Central Alabama Veterans Health Care System

BACKGROUND: Veterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine's effectiveness in delivering endocrinology care from Atlanta-based endocrinologists. METHODS: We conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth. RESULTS: Thirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans. CONCLUSIONS: Specialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.

PURPOSE OF REVIEW: In the United States, the number of parathyroidectomies among patients with chronic dialysis has remained stable in the last decade. A fall in serum calcium concentration is common postparathyroidectomy in patients with hyperparathyroidism, which usually resolves in 2-4 days. A severe drop in serum total calcium concentration less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days postparathyroidectomy is called hungry bone syndrome (HBS). Concomitant hypophosphatemia, hypomagnesemia, and hyperkalemia can be seen. Hypocalcemia and hypophosphatemia can persist for months to years. In contemporary clinical practice, HBS may be more commonly seen in patients with secondary compared to primary hyperparathyroidism. Preoperative radiological changes in bone, elevated serum alkaline phosphatase and parathyroid hormone (PTH) levels, and high numbers of osteoclasts on bone biopsy may identify patients at risk. Treatment consists of high-dose oral calcium and calcitriol supplementation. A low-dose pamidronate infusion 1-2 days prior to surgery may prevent HBS. RECENT FINDINGS: Recent in-vitro studies reported net calcium movement into bone because of a sudden fall in serum PTH level after a prolonged period of elevation. This supports a previous hypothesis that a sudden drop in serum PTH level after surgery results in the unopposed action of osteoblasts and influx of calcium into bone. SUMMARY: Incidence of HBS and its association with morbidity and mortality remains unclear in contemporary clinical practice. It is more common to encounter HBS in chronic dialysis patients with secondary hyperparathyroidism than those with primary hyperparathyroidism that undergo parathyroidectomies. Use of bisphosphonates to prevent HBS should be explored in future studies.

This study investigated the relationships among combat exposure, intrusive, and deliberate rumination, resilience, and posttraumatic stress disorder (PTSD) among service members who deployed to Iraq or Afghanistan (N = 191). Participants completed an online survey and hierarchical linear regression results indicated that enlisted rank, higher combat exposure, lower resilience, and higher intrusive rumination predicted higher levels of PTSD symptom severity. Resilience moderated the relationship between combat exposure and PTSD symptom severity, such that participants who had higher levels of resilience had lower levels of PTSD symptom severity at all levels of combat exposure. These findings suggest the importance of increasing resilience in combat veterans, specifically those of enlisted rank and veterans exposed to higher levels of combat. Findings also suggest that teaching veterans how to control or minimize intrusive rumination might help lower PTSD severity.

It is common for community-based healthcare providers (CHPs)-many of whom have not received specialised training in wound care-to deliver initial and ongoing management for various wound types and diverse populations. Wounds in any setting can rapidly transition to a stalled, hard-to-heal wound (HTHW) that is not following a normal healing trajectory. Failure to recognise or address issues that cause delayed healing can lead to increased costs, healthcare utilisation and suffering. To encourage early intervention by CHPs, a panel of wound care experts developed actionable evidence-based recommendations for CHPs delineating characteristics and appropriate care in identifying and treating HTHWs. A HTHW is a wound that fails to progress towards healing with standard therapy in an orderly and timely manner and should be referred to a qualified wound care provider (QWCP) for advanced assessment and diagnosis if not healed or reduced in size by 40%-50% within 4 weeks. HTHWs occur in patients with multiple comorbidities, and display increases in exudate, infection, devitalised tissue, maceration or pain, or no change in wound size. CHPs can play an important initial role by seeing the individual's HTHW risk, addressing local infection and providing an optimal wound environment. An easy-to-follow one-page table was developed for the CHP to systematically identify, evaluate and treat HTHWs, incorporating a basic toolkit with items easily obtainable in common office/clinic practice settings. A flow chart using visual HTHW clinical cues is also presented to address CHPs with different learning styles. These tools encourage delivery of appropriate early interventions that can improve overall healthcare efficiency and cost.

Objective: To compare the characteristics of people with fibromyalgia (FM) with those with other forms of nonmalignant chronic pain. Design: A prospective cohort study conducted in a chronic pain management clinic within an academic medical center. Setting: Many symptoms of the chronic pain syndrome FM are common to other pain or musculoskeletal syndromes. FM may be misdiagnosed by clinicians. Subjects: Thirty-three patients with a working diagnosis of FM were identified: 26 (78.8%) participated in the study. They were matched by age (mean = 53.0 years) and gender (80.8% female) to a control group with other forms of chronic nonmalignant pain. Methods: Standardized physical examinations for FM were undertaken using the 1990 and revised 2010 American College of Rheumatology (ACR) guidelines. The groups were compared using diagnoses of psychiatric disorders and responses to the Pain Disability Index, Personal Health Questionnaire, Revised Fibromyalgia Impact Questionnaire, and Rapid Estimate Adult Literacy in Medicine. Results: The most common psychiatric disorders were depression (44.4%) and anxiety (27.3%). Incidence of at least one psychiatric condition was 80.8%, and the only difference (P = 0.002) between the two populations was the mean number of tender points: 5.6 (±4.2) vs controls 3.2 (±2.2). Only three (11.5%) participants with a prior diagnosis of FM fulfilled the 1990 ACR diagnostic criteria, increasing to 38.5% when the 2010 criteria were applied; however, 46.1% of controls also met the revised diagnostic criteria. Conclusions: FM is commonly misdiagnosed: all patients with a working diagnosis should be reassessed and reviewed to ensure that the most appropriate treatment is provided.

Medication nonadherence is associated with adverse outcomes. To evaluate antihypertensive medication adherence and its association with blood pressure (BP) control, the authors described population adherence to prescribed antihypertensive medication (proportion of days covered ≥80%) and BP control (mean BP <140/90 mm Hg) among central Alabama veterans during the fiscal year 2015. Overall, 75.1% of patients receiving antihypertensive medication were considered adherent, and 66.1% had adequate BP control. Patients adherent to antihypertensive medication were more likely to have adequate BP control compared with patients classified as nonadherent (67.4% vs 62.0%; adjusted odds ratio 1.33; 95% confidence interval, 1.22-1.44 [P<.0001]). Among patients who had uncontrolled BP, 73.6% were considered adherent to medication. Adherence to antihypertensive medication was associated with adequate BP control; however, a substantial proportion of patients with inadequate BP control were also considered adherent. Interventions to increase BP control could address more aggressive medication management to achieve BP goals.

Abstract In response to COVID‐19, continued workforce training is essential to ensure that evidence‐based treatments are available on the frontline to meet communities’ ongoing and emerging mental health needs. However, training during a pandemic imposes many new challenges. This paper describes a multisite training and implementation pilot program, facets of which allowed for continued training despite the onset of the COVID‐19 pandemic and subsequent social distancing guidelines. This virtual facilitated learning collaborative in Written Exposure Therapy, an evidence‐based treatment for posttraumatic stress disorder, included virtual workshop training, phone‐based clinical consultation, implementation‐focused video calls for program leadership, and program evaluation. Data are presented about program enrollees and patient impact following the onset of COVID‐19–related social distancing restrictions. Challenges, successes, and practical guidance are discussed to inform the field regarding training strategies likely to be durable in an uncertain, dynamic healthcare landscape.

Frogs are the most species-rich and ecologically diverse group of amphibians and are characterized by a unique body plan including long legs, elongated ilia, and fused caudal vertebrae. Stem anurans such as Triadobatrachus or Czatkobatrachus have been suggested to have used jumping or hopping as part of their locomotor repertoire based on their anatomy. The earliest known true frog, Prosalirus bitis was suggested to have been a proficient jumper. However, data on jumping performance in frogs have never been used to attempt reconstruction of ancestral features at the base of the radiation. Here we provide data on jumping performance (forces and acceleration) in 20 species of extant frogs including representatives of most of the early radiating clades. We next use ancestral character value inferences to assess ancestral features. Our analyses suggest that frog ancestors were of small to medium size, had relatively short limbs, produced rather low jump forces, yet were capable of relatively high acceleration. Given the short limbs and low forces, the unique frog bauplan with a reduced vertebral column and a mobile ilio-sacral joint may not have been an adaptation for powerful jumping.

The present study compared personality and psychopathology profiles of veterans' wives against married women in the MMPI-2 restandardization sample. Differences in levels of distress and pathology were analyzed using the validity, clinical, and content scales of the MMPI-2. As expected, veterans' wives, when compared to restandardization wives, reported higher levels of psychopathology and distress, with symptoms such as depression, social maladjustment, and other negative, internal symptomatic behaviors. Findings are discussed in terms of the need for additional research examining this "at-risk" population.

Background: Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs. Objective: To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans. Methods: A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre–post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans. Results: A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P &lt; .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P &lt; .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P &lt; .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P &lt; .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P &lt; .001). Findings from the ITSA confirmed those of the pre–post analysis with sustained effects in the postintervention period. Conclusions: Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

BACKGROUND: Blood component irradiation is an accepted method of preventing transfusion-associated GVHD. Previous publications have largely focused on the technical aspects of the irradiation process itself, but relatively little attention has been paid to the details associated with the implementation of a blood irradiation program at the level of a community cancer center. STUDY DESIGN AND METHODS: An observational study was performed, detailing the specific operational, documentation, and quality assurance measures employed in providing a blood component-irradiation service within the institutional context of a community cancer center. RESULTS: The Montgomery Cancer Center irradiated 589 units of blood components in 1998 and 1999 to provide a local blood bank with an alternative for procurement of irradiated blood components while complying with applicable quality assurance and regulatory requirements. CONCLUSION: Blood component irradiation is within the scope of most well-equipped and adequately staffed community cancer centers. Establishment of a blood component irradiation program requires scrupulous physics and dosimetry support, both to ensure the quality of the irradiated component and to satisfy governmental agency regulatory requirements.

BACKGROUND: Community corrections populations are a high-risk group who carry multiple suicide risk factors. AIMS: To identify factors correlated with historical suicide attempts and ideation among African-American men, African-American women, White men, and White women in a community corrections population. METHOD: Self-report data from 18,753 enrollees in community corrections were analyzed. Multinomial logistic regression analyses were conducted to determine associations between historical suicidal ideation and attempts among the four demographic groups. RESULTS: Participants with historical suicide attempts tended to be younger, White, female, be taking psychotropic medication, have a history of physical or sexual abuse, and meet criteria for dependence on alcohol, amphetamines, cocaine, opioids, or sedatives. Five variables were commonly associated with suicide attempts for all four race/gender groups: younger age, being on disability or retirement, taking psychotropic medication, history of sexual or physical abuse, and cocaine dependence. Other demographic variables had race or gender specificities as risk factors for suicide attempts. CONCLUSIONS: Participants had high rates of historical suicide attempts with unique correlates differentiating attempters from ideators among different racial and gender groups. Cocaine dependence was universal predictor of suicide attempts, while other substance dependencies show specific racial and gender profiles associated with suicide attempts.

Purpose of Review: Individuals with a history of traumatic brain injury (TBI) are at a much greater risk for developing cardiovascular disease (CVD) compared to the general population. This review discusses dietary patterns as a means of addressing modifiable risk factors following TBI exposure. Evidence-based resources for practicing Physiatrists and Brain Injury Medicine specialists pertaining to nutrition education and counseling are also provided. Recent Findings: We examined Mediterranean, Dietary Approaches to Stop Hypertension, plant-based, ketogenic, and intermittent fasting dietary patterns through publications of clinical trials and systematic reviews. While many reviews had significant positive findings, some were limited by generalizability. Summary: While there is extensive literature on the immediate nutrition goals in the inpatient setting following an acute TBI exposure, there is limited literature discussing the nature of diet and nutrition in the post-acute setting. Fortunately, most individuals with TBI exposure survive their initial injury and continue into the recovery phase. The scientific literature supports increased morbidity and mortality with chronic TBI exposure compared to matched counterparts, most notably with CVD. A diet rich in fiber and nutrients but limited in added sugars, saturated fats, and excess calories would likely have the greatest cardiovascular and related neurologic protection. Future studies are needed to assess the specific impact of dietary interventions in the chronic phase of brain injury recovery.

BACKGROUND: Few studies have examined correlates of deliberate self-harm (DSH) among African-Americans. Moreover, most research on the correlates of DSH in general has focused on risk factors rather than protective factors. AIMS: This study examined differences in perceived social support, religiosity (both spirituality and church attendance) and overall life satisfaction between African-Americans with and without a history of DSH, as well as the moderating roles of gender and sexual orientation in these relations. METHOD: Participants were 244 African-American university students who completed questionnaires. RESULTS: Participants with (vs. without) DSH reported significantly lower levels of social support. Additionally, rates of DSH were significantly higher among participants who attended church irregularly versus regularly or rarely/never. However, the association between DSH and church attendance was significant only for women (vs. men) and LGBQ (vs. heterosexual) women. Further, gender moderated the relation between DSH and social support from both significant others and friends, with self-harming women (but not men) reporting less support than their non-DSH counterparts. CONCLUSIONS: Findings add to the literature on DSH among African-Americans, highlighting both social support and church attendance (depending on regularity) as potential protective factors within this population.

Background:Shared medical appointments (SMAs) are utilized across health care systems to improve access and quality of care, with limited evidence to support the use of SMAs to improve clinical outcomes and medication adherence among hypertensive patients. Objective: Improve access and quality of care provided within a Veterans Affairs health care system via implementation of a hypertension SMA to improve clinical outcomes and medication adherence. Methods: Veterans were eligible for enrollment in the SMA if they received care within the health care system, were aged ≥18 years, were receiving at least 2 antihypertensive medications, and had systolic blood pressure (SBP) &gt;140 mm Hg or diastolic blood pressure (DBP) &gt;90 mm Hg. A pre/post cohort design was used to evaluate the improvement in antihypertensive medication adherence as well as the change in SBP and DBP for all Veterans who attended at least 2 SMAs. Results: Twenty-one Veterans participated in at least 2 SMAs and were included in the analysis; 76.2% had a reduction in SBP with an overall average decrease of −8.3 mm Hg ( P = .02). The proportion of Veterans considered to have controlled blood pressure (BP; &lt;140/90 mm Hg) increased from 14.3% at baseline to 42.9% during the SMA period ( P = .03). There was no significant difference found for the proportion of Veterans considered adherent to their prescribed antihypertensive medications (95.2% vs 85.7%, respectively; P = .50). Conclusions: SBP significantly improved for patients enrolled in a pharmacist-led SMA at a VA health care system, and the proportion of patients considered to have controlled BP increased significantly.

OBJECTIVE: To summarize and review current medical literature regarding the efficacy and safety of antithrombotic therapy for primary venous thromboembolism (VTE) prophylaxis in various ambulatory cancer populations. DATA SOURCES: A literature search was conducted in PubMed (1966-September 2012) and International Pharmaceutical Abstracts (1970-September 2012) using the terms venous thromboembolism, primary prophylaxis, anticoagulation, antithrombotic agents, cancer, and ambulatory. The bibliographies of pertinent studies and topic articles were reviewed for additional references. STUDY SELECTION AND DATA EXTRACTION: All English-language articles were evaluated for inclusion. All randomized trials were included in the review. DATA SYNTHESIS: Malignancy has been identified as a major independent risk factor for the development of VTE in the surgical, medically ill, and ambulatory populations. Primary VTE prophylaxis has been identified as an area of great impact in cancer patients because of the difficulties associated with the treatment of VTE and the greater risk for its recurrence in this population. Although primary VTE prophylaxis is recommended in all surgical and hospitalized cancer patients without contraindications to anticoagulants, its role in ambulatory cancer patients is less certain because of varying patient, cancer, and treatment-related factors. Fourteen randomized studies have investigated the use of antithrombotic agents for primary VTE prophylaxis in ambulatory cancer patients. Strong evidence for primary prophylaxis exists for several populations with advanced or metastatic cancer considered to be at high risk, including those with pancreatic cancer, lung cancer, or multiple myeloma. Evidence is inconsistent or lacking for lower risk cancer populations, such as those with breast cancer, or for those with malignant glioma, which carries a high risk for VTE and bleeding relative to the general ambulatory cancer population. CONCLUSIONS: Use of antithrombotic agents has reduced the rate of primary VTE, with minimal increases in bleeding risk in specific ambulatory cancer populations. Further investigation is needed to guide and narrow recommendations for primary VTE prophylaxis in ambulatory cancer patients.

OBJECTIVE: Assess evidence describing the effect of Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors on total daily insulin (TDI) requirements in insulin-dependent patients with type 2 diabetes. DATA SOURCES: A scoping review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Protocols and Scoping Reviews (PRISMA-ScR) guidelines. The search was conducted in PubMed; citation mapping was completed in Web of Science. Filters for human studies, English language, and a publication date, from January 1, 2005 to April 12, 2021, were applied. STUDY SELECTION AND DATA EXTRACTION: Studies assessing insulin dose requirements with concurrent use of an SGLT2 inhibitor for patients with type 2 diabetes were included. DATA SYNTHESIS: Sixteen studies were included and demonstrated that addition of an SGLT2 inhibitor typically reduced TDI requirements. Insulin reductions were often statistically significant, occurring in studies evaluating (1) within subjects who received SGLT2 inhibitors, and (2) between subjects receiving SGLT2 inhibitors versus placebo. Compared with placebo, insulin dose reduction ranged from -0.72 to -19.2 units. However, studies were relatively small, not designed to assess TDI change, and some utilized fixed dose insulin protocols or empiric insulin dose reductions. CONCLUSIONS: Lowering insulin requirements may have benefits, such as decreased hypoglycemia risk, insulin resistance, and cost. Addition of an SGLT2 inhibitor may modestly reduce TDI requirements for patients with type 2 diabetes. Evidence indicating SGLT2 inhibitor use reduces TDI may lead to additional implementation in practice and inform future research. Further research is needed to clarify insulin type (i.e., basal or prandial) and degree of TDI reduction expected with addition of an SGLT2 inhibitor.

OBJECTIVE: To assess sociodemographic, diagnostic, and services use factors associated with veterans' repeated, episodic use of Veterans Health Administration (VHA) Homeless Programs. DESIGN: This retrospective cohort study used stepwise multivariate logistic regression to assess the odds of veterans being frequent episodic utilizers of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period). SETTING: The study used administrative data from veterans who accessed VHA services across the United States. PARTICIPANTS: The sample comprised 31 098 veterans who completed a VHA Homeless Program intake assessment in 2013 and accessed VHA Homeless Programs during 2013-2016. MAIN OUTCOME MEASURE: Frequent episodic use of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period). RESULTS: Only 2.4% of the study sample had 4 or more episodes of VHA Homeless Program use during the observation period; risk factors included experience of military sexual trauma, history of incarceration, diagnosis of psychosis and substance use disorder, and use of acute care. CONCLUSIONS: Addressing veterans' needs related to poverty, income, and postincarceration reintegration may reduce the frequent episodic use of VHA Homeless Programs. Interventions embedded in emergency departments and inpatient units may also be considered.

Patients undergoing total hip arthroplasty (THA) are at high risk for developing venous thromboembolism and, therefore, require short term prophylaxis with antithrombotic agents. Recently, target specific oral anticoagulants (TSOA) including the direct thrombin inhibitor, dabigatran, and the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban have been approved for THA thrombopropylaxis in various countries. The TSOAs provide a rapid acting, oral alternative to parenteral agents including low-molecular weight heparins (LMWH) and fondaparinux; and compared to warfarin, they do not require routine laboratory monitoring and possess much fewer drug-drug interactions. Based on phase III clinical studies, TSOAs have established themselves as an effective and safe option for thromboprophylaxis after THA compared to LMWH, particularly enoxaparin, but require additional evaluation in specific populations such as the renally impaired or elderly. The ability to monitor and reverse these TSOAs in the case of bleeding complications or suspected sub- or supra-therapeutic anticoagulation is of importance, but remains investigational. This review will focus on the drug-specific characteristics, efficacy, safety, and economic impact of the TSOAs for thromboprophylaxis following THA, as well as the aspects of therapeutic monitoring and anticoagulation reversal in the event of bleeding complications or a need for urgent reversal.

Pharmacogenomics (PGx) utilizes a patient's genome to guide drug treatment and dosing. The Accreditation Council for Pharmacy Education (ACPE) included PGx as a critical content area. Pharmacists are increasingly involved in providing this service, which necessitates training. Second-year pharmacy students at Samford University McWhorter School of Pharmacy have didactic training in the principles of PGx and managing drug therapy using PGx data. A clinical skills lab activity was developed to reinforce these principles and allow students to navigate resources to develop and communicate recommendations for drug therapy. The activity was initially planned as synchronous, but transitioned to asynchronous when students began remote learning in the spring of 2020 due to the COVID-19 pandemic. The investigators sought students' perceptions of the PGx lab activity and the delivery of its content via a virtual format. This study gathered data from an anonymous, voluntary student survey through Samford University's course management system, Canvas, in the spring of 2020 soon after completion of the virtual PGx learning activity. The investigators' goal is to obtain the information and insights obtained from the students who participated in the PGx lab activity to provide guidance for the improvement of their PGx lab activity and for other schools of pharmacy to deliver a PGx lab activities using nontraditional teaching methodologies.