James E. Van Zandt VA Medical Center

Since the 1980s, the mortality rate from breast cancer in the United States has dropped almost 40%. The quality of life and survival gains from early detection and improved treatment have not been shared equally by all ethnic groups, however. Many factors, including social determinants of health, unequal access to screening and oncologic care, and differences in incidence, tumor biology, and risk factors, have contributed to these unequal breast cancer outcomes. As breast radiologists approach their own patients, they must be aware that minority women are disproportionately affected by breast cancer at earlier ages and that non-Hispanic Black and Hispanic women are impacted by greater severity of disease than non-Hispanic White women. Guidelines that do not include women younger than 50 and/or have longer intervals between examinations could have a disproportionately negative impact on minority women. In addition, the COVID-19 pandemic could worsen existing disparities in breast cancer mortality. Increased awareness and targeted efforts to identify and mitigate all of the underlying causes of breast cancer disparities will be necessary to realize the maximum benefit of screening, diagnosis, and treatment and to optimize quality of life and mortality gains for all women. Breast radiologists, as leaders in breast cancer care, have the opportunity to address and reduce some of these disparities for their patients and communities.

Importance: Telehealth can expand access to care, but digital needs present barriers for some patients. Objective: To investigate sociodemographic and clinical associations of digital needs among veterans. Design, Setting, and Participants: This quality improvement study used data collected between July 2021 and September 2023 from Assessing Circumstances and Offering Resources for Needs (ACORN), a Department of Veterans Affairs (VA) initiative to systematically screen for, comprehensively assess, and address social risks and social needs. Eligible participants were veterans screened for social risks and social needs during routine care at 12 outpatient clinics, 3 emergency departments, and 1 inpatient unit across 14 VA medical centers. Data analysis occurred between October 2023 and January 2024. Exposure: The ACORN screening tool was administered by clinical staff. Main Outcomes and Measures: Veterans were considered positive for a digital need if they reported no smartphone or computer, no access to affordable and reliable internet, running out of minutes and/or data before the end of the month, and/or requested help setting up a video telehealth visit. Results: Among 6419 veterans screened (mean [SD] age, 67.6 [15.9] years; 716 female [11.2%]; 1740 Black or African American [27.1%]; 202 Hispanic or Latino [3.1%]; 4125 White [64.3%]), 2740 (42.7%) reported 1 or more digital needs. Adjusting for sociodemographic and clinical characteristics, the adjusted prevalence (AP) of lacking a device among veterans aged 80 years or older was 30.8% (95% CI, 27.9%-33.7%), 17.9% (95% CI, 16.5%-19.2%) among veterans aged 65 to 79 years, 9.9% (95% CI, 8.2%-11.6%) among veterans aged 50 to 64 years, 3.4% (95% CI, 2.1%-4.6%) among veterans aged 18 to 49 years, 17.6% (95% CI, 16.7%-18.6%) for males, and 7.9% (95% CI, 5.5%-10.3%) for females. AP of lacking affordable or reliable internet was 25.3% (95% CI, 22.6%-27.9%) among veterans aged 80 years or older, 15.0% (95% CI, 12.1%-18.0%) among veterans aged 18 to 49 years, 31.1% (95% CI, 28.9%-33.4%) for Black or African American veterans, 32.1% (95% CI, 25.2%-39.0%) for veterans belonging to other racial groups (ie, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, as well as those with more than 1 race captured in their medical record), and 19.4% (95% CI, 18.2%-20.6%) for White veterans. Veterans with dementia were at higher risk of lacking a device (adjusted relative risk [aRR], 1.21; 95% CI, 1.00-1.48). Veterans with high medical complexity were at higher risk of lacking internet (aRR, 1.26; 95% CI, 1.11-1.42). Veterans with dementia (aRR, 1.58; 95% CI, 1.24-2.01) or substance use disorder (aRR, 1.22; 95% CI, 1.00-1.49) were more likely to want help scheduling a telehealth visit than those without. Conclusions and Relevance: In this quality improvement study of veterans screened for social risks and social needs, there were substantial disparities in digital needs. These findings suggest that routine screening is important to understand patients' digital access barriers and connect patients with telehealth resources to address inequities in health care.

Nine new species of Caenis from Angola are described herein: Caenis wegeneriana sp. n. (imago), Caenis angolensis sp. n. (imago and larva), Caenis branchiata sp. n. (larva), Caenis filappendicessp.n.(imago),Caenisulesisp.n.(larva),Caeniscubangosp.n.(larva),Caenisarmata sp. n. (imago), Caenis brevispinata sp. n. (imago), and Caenis gallocristata sp. n. (imago). The relationship between the newly described species and other known African species is discussed. The vicariant biogeographic affiliation of Caenis wegeneriana to a related species group in South America, separated by continental drift, is considered. A key to the male imagoes is provided, including Caenis antelucana Malzacher, 1990, Caenis brevipes Kimmins, 1956, Caenis douglasi Malzacher, 1993 and Caenis jinjana Kimmins, 1956, which have previously been recorded in the Cunene River, along the shared border with Namibia.

Falls pose a significant threat to older adults, resulting in injuries and mortality. Concurrently prescribed opioids and gabapentin for pain management may increase fall risks in older patients. This study aimed to estimate fall risks associated with the concurrent use of gabapentin and opioids, comparing them to opioid monotherapy in older adults. A retrospective case-control study of 1,813 patients aged 65-89 on chronic opioid therapy (2017-2020), excluding those with a fall history, analysis focused on the first fall occurrence. Logistic regression assessed the association between concurrent gabapentin and opioid use and fall events. Out of eligible patients, 122 (6.73%) experienced falls during opioid therapy, with 232 (12.80%) having concurrent gabapentin use. Concurrent use significantly increased fall risk (AOR = 1.73; 95% CI: 1.08-2.78). Being female, aged ≥81, and having more chronic conditions also increased risk. Mitigating fall risk in older adults requires education on prevention, exploring alternative pain management, and careful consideration of prescribing. Further research is crucial to understand adverse events linked to combined opioid and gabapentin use in the geriatric population.

Abstract Background Tobacco and cannabis are among the most widely used substances globally, and rates of co-use are on the rise. Understanding the impact of inhaled tobacco-cannabis co-use on health outcomes and tobacco cessation is critical for guiding patients and clinicians. Objectives To summarize the existing evidence, identify knowledge gaps, and prioritize research questions related to effects of inhaled tobacco-cannabis co-use on tobacco cessation and lung health. Methods A multidisciplinary committee was convened to review the evidence, identify knowledge gaps, and develop research questions in four priority research areas: 1) common data elements and terminology, 2) patterns and prevalence of co-use, 3) impact of co-use on tobacco cessation, and 4) effects of co-use on lung health. A modified Delphi process was conducted in three rounds to reach consensus on prioritizing research questions. Results The evidence reviewed by the expert panel in four priority research areas yielded the following gaps in the literature with high priority to address with future research: 1) lack of consensus on terminology and recommended co-use data elements, 2) limited research on co-use and tobacco-related disparities, 3) insufficient evidence on how cannabis use affects tobacco cessation, and 4) alarming yet inconsistent findings on the effects of co-use on lung health. Conclusions This statement outlines and guides a research agenda on the effects of inhaled tobacco-cannabis co-use on tobacco cessation and lung health. Consensus-driven recommendations include adopting harmonized terms and minimum data elements, studying the prevalence of co-use among populations experiencing tobacco-related disparities, evaluating the impact of co-use on tobacco cessation pharmacotherapies, and assessing the effects of co-use on the development and progression of lung diseases.

Telehealth provides greater opportunity for specialty access but lacks components of the physical exam. Point-of-care ultrasound (POCUS) may assist telehealth as a visual substitute for the provision of palpation. We conducted a prospective observational pilot project to survey oncologists about (1) their expectations of POCUS, (2) their use of POCUS in oncology telehealth visits, and (3) post-project assessment of their experiences. The results of the pre-assessment survey showed an interest among the oncologists in the ability to evaluate structures remotely via POCUS. POCUS was utilized in 6.4% of visits, most commonly for lymph node assessment (60% of use). POCUS was not utilized most often due to not being applicable to the patient's visit. There were 14 instances of technical issues limiting views of the relevant anatomy reported. Oncologists rated the use of POCUS as very satisfied or satisfied in the vast number of recorded responses. This pilot study suggests POCUS can be integrated into oncology telehealth visits for specific applications such as lymph node assessment. The surveys indicated a potential interest and positive responses that provide for the foundation of expansion to subspecialty care access for patients with telehealth supported by POCUS.

270 Background: The VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Network was launched in January 2018 as the next step after we had established an electronic consult service where 555 hematology electronic consults were completed at VAPHS in FY17. The clinical video telehealth (CVT) clinic allows veterans from central Pennsylvania to receive their anticancer therapy at the VA in Altoona, Pennsylvania where the oncology pharmacy, nursing, telehealth, and supportive oncology staff are on site, while the patients continue to follow regularly during treatment via CVT visits with their oncologist located 93 miles away at the VA in Pittsburgh. Methods: A chemotherapy pharmacy and nursing infusion clinic were created at the VA in Altoona. CVT visits started in January 2018. Data including zip code and clinic visit details were examined through descriptive statistics. Results: A total of 89 CVT visits for 27 patients were completed from January 2018 to May 2018. All patient visits were follow-ups while patients were receiving active treatment. 16 patients received intravenous treatments, and 11 received oral anticancer therapy. 100% of the patients were male. Median age was 73 (range 56-89). The most common diagnosis was prostate cancer (26%). The majority of the patients were receiving therapy for palliative intent. 100% of patients chose VA Altoona rather than VAPHS as their treatment clinic location. Five oncology physicians and one oncology clinical nurse specialist completed the clinical video telehealth visits from VAPHS. Total commuting distance averted was 14,828 miles. With an average commuting speed of 60 mph and a travel cost per mile of 0.5 dollars, the total commute time saved for veterans was 247 hours, and the total mileage costs saved was $7414. Appointment compliance was 100%, and there were no missed opportunities. Conclusions: Implementing the Virtual Cancer Care Network has decreased the travel time and costs for veterans who previously would have travelled from central Pennsylvania to VAPHS for their oncology treatment. The integration of CVT technology has improved patient access to oncology care and maintains the patients’ primary relationships with their oncologists.

6546 Background: The VA Pittsburgh Healthcare System (VAPHS) Virtual Cancer Care Network was launched in January 2018 after we had established an electronic consult service where 555 hematology electronic consults were completed at VAPHS in FY17. The clinical video telehealth (CVT) clinic allows veterans from central Pennsylvania to receive their anticancer therapy at the VA in Altoona, Pennsylvania where the oncology pharmacy, nursing, telehealth, and supportive oncology staff are on site. Patients follow regularly and remotely during treatment via CVT visits with their oncologist located 93 miles away at the VA in Pittsburgh. Methods: A chemotherapy pharmacy and nursing infusion clinic were created at the VA in Altoona. CVT visits started in January 2018. Data including treatment, adverse events defined through CTCAE v5.0, gender, age, zip code, and other details were examined retrospectively. Results: 279 CVT visits for 89 patients were completed January 2018 through Sept 2018. 87 were male, 2 were female. Average age was 70 (range 45-90). Most common primary disease sites were prostate (19.1%), colorectal (13.4%), and lung (9%). 61.8% of patients were on treatment. Non-treatment visits were for surveillance and survivorship. Treatment administered included platinum doublets, fluorouracil doublets, immunotherapy, and oral anticancer therapy. 5.4% of patients had Grade 3-4 events due to febrile neutropenia, increased liver enzymes, and hemolytic anemia. 41.7% had grade 1-2 events due to peripheral neuropathy, neutropenia, anemia, thrombocytopenia, and infusion-related reactions. Using an average commuting speed of 60 mph and a travel cost of $ 0.56 per mile, the total commute distance averted was 49,579 miles. Mean distance averted per patient was 557 miles. Total commute time saved for veterans was 826 hours. Total mileage costs saved for veterans was $27,764. Conclusions: The Virtual Cancer Care Network reduced the travel time and costs for veterans who previously would have travelled from central Pennsylvania to VAPHS for their oncology treatment. Adverse events were tolerable and managed by the VA in Altoona. Integration of CVT secures safe access to cancer care and maintains patients’ primary relationships with their oncologists.

The Imaging system captures clinical images, scanned documents, electrocardiogram (EKG) waveforms, and radiology images. Image and text data are provided in an integrated manner that facilitates the clinician's and nurses task of correlating the data and making patient care decisions in a timely and accurate way. It serves five important purposes: documents findings, makes images accessible to clinicians and nurses within the hospital, assists in conference decision making and education, aids in follow-up treatment of patients and facilitates telemedicine. The captured images are extremely helpful in follow-up care. The images are real time; so waiting time is decreased and patient care decisions are sooner. With the Image system, the process flow has completely changed. There is no longer a waiting time for x-ray's or EKG's to be brought to the units for the physicians or nurses to review, they can now access and view these reports from the computer at their work stations.

Misty C. Toro is a certified registered nurse practitioner at James E. Van Zandt VA Medical Center in Altoona, Pa.

Abstract Rationale: Smoking cessation has proven to be the most effective non-pharmacological intervention to tackle poor outcomes in asthma and COPD. Therefore we aimed to investigate whether respiratory symptomatic patients have specific times when they are more open to behavioral change, and which health events or diagnoses could create treatable moments for nicotine dependence to facilitate smoking cessation. Methods: In Belgian chronic users of medication for obstructive lung diseases who were currently smoking tobacco, the impact of potential triggering events on a smoking cessation attempt was investigated by multivariable Cox proportional hazard models over the time period 2017-2022. Results: Among 94,788 chronic users of pulmonary medication (mean age 62 years, 49% female), 12,499 (13.2%) patients attempted smoking cessation during follow-up. Severe exacerbations (aHR 1.75, 95%CI 1.67-1.84), alcoholism (aHR 1.74, 95%CI 1.66-1.82), use of antidepressants (aHR 1.63, 95%CI 1.57-1.69), cachexia (aHR 1.45, 95%CI 1.33-1.58), lung cancer (aHR 1.40, 95%CI 1.29-1.52), peripheral vascular disease (aHR 1.37, 1.30-1.44), acute myocardial infarction (aHR 1.34, 95%CI 1.22-1.46), admission to critical care (aHR 1.30, 1.24-1.37), use of antithrombotic agents (aHR 1.29, 95%CI 1.22-1.35), spirometry testing (aHR 1.26, 95%CI 1.21-1.32) and stroke (aHR 1.25, 95%CI 1.16-1.36) all triggered an increased likelihood of a smoking cessation attempt by more than 25%. Conclusions: In this large real-life cohort study of respiratory symptomatic patients, we demonstrated that there are powerful treatable moments to facilitate smoking cessation for patients with asthma and/or COPD including spirometry testing and exacerbations resulting in hospitalizations.

= 0.013). These findings support the use of buprenorphine as a treatment option when endocrine-related side effects are a concern.

Background: Assessing Circumstances and Offering Resources for Needs (ACORN) is a US Department of Veterans Affairs (VA) clinical intervention designed to identify and address social needs to improve health and well-being among all veterans. We co-designed the ACORN Dashboard to facilitate access to real-time social needs and intervention data for VA clinical care teams and leadership. Objective: This study aimed to (1) describe the iterative development of the ACORN Dashboard, (2) assess end user feedback and Dashboard usage, and (3) discuss the role of social needs dashboards in facilitating continuous quality improvement in health care settings. Methods: An interprofessional team of subject-matter experts and end user feedback contributed to the design. Phase 1 included more than 7 months of weekly working meetings. We initially constructed a wireframe in Microsoft PowerPoint, then translated it into a prototype in Power BI, a data visualization software. Using Microsoft Power BI, we built data visualizations to communicate population-level sociodemographic and ACORN screening data. Through feedback sessions, staff from 8 VA medical centers (VAMCs) reviewed the prototype and recommended improvements regarding the Dashboard's purpose, content, and usability. Phase 2 involved 6 weeks of weekly working meetings, where we developed and iteratively refined 5 written drafts of clinically relevant variables for potential inclusion in the Patient-Level Data Page. This list informed a Power BI prototype. We also developed the ACORN Implementation Map page in Power BI to display implementation locations and settings. We again used feedback sessions with 8 VAMCs to review and refine the newly added pages and discuss improvements. To assess usage, we obtained metadata from a VA-specific Power BI report and user experience data from an ACORN VAMC survey. Results: The ACORN Dashboard displays national data that are updated daily, reflecting 83,546 screens administered across 82 VAMCs facilities between July 1, 2021, and April 30, 2025. The Dashboard was viewed 18,192 times by 2251 unique users, and, on average, 263 (SD 91.2) unique users viewed the Dashboard every month between October 1, 2023, and April 30, 2025. Dashboard variables include the number of screens completed, sociodemographic characteristics of veterans screened, prevalence of social needs, and interventions provided to address needs. Phase 1 semistructured feedback sessions included recommendations for a page with patient-level data to supplement the population-level pages, incorporation of additional filters to select specific data, and development of a user guide. In phase 2, key insights included enhancement of end users' ability to search by veteran or staff name, guidance about screening frequency, changing the display order of variables, and the inclusion of variable definitions. Conclusions: Using co-design to develop, maintain, and continually refine data dashboards enhances implementation of social screening and interventions in health care settings. In addition to supporting individual-level patient care, population-level dashboard data inform continuous quality improvement, promote health equity, and identify gaps in services to address identified needs.

Introduction: The primary objective of this study was to compare the incidence of antipsychotic use in those with venous thromboembolism (VTE) resulting in hospital admission. This study expands upon current knowledge regarding VTE risk and antipsychotic use and investigates potential risk factors and lab values that may precede antipsychotic-induced coagulopathy. Methods: This retrospective, case-control, chart review investigated patients admitted to an acute care hospital with either a VTE or non-VTE diagnosis. Primary outcome analysis compared the presence of an antipsychotic medication in patients who had a VTE versus those who did not. Secondary analysis included: 1) the duration, class, dose, frequency, and route of antipsychotic and 2) coagulation parameters, patient characteristics, and VTE risk factors. Results: Analysis included 400 participants with 200 participants in each group (VTE and non-VTE). Of the 51 patients who received an antipsychotic, 29 (56.9%) developed or presented with a VTE. However, there was no significant difference in VTE development between groups when controlled for antipsychotic use (OR 1.37, 95% CI 0.76-2.50, P-value=0.30). Conclusion: While primary study findings were not statistically significant, results support a weak association of exposure to antipsychotic(s) in VTE groups compared to control (non-VTE). Obesity significantly increased the odds of VTE whereas a history of type 2 diabetes significantly decreased the odds of VTE.

Many patients with dementia won't take well to hospitalization. By developing a better understanding of these patients' special needs, you'll contribute to safe, uneventful hospital stays and ease the stress on the patient, staff, and caregivers.

<bold>Introduction:</bold> Smoking prevention and cessation have proven to be the most effective non-pharmacological intervention to tackle poor outcomes in asthma and COPD. <bold>Aims:</bold> To investigate whether respiratory symptomatic patients who smoke tobacco have specific moments when they are more receptive to behavioural change, and which health events or diagnoses could create treatable moments for nicotine dependence to facilitate a first smoking cessation attempt. <bold>Methods:</bold> In Belgian patients aged ≥18 years who chronically used medication for obstructive lung diseases between 2017-2022 and who were currently smoking tobacco, the impact of potential triggering events on initiating a first smoking cessation attempt was assessed by multivariable Cox proportional hazards models. <bold>Results:</bold> Among 78,452 chronic users of pulmonary medication (median age 63 years, 49% female), 8,822 (11.2%) patients attempted smoking cessation. A severe exacerbation provided the greatest opportunity (aHR 1.73, 95%CI 1.63-1.83) for a first smoking cessation attempt, followed by alcoholism registration (aHR 1.70, 95%CI 1.61-1.80), antidepressant use (aHR 1.63, 95%CI 1.56-1.71) and acute myocardial infarction (aHR 1.50, 95%CI 1.35-1.66). <fig><object-id>erj;66/suppl_69/PA3760/F1</object-id><object-id>F1</object-id><object-id>F1</object-id><graphic></graphic></fig> <bold>Conclusions:</bold> This large real-life cohort study among asthma and COPD patients highlights that exacerbations resulting in hospitalization provide an important treatable moment to initiate smoking cessation.

INTRODUCTION: This Clinical Practical Guideline provides recommendations based on a systematic review of the evidence to address critical decision points in the management of pregnancy. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG is based on a systematic review of both clinical and epidemiological evidence and was developed by a panel of multidisciplinary experts. The Work Group provides clear and comprehensive evidence-based recommendations incorporating current information and practices targeting practitioners throughout the DoD and VA Health Care systems. The guideline is intended to improve patient outcomes and local management of patients who are pregnant. This CPG does not address every aspect of routine pregnancy care and is not intended to be a comprehensive guide to all care needed in pregnancy. It also addresses some clinically important and generally accepted standards of pregnancy care interventions that do not have sufficient high-quality evidence to support standalone recommendations. Additionally, it highlights emerging topics that have the potential to impact pregnancy care in the future and identifies gaps in the literature that warrant further research. MATERIALS AND METHODS: The development of all VA/DoD guidelines is directed by the Evidence-Based Practice Guideline Work Group and adheres to the standards for trustworthy guidelines that were set by the National Academy of Medicine. A patient focus group was convened to assess important aspects of treatment for patients and to gain information about patient values and preferences. The Lewin Group, a contracted third party with expertise in CPG development, facilitated meetings and the development of key questions using the population, intervention, comparison, outcome, timing, and setting format. Consensus was achieved among the Work Group through an iterative process involving discussions on conference calls and in person during the recommendation development meeting. An independent third party, ECRI, conducted the systematic evidence review, which the guideline Work Group then used to develop recommendations using the Grading of Recommendations Assessment, Development and Evaluation system (7-9). The search methods and results are detailed in the full guideline. RESULTS: This CPG provides 28 clinical practice recommendations that cover selected topics that the Work Group deemed had high priority need for evidence-based standards. The recommendations are divided into 3 main categories: routine care, complicated obstetrics, and mental health. An algorithm delineating recommended interventions and appropriate timing of these interventions over the course of the pregnancy and postpartum period was also created. CONCLUSION: The CPG is not intended to define standards of care nor address all care needed in pregnancy; it does provide comprehensive guidance for routine pregnancy care. It aligns with the VA and DOD's goal of providing care that is consistent in quality and utilization of resources in efforts to reduce errors and inappropriate variations in practices. In total, the Work Group identified 71 items needing further study, including areas requiring stronger evidence to support current recommendations and newer topics that will guide future guideline development.