADR for testosterone. In the posttemplate period, 18 of 45 (44%) eligible veterans had a completed PADR but only 7 (17%) had the testosterone order template completed. In the posttemplate/no alternative ordering pathways period, 13 (68%) and 11 (58%) of 19 eligible veterans had a completed PADR and testosterone order template, respectively. In all 3 periods, documentation of clinical symptoms and a discussion of risks and benefits were similar. In contrast, the proportion of veterans who had ≥ 2 low testosterone levels with LH and FSH levels measured in the posttemplate and posttemplate/no alternative ordering pathways periods were higher (41% and 37%, respectively) vs the pretemplate period (23%). Veterans with documented clinical symptoms, discussion of risks and benefits, and ≥ 2 low testosterone with gonadotropin measurements were 100%, 57%, and 71%, respectively, in the posttemplate/no alternative ordering pathways period. Implementation of a PADR order template may be a promising approach to improve the diagnosis of hypogonadism and appropriate testosterone therapy in accordance with established evidence-based clinical practice guidelines, particularly in veterans who are receiving new prescriptions.

Discrimination Persistent Barrier to Care for OUD Patients

Discrimination Persistent Barrier to Care for OUD Patients

Experience of a Pituitary Clinic for US Military Veterans With Traumatic Brain Injury.

Traumatic brain injury (TBI) is considered the "signature" injury of veterans returning from wartime conflicts in Iraq and Afghanistan. While moderate/severe TBI is associated with pituitary dysfunction, this association has not been well established in the military setting and in mild TBI (mTBI). Screening for pituitary dysfunction resulting from TBI in veteran populations is inconsistent across Veterans Affairs (VA) institutions, and such dysfunction often goes unrecognized and untreated. This work aims to report the experience of a pituitary clinic in screening for and diagnosis of pituitary dysfunction. A retrospective analysis was conducted in a US tertiary care center of veterans referred to the VA Puget Sound Healthcare System pituitary clinic with a history of TBI at least 12 months prior. Main outcome measures included demographics, medical history, symptom burden, baseline hormonal evaluation, brain imaging, and provocative testing for adrenal insufficiency (AI) and adult-onset growth hormone deficiency (AGHD). Fatigue, cognitive/memory problems, insomnia, and posttraumatic stress disorder were reported in at least two-thirds of the 58 patients evaluated. Twenty-two (37.9%) were diagnosed with at least one pituitary hormone deficiency, including 13 (22.4%) AI, 12 (20.7%) AGHD, 2 (3.4%) secondary hypogonadism, and 5 (8.6%) hyperprolactinemia diagnoses; there were no cases of thyrotropin deficiency. A high prevalence of chronic AI and AGHD was observed among veterans with TBI. Prospective, larger studies are needed to confirm these results and determine the effects of hormone replacement on long-term outcomes in this setting.

Multicenter, Head-to-Head, Real-World Validation Study of Seven Automated Artificial Intelligence Diabetic Retinopathy Screening Systems.

OBJECTIVEWith rising global prevalence of diabetic retinopathy (DR), automated DR screening is needed for primary care settings. Two automated artificial intelligence (AI)–based DR screening algorithms have U.S. Food and Drug Administration (FDA) approval. Several others are under consideration while in clinical use in other countries, but their real-world performance has not been evaluated systematically. We compared the performance of seven automated AI-based DR screening algorithms (including one FDA-approved algorithm) against human graders when analyzing real-world retinal imaging data.RESEARCH DESIGN AND METHODSThis was a multicenter, noninterventional device validation study evaluating a total of 311,604 retinal images from 23,724 veterans who presented for teleretinal DR screening at the Veterans Affairs (VA) Puget Sound Health Care System (HCS) or Atlanta VA HCS from 2006 to 2018. Five companies provided seven algorithms, including one with FDA approval, that independently analyzed all scans, regardless of image quality. The sensitivity/specificity of each algorithm when classifying images as referable DR or not were compared with original VA teleretinal grades and a regraded arbitrated data set. Value per encounter was estimated.RESULTSAlthough high negative predictive values (82.72–93.69%) were observed, sensitivities varied widely (50.98–85.90%). Most algorithms performed no better than humans against the arbitrated data set, but two achieved higher sensitivities, and one yielded comparable sensitivity (80.47%, P = 0.441) and specificity (81.28%, P = 0.195). Notably, one had lower sensitivity (74.42%) for proliferative DR (P = 9.77 × 10−4) than the VA teleretinal graders. Value per encounter varied at $15.14–$18.06 for ophthalmologists and $7.74–$9.24 for optometrists.CONCLUSIONSThe DR screening algorithms showed significant performance differences. These results argue for rigorous testing of all such algorithms on real-world data before clinical implementation.

Polysubstance Use Common in Buprenorphine Deaths

Polysubstance Use Common in Buprenorphine Deaths

Cognitive trajectory changes in African American veterans with combat PTSD

AbstractBackgroundEpidemiological study shows that posttraumatic stress disorder (PTSD) has been linked to increased risk of Alzheimer’s disease (AD). However, longitudinal study of Holocaust survivors does not show accelerated cognitive decline in those with PTSD. We compared cross‐sectional and longitudinal cognitive function in a cohort of African American (AA) veterans with combat PTSD to that in a cohort of elderly AA males without PTSD to determine if PTSD was associated with a more rapid cognitive decline.MethodEighteen male AA Veterans with the combat PTSD who received treatment at the VA Puget Sound Health Care System in Seattle, participated in a longitudinal study of aging at UW ADRC between 2007‐16. Fifty‐four male AA subjects without PTSD were selected from the National Alzheimer’s Coordinating Center (NACC) dataset and matched by age (± 4 years), education (± 1 year), and MMSE score (± 2 points) as a comparison group (Table 1). Longitudinal data were available for 16 PTSD+ and 40 PTSD‐ participants. All participants were free of dementia or Mild Cognitive Impairment (MCI) and were assessed using the NACC Uniform Data Set version 2 (UDS 2.0) neuropsychological test battery. Linear mixed effects regression was used to estimate mean cognitive outcome at baseline and mean slope of change over follow‐up.ResultAs shown in the Figure 1, mean MMSE score at baseline and slope of change did not significantly differ between those with and without PTSD (p ≥ .35). The mean immediate and delayed recall scores from the Wechsler Memory Scale‐Revised Logical Memory were similar at baseline (p &gt;.98) and showed no difference in change from baseline (p &gt; .69). Similarly, there were no statistical differences in means at baseline or slope of change by group for Digit Span Forward and Backward, Category Fluency (animals and vegetables), WAIS‐R Digit Symbol test, and Trail Making Test (A and B) (all p‐values &gt;.27).ConclusionCognitive function in AA veterans with combat PTSD was comparable to AA men without PTSD over an average of 4 years. These findings need to be replicated in a larger cohort with a longer duration of follow‐up.

Multi-Institutional Collaborative Resident Education in the Era of COVID-19.

The 2019-2020 coronavirus pandemic has had a significant impact on all aspects of health care. Decrease in clinical and operative volume and limitations for conferences has drastically decreased educational opportunities for resident trainees. We describe the formation and initial success of the Collaborative Online Video Didactics lecture series, a multi-institutional online video didactics collaboration. Zoom data extraction and postlecture evaluation surveys were used to collect data on the impact of the pandemic on local educational activities as well as feedback about the lecture series. Lectures are being given by faculty from 35 institutions. The twice daily, hour-long webinar averages more than 470 live viewers per session with an average of 33.5 questions per session and has over 7,000 YouTube views of the recordings after the first 2 weeks. Viewers reported significant decreases in outpatient (75.2%), inpatient (64.9%) and operating room (77.7%) volumes at local programs, and only half (52.7%) of the survey responders indicated an increase in didactics locally. The lectures have been well-received, with over 90% of respondents giving the lecturers and series above average or excellent ratings. A significant majority of responders indicated that the lecture series has allowed for ongoing education opportunities during the pandemic (95.0%), helped to access faculty experts from other institutions (92.3%) and provided a sense of community connectedness during this period of social isolation (81.7%). We strongly encourage other institutions and trainees to participate in the didactic series and hope that this series can continue to evolve and be of benefit beyond the pandemic.

SAMHSA Issues Guidance on OUD Treatment During COVID-19

SAMHSA Issues Guidance on OUD Treatment During COVID-19

COVID-19 Lung Injury is Not High Altitude Pulmonary Edema.

Not applicable.

Mantle cell lymphoma relapsed after autologous stem cell transplantation: a single-center experience.

BackgroundAutologous stem cell transplantation (autoSCT) can extend remission of mantle cell lymphoma (MCL), but the management of subsequent relapse is challenging.MethodsWe examined consecutive patients with MCL who underwent autoSCT at Veterans Affairs Puget Sound Health Care System between 2009 and 2017 (N=37).ResultsTen patients experienced disease progression after autoSCT and were included in this analysis. Median progression free survival after autoSCT was 1.8 years (range, 0.3–7.1) and median overall survival after progression was only 0.7 years (range, 0.1 to not reached). The 3 patients who survived more than 1 year after progression were treated with ibrutinib.ConclusionOur findings suggest that ibrutinib can achieve relatively prolonged control of MCL progressing after autoSCT.

Comparing 4- and 6-week post-flap protocols in patients with spinal cord injury

Objective: For patients with spinal cord injury (SCI) who undergo flap surgery to treat pressure injuries (PIs), the optimal duration of post-operative bedrest to promote healing and successful remobilization to sitting is unknown. At the study center, the minimum duration of post-operative bedrest was changed from 4 to 6 weeks. The purpose of this study is to compare outcomes of patients who underwent flap surgery using bedrest protocols of different duration. Design: This was a retrospective review of all flap procedures completed at VA Puget Sound Health Care System from 1997 to 2016 to treat PIs in patients with SCI. Surgeries were excluded if they were not a flap (i.e. primary skin closure or graft), involved a non-pelvic region, or were a same-hospitalization revision of a prior surgery. The primary outcome of this investigation was the number of days between surgery and the first time the patient mobilized to sitting out of bed for 2 h with an intact surgical incision. Methods: 190 patients received a total of 286 flap surgeries from 1994 to 2016. A chart review of each case was completed to determine the planned duration of bedrest (4- vs 6-weeks), first date of successful mobilization out of bed for 2 h, length of stay post-surgery, and occurrence of complications such as dehiscence or need for operative revisions. Results: Among 286 primary surgeries, 171 surgeries used the 4-week protocol and 115 used the 6-week protocol. When compared to the 4-week protocol, patients treated with the 6-week protocol were slightly older, more likely to have a diagnosis of diabetes, and less likely to be current smokers. Healing was never achieved after 4 surgeries in the 4-week group and 2 surgeries in the 6-week group. With the analysis restricted to a single surgery per subject who achieved healing (109 treated with 4-week protocol and 75 with 6-week protocol), there was a significant difference in days until 2-h sitting: median 54 days for the 4-week protocol compared to 60 days for the 6-week protocol (p = 0.041). Up to about 60 days post-operatively, the 4-week protocol produced a greater proportion remobilized to sitting, and thereafter the proportion of patients successfully remobilized did not differ between protocols. Conclusions: The 6-week protocol was not associated with improved remobilization outcomes (reduced rates of dehiscence or surgical revisions), and the 4-week protocol resulted in a significantly shorter time to remobilization to sitting for 2 h as well as a shorter length of stay. We did not identify any subgroup of patients that benefited from the longer protocol.

Federal Judge Rules Safe Injection Site Is Legal

Federal Judge Rules Safe Injection Site Is Legal

2058-P: Leptin and Adiponectin Concentrations Independently Predict Future Accumulation of Visceral Adiposity in Nondiabetic Japanese Americans

Objectives: The adipokines leptin and adiponectin are associated with change in body composition and are highly correlated, raising questions about whether they exert independent effects. We investigated whether these two adipokines are independently associated with regional body fat accumulation in a prospective study of Japanese Americans. Methods: Nondiabetic participants between the ages of 34 to 74 years were followed for 5 years to assess change in body composition. Leptin and adiponectin concentrations and single slice CT-measurements of intra-abdominal fat (IAF), abdominal (SCF) and thigh (TF) subcutaneous fat cross-sectional areas were evaluated at baseline and 5 year follow-up study visits. Multiple linear regression analysis was used to estimate the association between leptin and adiponectin and future 5-year accumulation of IAF. Results: 96 men and 95 women without diabetes included in this analysis had the following baseline mean (SD) values: age 45.7 (3.5) years and 46.4 (3.9) years; BMI 25.5 (3.1) kg/m2 and 24.0 (3.9) kg/m2; IAF 78.7 (38.6) cm2 and 62.1 (39.0) cm2; leptin concentration 4.5 (2.3) μg/L and 10.2 (5.2) μg/L; and adiponectin concentration 7.4 (3.2) μg/mL and 10.8 (4.7) μg/mL, respectively. Baseline leptin (β = 1.7722, p=0.014) and adiponectin concentrations (β = -0.4162, p&amp;lt;0.001) were significantly associated with ΔIAF over 5 years in multivariable models adjusting for age, sex, diabetes family history, weight change over 5 years, and baseline measurements of BMI, IAF, abdominal SCF, abdominal circumference, TF, and HOMA-IR. Conclusions: In nondiabetic Japanese Americans, baseline concentrations of leptin and adiponectin were independent predictors of IAF accumulation at 5 years. Higher levels of leptin and adiponectin were associated with greater and lesser accumulation of IAF, respectively. These relationships were independent of age, sex, insulin sensitivity, and body composition. Disclosure S. Song: None. S.E. Kahn: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Intarcia Therapeutics, Inc., Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk A/S. Consultant; Self; Neurimmune. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk A/S. D.L. Leonetti: None. W.Y. Fujimoto: None. E.J. Boyko: None. Funding National Institutes of Health DK31170, HL49293); University of Washington (DK017047, DK035816, RR-000037); VA Puget Sound Health Care System (to E.J.B., S.E.K.)