Veterans Affairs Ann Arbor Healthcare Research Articles

Telepharmacy Model of Care

PurposeThis study assessed the feasibility of the Telepharmacy Model of Care, a medication review and deprescribing model for use in older adults, with innovations in cognitive and functional evaluation, in telemedicine delivery, and in the use of a pharmacy technician. MethodsThis retrospective medical record review/abstraction analyzed (from March 1, 2022, to December 31, 2022) data from US veteran participants in a pilot implementation (April 13, 2021, to May 20, 2022) of the Telepharmacy Model of Care at the Veterans Affairs Ann Arbor Healthcare System (Ann Arbor, Michigan). The project team assessed and made recommendations about multiple factors in medication management: medication list accuracy; safety of medications and their combinations; older adults' cognition, health literacy, and physical abilities and impairments in self-managing medications; and caregivers' ability to compensate for those impairments. FindingsThe pilot included 60 US veterans (mean age, 75 years [range, 59–93 years]; 97% were men). Overall, participants were successful in using telemedicine (98%). Encounters required 30 to 45 minutes for the visit and 20 minutes for follow-up and documentation (P = 0.14 pharmacist vs pharmacy technician). The median number of medications per patient was 18. A total of 57% of patients had four or more medication-related discrepancies; fewer patients experienced medication-adherence problems, drug–drug interactions, problematic medication combinations, and untreated/undertreated conditions. Using the Safe Medication Algorithm for Older Adults tool, 35% were identified as taking a Red Flag medication (contraindicated in older adults), and 74%, a High Risk medication (eg, an anticoagulant). A total of 37% had cognitive and health literacy impairments, and 45%, physical impairments, interfering with the ability to self-manage medications. Recommendations on deprescribing were made in 98% of patients. ImplicationThe telemedicine-based and pharmacist/pharmacy technician–delivered model was a feasible method for addressing comprehensive medication review and deprescribing in these cognitively and functionally impaired US veterans.

Comparison of Administrative versus Electronic Health Record-based Methods for Identifying Sepsis Hospitalizations.

Rationale: Despite the importance of sepsis surveillance, no optimal approach for identifying sepsis hospitalizations exists. The Centers for Disease Control and Prevention Adult Sepsis Event Definition (CDC-ASE) is an electronic medical record-based algorithm that yields more stable estimates over time than diagnostic coding-based approaches but may still result in misclassification. Objectives: We sought to assess three approaches to identifying sepsis hospitalizations, including a modified CDC-ASE. Methods: This cross-sectional study included patients in the Veterans Affairs Ann Arbor Healthcare System admitted via the emergency department (February 2021 to February 2022) with at least one episode of acute organ dysfunction within 48 hours of emergency department presentation. Patients were assessed for community-onset sepsis using three methods: 1) explicit diagnosis codes, 2) the CDC-ASE, and 3) a modified CDC-ASE. The modified CDC-ASE required at least two systemic inflammatory response syndrome criteria instead of blood culture collection and had a more sensitive definition of respiratory dysfunction. Each method was compared with a reference standard of physician adjudication via medical record review. Patients were considered to have sepsis if they had at least one episode of acute organ dysfunction graded as "definitely" or "probably" infection related on physician review. Results: Of 821 eligible hospitalizations, 449 were selected for physician review. Of these, 98 (21.8%) were classified as sepsis by medical record review, 103 (22.9%) by the CDC-ASE, 132 (29.4%) by the modified CDC-ASE, and 37 (8.2%) by diagnostic codes. Accuracy was similar across the three methods of interest (80.6% for the CDC-ASE, 79.6% for the modified CDC-ADE, and 84.2% for diagnostic codes), but sensitivity and specificity varied. The CDC-ASE algorithm had sensitivity of 58.2% (95% confidence interval [CI], 47.2-68.1%) and specificity of 86.9% (95% CI, 82.9-90.2%). The modified CDC-ASE algorithm had greater sensitivity (69.4% [95% CI, 59.3-78.3%]) but lower specificity (81.8% [95% CI, 77.3-85.7%]). Diagnostic codes had lower sensitivity (32.7% [95% CI, 23.5-42.9%]) but greater specificity (98.6% [95% CI, 96.7-99.55%]). Conclusions: There are several approaches to identifying sepsis hospitalizations for surveillance that have acceptable accuracy. These approaches yield varying sensitivity and specificity, so investigators should carefully consider the test characteristics of each method before determining an appropriate method for their intended use.

Longitudinal Dynamic in Weight Loss Impacts Clinical Outcomes for Veterans Undergoing Curative Surgery for Colorectal Cancer.

Definitions of malnutrition imperfectly reflect nutritional status or predict perioperative consequences. We sought to identify predictive nutritional trends by examining the effect of preoperative weight on postoperative outcomes in patients with colorectal cancer (CRC). This retrospective review examined 148 patients with CRC treated with curative-intent surgery at the Veterans Affairs Ann Arbor Healthcare System in Michigan from January 1, 2015 to December 31, 2019. We evaluated weight dynamics of patients, starting 1 year before cancer diagnosis until 1 year after surgery. We evaluated the association of these weight dynamics with surgical outcomes. Primary outcomes observed were hospital readmission and length of stay (LOS), chemotherapy completion, and delayed recovery defined as abnormal clinical developments. There were 115 patients in the colon cancer (CC) cohort and 33 in the rectal cancer (RC) cohort. Low preoperative albumin (< 3.5 g/dL) was present in 25 patients with CC (22%) and 11 patients with RC (33%). Six-month preoperative weight loss of at least 3% occurred in 32 patients with CC (36%). Delayed recovery was observed in 35 patients with CC (30%) and 21 patients with RC (64%). Nutrition consultation rates for the CC and RC groups were 15% and 36%, respectively, before the operation; 95% and 100%, respectively, for postoperative inpatients; and 12% and 73%, respectively, for postoperative outpatients. Six-month preoperative weight loss of ≥ 3% was significantly associated with delayed recovery (P < .001) and 60-day readmissions (P = .015) but not increased LOS or chemotherapy noncompletion. A ≥ 3% weight loss 6 months preceding curative surgery for CRC was associated with adverse outcomes. An intensive nutrition prehabilitation program initiated at the time of cancer diagnosis is needed and may reduce associated complications.

Safety and Efficacy of GLP-1 Receptor Agonists and SGLT2 Inhibitors Among Veterans With Type 2 Diabetes.

Choosing the best medication regimen for a patient with type 2 diabetes mellitus (T2DM) depends on glycemic control, adherence, adverse effect profile, and comorbid conditions. Two new medication classes, glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i), have demonstrated cardiovascular and renal protective properties, creating a new way to care for patients with T2DM. This study evaluated the safety and efficacy of the combined use of GLP-1 RA and SGLT2i medications in a veteran population with T2DM. We conducted a pre-post, retrospective chart review of patients at the Veterans Affairs Ann Arbor Healthcare System in Michigan who were prescribed both a GLP-1 RA and SGLT2i medications. The primary objective was to determine the effect on hemoglobin A1c levels (HbA1c) at 12 weeks when using a GLP-1 RA and SGLT2i in combination. HbA1c levels decreased by 1% after 12 weeks of combination therapy from baseline (P < .001), and this reduction was sustained through the duration of the study period. At 26 and 56 weeks of combination therapy, body weight decreased by about 5 kg (5%) from baseline (P < .001). Systolic blood pressure (BP) reduction from baseline reached statistical significance after 26 and 52 weeks of combination therapy (P < .01 and P < .05, respectively). There was no significant change in diastolic BP, serum creatinine, or estimated glomerular filtration rate during the study period. The combined use of GLP-1 RA and SGLT2i resulted in statistically significant improvement in HbA1c levels, weight, and systolic BP compared with separate use.

Vaccine breakthrough infections in veterans hospitalized with coronavirus infectious disease-2019: A case series

BackgroundWhile Severe Acute Respiratory Syndrome Coronavirus-2 vaccine breakthrough infections are expected, reporting on breakthrough infections requiring hospitalization remains limited. This observational case series report reviewed 10 individuals hospitalized with vaccine breakthrough infections to identify patient risk factors and serologic responses upon admission. MethodsElectronic medical records of BNT162b2 (Pfizer-BioNTech) or mRNA-1732 (Moderna) vaccinated patients admitted to Veterans Affairs Ann Arbor Healthcare System with newly diagnosed Coronavirus Infectious Disease 2019 (COVID-19) between March 15, 2021 and April 15, 2021 were reviewed. Patient variables, COVID-19 lab testing including anti-S IgM, anti-N IgG antibodies, and hospital course were recorded. Based on lab testing, infections were defined as acute infection or resolving/resolved infection. ResultsOf the 10 patients admitted with breakthrough infections, all were >70 years of age with multiple comorbidities. Mean time between second vaccine dose and COVID-19 diagnosis was 49 days. In the 7 individuals with acute infection, none had observed serologic response to mRNA vaccination, 5 developed severe disease, and 1 died. Three individuals had anti-N IgG antibodies and a high polymerase chain reaction cycle threshold value, suggesting resolving/resolved infection. ConclusionsGiven the variability of vaccine breakthrough infections requiring hospitalization, serologic testing may impart clarity on timing of infection and disease prognosis. Individuals at risk of diminished response to vaccines and severe COVID-19 may also benefit from selective serologic testing after vaccination to guide risk mitigation strategies in a post-pandemic environment.

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Alternative cardiac intensive care unit locations during the COVID-19 pandemic at an academic medical center

Effects of an Electronic Medical Record Intervention on Appropriateness of Transthoracic Echocardiograms: A Prospective Study

Transthoracic echocardiograms (TTEs) account for approximately half of U.S. spending on cardiac imaging. We developed an electronic medical record (EMR)-based decision-support algorithm for TTE ordering and hypothesized that it would increase the appropriateness of TTE orders. This prospective observational study was performed at the Veterans Affairs Ann Arbor Healthcare System. From October to December 2016 (preintervention), consecutive TTEs ordered in the inpatient, outpatient, and emergency department settings were included. In May 2017, a decision-support algorithm was incorporated into the EMR, giving immediate feedback to providers. Chart review was performed for TTEs ordered from June to August 2017 (early intervention) and from June to August 2018 (late intervention). Appropriateness was determined based on the 2011 appropriate use criteria for echocardiography. Appropriate TTE orders increased from 87.6% preintervention to 94.5% at early intervention (z=0.00018) but decreased to 90.0% at late intervention (z=0.51, compared with preintervention). Among patients with no previous TTEs in our system, 95.3% of TTEs were appropriate, compared with 87.7% of TTEs for patients with prior TTEs within 30days prior (odds ratio=2.85; 95% CI, 1.18-6.31; P=.005). The EMR algorithm initially increased the percentage of appropriate TTEs, but this effect decayed over time. Further study is needed to develop EMR-based interventions that will have lasting impacts on provider ordering patterns.

Age and Life-Sustaining Treatment Preferences in Parkinson Disease.

Advance Care Planning (ACP) is one of 10 key elements in the American Academy of Neurology Parkinson disease (PD) clinical practice quality measures. We know little about how aging influences ACP views in people with PD. We conducted a cross-sectional survey of 39 participants (mean age 70.3 years; range: 52-81) with PD to explore correlations between older age and life-sustaining treatment preferences while controlling for confounders including years of education, Montreal Cognitive Assessment score and Movement Disorders Society Unified Parkinson's disease Rating Scale motor score. Scenarios asked participants to choose their level of interest in pursuing life-sustaining measures in the setting of specific medical illnesses including stroke, metastatic cancer, severe heart attack, and dementia. All participants were men and were recruited from the Veterans Affairs Ann Arbor Healthcare System. In the hypothetical stroke, metastatic colon cancer, and dementia scenarios, older age correlated with more aggressive care goals related to the use cardiopulmonary resuscitation to treat cardiopulmonary arrest. Advancing age in PD may correlate with paradoxically more aggressive goals as it relates to life-sustaining treatment preferences including cardiopulmonary resuscitation. This may reflect a response to heightened concern among older adults with PD about the potential for compromised autonomy in the setting of aging.

Creating an Intensive Care Unit From a Postanesthesia Care Unit for the COVID-19 Surge at the Veterans Affairs Ann Arbor Healthcare System.

To prepare for the predicted surge of patients with COVID-19 in Southeast Michigan, the US Department of Veterans Affairs Ann Arbor Healthcare System engineered, built, and staffed a 12-bed intensive care unit (ICU) from the existing postanesthesia care unit (PACU). Considerations including floor planning, reversal of airflow, strict airborne precautions, sealing off a dedicated nursing station, and developing an infection control plan in an open care unit. A staffing model was created that included anesthesiologist intensivists, advanced practice providers, residents, certified registered nurse anesthetists, and perioperative nurses working alongside ICU trained nurses. Challenges arose in infection control, communication, mechanical ventilation using anesthesia machines, providing renal replacement therapy, and maintaining patient privacy in an open unit. This article describes the setup, challenges, and solutions that allowed the creation of the PACU-ICU to help serve veterans and civilians during a time of unprecedented strain on the health care system due to COVID-19.

‘What I Wish My Surgeon Knew’: A Novel Approach to Promote Empathic Curiosity in Surgery

Physician empathy is associated with a variety of superior patient and physician outcomes. Teaching physicians to practice empathic curiosity is challenging however, and relatively few efficient and effective methods have been proposed toward this end. The goal of this study was to evaluate the impact and feasibility of a novel approach to foster empathic curiosity during surgical training. We used an exploratory qualitative approach for our study. Postoperative patients at a single hospital were invited to participate in brief semistructured interviews to better understand their unmet needs. The interview began with the question, "What do you wish your surgeon knew about you?" We audio recorded and transcribed each patient interview. We then iteratively read the transcripts, applied an inductive approach to coding, and used qualitative content analysis to identify themes. Veterans Affairs Ann Arbor Healthcare System, an academic-affiliated tertiary care facility. Patients who underwent general surgery procedures (n = 23) between July and August 2017. Of those who provided demographic information (n = 21), all were male and 95% were white with a mean age of 63.9 (34-77) years. Of these, 33% (n = 7) of patients experienced a postoperative complication. Patients described 3 broad categories of unmet need in the perioperative setting including: (i) being treated holistically and with dignity; (ii) using clear communication and delineating provider roles; and (iii) setting specific and realistic expectations. Promoting the use of empathically curious questions, such as "What do you wish your surgeon knew about you?" may help surgical trainees to identify unmet needs that are crucial for optimizing surgical care.

Patient Attitudes Toward Individualized Recommendations to Stop Low-Value Colorectal Cancer Screening

Guidelines for colorectal cancer (CRC) screening recommend an individualized approach in older adults that is informed by consideration of life expectancy and cancer risk. However, little is known about how patients perceive individualized screening recommendations. To assess veterans' attitudes toward and comfort with cessation of low-value CRC screening (defined as screening in a patient for whom the benefit is expected to be small based on quantitative estimates from hypothetical risk calculators). This survey study included patients older than 50 years who had undergone prior screening colonoscopy with normal results at the Veterans Affairs Ann Arbor Healthcare System. A total of 1500 surveys were mailed to potential participants from November 1, 2010, to January 1, 2012. Survey data were analyzed from January 1, 2016, to December 31, 2017. Response to the question, "If you personally had serious health problems that were likely to shorten your life and your doctor did not think screening would be of much benefit based on the calculator, how comfortable would you be with not getting any more screening colonoscopies?" Of the 1500 surveys mailed, 85 were returned to sender, leaving 1415 potential respondents; 1054 of these respondents (median age range, 60-69 years; 884 [85.9%] white and 965 [94.2%] male) completed the survey (response rate, 74.5%). A total of 300 (28.7%) were not at all comfortable with cessation of low-value CRC screening, and 509 (49.3%) thought that age should never be used to decide when to stop screening. In addition, 332 (31.7%) thought it was not at all reasonable to use life expectancy calculators, and 255 (24.3%) thought it was not at all reasonable to use CRC risk calculators to guide these decisions. In ordered logistic regression analysis, factors associated with more comfort with screening cessation were (1) higher trust in physician (odds ratio [OR], 1.19; 95% CI, 1.07-1.32), (2) higher perceived health status (OR, 1.41; 95% CI, 1.23-1.61), and (3) higher barriers to screening (OR, 1.20; 95% CI, 1.11-1.30). Factors that were associated with less comfort with screening cessation included (1) greater perceived effectiveness of screening (OR, 0.86; 95% CI, 0.80-0.94) and (2) greater perceived threat of CRC (OR, 0.81; 95% CI, 0.73-0.89). The findings suggest that many veterans have strong preferences against screening cessation even when given detailed information about why the benefit may be low. Efforts to tailor screening recommendations may be met by resistance unless they are accompanied by efforts to address underlying perceptions about the benefit of screening.

Efficacy of Prolonged Exposure Therapy, Sertraline Hydrochloride, and Their Combination Among Combat Veterans With Posttraumatic Stress Disorder

ImportanceMeta-analyses of treatments for posttraumatic stress disorder (PTSD) suggest that trauma-focused psychotherapies produce greater benefits than antidepressant medications alone.ObjectiveTo determine the relative efficacy of prolonged exposure therapy plus placebo, prolonged exposure therapy plus sertraline hydrochloride, and sertraline plus enhanced medication management in the treatment of PTSD.Design, Setting, and ParticipantsThe Prolonged Exposure and Sertraline Trial was a randomized, multisite, 24-week clinical trial conducted at the Veterans Affairs Ann Arbor Healthcare System, Veterans Affairs San Diego Healthcare System, Ralph H. Johnson Veterans Affairs Medical Center, and Massachusetts General Hospital Home Base Veterans Program between January 26, 2012, and May 9, 2016. Participants and clinicians were blinded to pill condition, and outcome evaluators were blinded to assignment. Participants completed assessments at weeks 0 (intake), 6, 12, 24, and 52 (follow-up). Participants (N = 223) were service members or veterans of the Iraq and/or Afghanistan wars with combat-related PTSD and significant impairment (Clinician-Administered PTSD Scale score, ≥50) of at least 3 months’ duration. Analyses were on an intent-to-treat basis.InterventionParticipants completed up to thirteen 90-minute sessions of prolonged exposure therapy by week 24. Sertraline dosage was titrated during a 10-week period and continued until week 24; medication management was manualized.Main Outcomes and MeasuresThe primary outcome was symptom severity of PTSD in the past month as assessed by the Clinician-Administered PTSD Scale score at week 24.ResultsOf 223 randomized participants, 149 completed the study at 24 weeks, and 207 (180 men and 27 women; mean [SD] age, 34.5 [8.3 years]) were included in the intent-to-treat analysis. Modified intent-to-treat analysis using a mixed model of repeated measures showed that PTSD symptoms decreased significantly during the 24 weeks (sertraline plus enhanced medication management, 33.8 points; prolonged exposure therapy plus sertraline, 32.7 points; and prolonged exposure therapy plus placebo, 29.4 points; β,–9.39; 95% CI, −11.62 to −7.16; P < .001); however, slopes did not differ by treatment group (prolonged exposure therapy plus placebo group, –9.39; sertraline plus enhanced medication management group, –10.37; and prolonged exposure therapy plus sertraline group, –9.99; P = .81).Conclusions and RelevanceNo difference in change in PTSD symptoms or symptom severity at 24 weeks was found between sertraline plus enhanced medication management, prolonged exposure therapy plus placebo, and prolonged exposure therapy plus sertraline.Trial RegistrationClinicalTrials.gov Identifier: NCT01524133

Impact of a Pharmacist-led Cardiology Pharmacotherapy Clinic on Chronic Heart Failure Management

Introduction There are limited data on the impact of pharmacist-led heart failure (HF) clinics on care processes and outcomes. We compared the impact of pharmacist interventions in a cardiology pharmacotherapy clinic (CPC) versus standard care in general cardiology and HF subspecialty clinics on medication titration and non-fatal HF events in patients with HF with reduced ejection fraction (HFrEF) at the Veterans Affairs Ann Arbor Healthcare System (VAAAHS). Hypothesis Patients referred to CPC will be more likely to achieve target doses of guideline-recommended therapies and have fewer non-fatal HF events when compared to general cardiology. Methods This was a single-center retrospective chart review conducted at the VAAAHS in HFrEF patients (New York Heart Association Class II-IV) enrolled in general cardiology, HF subspecialty clinic, or CPC from July 1, 2009 to September 7, 2016. Exclusion criteria included terminal illness, dementia, investigational drug use, nursing home resident, and hospitalization in last month. The primary outcome was the proportion of patients on goal dose guideline-recommended therapies after 1 year of follow-up. Other outcomes included non-fatal HF events, defined as ER visits and hospital admissions for HF. Between-group differences were evaluated by t-testing or chi-square, and pre-post differences by McNemar's test. Results A total of 240 patients were evaluated and followed for 1 year. Patients in the CPC had an intermediate risk profile between general cardiology and HF subspecialty clinics. Patients referred to CPC were similarly likely to be on goal doses of ACEI/valsartan (ACE/ARB), evidence-based beta blockers (carvedilol/metoprolol succinate/bisoprolol; BB), and mineralocorticoid antagonists (MRA) as general cardiology, and less likely to be on target dose at baseline when compared to the HF subspecialty clinic. Between referral and 1 year of follow-up, the proportion of patients on goal-dose ACE/ARB (p = 0.02) and BB (p Table ). There were slightly more ER visits in CPC patients, but no between-clinic differences in hospital admissions. Conclusions Patients with HFrEF referred to a pharmacist-led clinic had more effective titration of evidence-based medications than through usual care in general cardiology.

Spreading Blame For Prescription Drug AbuseDrug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It’s So Hard To Stop By Lembke Anna Baltimore (MD) : Johns Hopkins University Press , 2016 192 pp., $19.95

Spreading Blame For Prescription Drug AbuseDrug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, And Why It’s So Hard To Stop By Lembke Anna Baltimore (MD) : Johns Hopkins University Press , 2016 192 pp., $19.95

Posttraumatic stress disorder symptoms, levels of social support, and emotional hiding in returning veterans.

The current study examines the associations among levels of social support, emotional hiding, and screening positive for posttraumatic stress disorder (PTSD) within a sample of 536 Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans. Michigan and Ohio OIF/OEF veterans were contacted to complete a postdeployment mental health screening questionnaire developed as part of the Department of Veterans Affairs Ann Arbor Healthcare System's Serving Returning Veterans Mental Health Program. Approximately 30% of veterans screened positive for PTSD. All sources of social support, as well as emotional hiding, were significantly associated with screening positive for PTSD. Each unit increase of emotional hiding from spouses or significant others, friends, and family was associated with a 32% to 44% increase in odds of screening positive for PTSD. Additional research is needed to examine constructs related to social support and PTSD, such as emotional hiding, in order to identify areas for intervention.

Evaluation of the Efficacy and Safety of a Hydrochlorothiazide to Chlorthalidone Medication Change in Veterans With Hypertension

BackgroundThere are few data available examining the clinical impact of switching patients from hydrochlorothiazide (HCTZ) to chlorthalidone for blood pressure management. ObjectivesThe goal of this study was to compare within-patient clinic blood pressure readings, serum electrolyte levels, and renal function markers before and after a medication change from HCTZ to chlorthalidone in a veteran population. MethodsThis was a retrospective, pre- and postmeasure, self-controlled study. Veterans Affairs Ann Arbor Healthcare System patients switched from HCTZ to chlorthalidone between January 1, 2001, and January 31, 2012, who had at least 1 follow-up clinic blood pressure reading recorded between 2 and 8 weeks from the date of the medication change were included in the study. Mean pre- and postmeasure values for systolic and diastolic clinic blood pressures, serum potassium, serum sodium, serum calcium, serum creatinine, and blood urea nitrogen were compared by using a 2-tailed, paired t test with a significance level (α) of 0.05. ResultsOf the 40 patients included in the study 95% were male, 65% were white, and the mean age was 64.9 (10.8) years. Both mean systolic (–15.8 mm Hg [95% CI, 8.9 to 22.6], P < 0.0001) and mean diastolic (–4.2 mm Hg [95% CI, 1.5 to 6.9], P = 0.0035) blood pressures showed statistically and clinically significant reductions after the medication change. A statistically significant decrease in mean sodium (–1.1 mmol/L [95% CI, 0.4 to 1.9], P = 0.003) and an increase in mean serum creatinine (0.06 mg/dL [95% CI, –0.09 to –0.02], P = 0.002) was observed; however, these changes may not be viewed as clinically significant by many practitioners. No statistically significant changes were observed in any of the other outcomes examined. Most patients (38 of 40) were taking at least 1 additional antihypertensive agent; 73% of patients were using ≥3 antihypertensive agents at the time of the medication change. ConclusionsIn patients with hypertension already taking HCTZ, switching to chlorthalidone seems to further reduce systolic and diastolic blood pressures without any clinically significant changes in renal function or electrolyte levels.

Cerebral Amyloid Deposition and Serotoninergic Innervation in Parkinson Disease

BACKGROUND Prior studies suggest that serotoninergic neurotransmission reduces β-amyloid (Aβ) production. OBJECTIVE To determine whether serotoninergic system degeneration in Parkinson disease promotes Aβ deposition, using in vivo positron emission tomographic probes of serotonin system integrity and Aβ deposition. DESIGN, SETTING, AND PATIENTS Cross-sectional study of 13 subjects with Parkinson disease from the movement disorders clinics at the University of Michigan Health System and Veterans Affairs Ann Arbor Healthcare System, with positron emission tomography using the serotonin transporter ligand carbon 11 ([11C])-labeled 3-amino-4-(2-dimethylaminomethyl-phenylsulfaryl)-benzonitrile (DASB) and the Aβ ligand [11C]Pittsburgh compound B. RESULTS Inverse correlations were found between DASB and Pittsburgh compound B distribution volume ratios in the neocortex (ρ=-0.577; P=.04) and striatum (ρ=-0.780; P=.002). CONCLUSION Serotoninergic system degeneration in Parkinson disease may promote the development of cerebral amyloidopathy.

Med Check

Med Check

Time to Treatment in Patients With Stage III Non–Small Cell Lung Cancer

To determine whether time to treatment (TTT) has an effect on overall survival (OS) in patients with unresectable or medically inoperable Stage III non-small cell lung cancer (NSCLC) and whether patient or treatment factors are associated with TTT. Included in the study were 237 consecutive patients with Stage III NSCLC treated at University of Michigan Hospital (UM) or the Veterans Affairs Ann Arbor Healthcare System (VA). Patients were treated with either palliative or definitive radiotherapy and radiotherapy alone (n = 106) or either sequential (n = 69) or concurrent chemoradiation (n = 62). The primary endpoint was OS. Median follow-up was 69 months, and median TTT was 57 days. On univariate analysis, the risk of death did not increase significantly with longer TTT (p = 0.093). However, subset analysis showed that there was a higher risk of death with longer TTT in patients who survived >or= 5 years (p = 0.029). Younger age (p = 0.027), male sex (p = 0.013), lower Karnofsky Performance Score (KPS) (p = 0.002), and treatment at the VA (p = 0.001) were significantly associated with longer TTT. However, on multivariate analysis, only lower KPS remained significantly associated with longer TTT (p = 0.003). Time to treatment is significantly associated with OS in patients with Stage III NSCLC who lived longer than 5 years, although it is not a significant factor in Stage III patients as a whole. Lower KPS is associated with longer TTT.

Just world beliefs, perceived stress, and health behavior: The impact of a procedurally just world*

Recent research suggests that a just world view may promote good health while low belief in a just world may deleteriously affect well-being. However, this research is limited in that specific components of justice beliefs that are important to health are not well articulated. Additionally, many potential pathways linking perceived fairness to physical health remain largely unexplored. In the present study, we examined how individual differences in both distributive (outcomes and allocations) and procedural (rules and processes) just world beliefs are associated with stress and health behavior. Participants were recruited from two universities (N = 426) to complete individual differences measures of procedural and distributive just world beliefs, and also measures of perceived stress, health behavior, and physical symptoms. Results suggested that procedural, but not distributive just world views were important to well-being. In particular, belief in a procedurally just world was associated directly with lower perceived stress, and also indirectly with adaptive health behaviors and fewer physical health complaints. In general, these results suggest that beliefs about a procedurally just world may be particularly important to well-being, while also suggesting specific directions and mechanisms for future attempts at developing justice-oriented health interventions. *Portions of this research were conducted while the first author was a postdoctoral researcher at the Center for Behavioral and Decision Sciences in Medicine (Veterans Affairs Ann Arbor Healthcare System & University of Michigan), and also a visiting instructor at Albion College (Albion, MI).