Veterans Health Care System of the Ozarks

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RA) have delayed gastric emptying properties; however, the impact on esophagogastroduodenoscopy (EGD) visualization is unknown. OBJECTIVE: This study examines the impact of GLP-1RA use on EGD visualization and gastric content retention. METHODS: This was a retrospective cohort study with matched controls. The primary endpoint was the odds of retained food documented during EGD. Secondary endpoints included incidence of lavage and need for repeat EGD due to poor visualization and were compared using Fisher exact test. Analyses were performed in R Studio. RESULTS: There were 59 patients in the cohort prescribed a GLP-1RA with 118 matched controls. Food retention was documented with 4 patients (6.8%) in the GLP-1RA cohort versus 2 patients (1.7%) in the control group (odds ratio [OR] 4.22 [95% CI 0.87-20.34]). No difference was observed in the need for lavage during EGD or in the need for repeat EGD attributed to poor visualization. CONCLUSION AND RELEVANCE: This study addresses a previously uninvestigated question in clinical practice. GLP-1RA did not significantly increase odds of retained food on EGD. Although a numerical difference was observed, it did not reach statistical difference. No cases required repeat EGD due to poor visualization, and no change to EGD pre-procedure instructions were warranted at the study facility.

OBJECTIVES: Multiple systematic reviews have evaluated fluorides for caries prevention in children, but a need to review the literature regarding supplemental fluoride use in adults still remains. The purpose of this systematic review is to evaluate the research regarding professional and/or supplemental self-applied fluoride for preventing and remineralizing caries in moderate and high caries risk adults. METHODS: Utilizing multiple databases, a comprehensive search was undertaken in both foreign and English languages. Studies included were randomized control trials (RCT) or clinical trials conducted in moderate or high caries risk adult populations, evaluating self- or professionally applied fluoride with the outcomes of caries reduction/remineralization. Studies were excluded if they were in situ, in vitro, split mouth design, or with unclear outcomes specific to fluorides. A quality evaluation of the studies used a checklist of critical domains and elements for an RCT. RESULTS: Seventeen studies were included in the systematic review. Findings were categorized into the following groups: sodium fluoride (NaF) and amine/potassium fluoride mouthrinses of varying strengths, NaF gels and pastes, NaF varnish, and stannous fluoride. Quality evaluation scores varied from 50.2 percent to 88.9 percent. CONCLUSIONS: The strongest studies demonstrated the following modalities as moderately effective in higher caries risk adults: low strength NaF rinses [risk reduction (RRR) for carious lesions: 50-148 percent]; 1.1 percent NaF pastes/gels (RRR for root lesion remineralization: 35-122 percent); fluoride varnishes [RRR for RC remineralization: 63 percent; RRR for decrease in decayed, missing, and filled surfaces: 50 percent]. Evidence regarding 1.1 percent NaF and 5 percent NaF varnishes related primarily to root caries and older adults.

BACKGROUND: A primary goal of early intervention is to assist children in achieving age-appropriate language skills. The amount of intervention a child receives is ideally based on his or her individual needs, yet it is unclear if language ability impacts amount of intervention and/or if an increased frequency of intervention sessions results in better outcomes. The purpose of this study was to determine the relationship between the frequency of early intervention sessions and vocabulary outcomes in young children with hearing loss. METHODS: This was a longitudinal study of 210 children 9 to 36 months of age with bilateral hearing loss living in 12 different states. Expressive vocabulary skills were evaluated using the MacArthur-Bates Communicative Development Inventories. RESULTS: A higher number of intervention sessions reported at the first assessment predicted better vocabulary scores at the second assessment, and more sessions reported at the second assessment predicted better scores at the third assessment. For each increase in the number of sessions reported, there was a corresponding, positive increase in vocabulary quotient. In contrast, children's vocabulary ability at an earlier time point did not predict intervention session frequency at a later point in time. CONCLUSIONS: A significant prospective effect was apparent with more therapy sessions resulting in improved vocabulary scores 9 months later. These findings underscore the importance of early intervention. Pediatricians and other health care professionals can help apply these findings by counseling parents regarding the value of frequent and consistent participation in early intervention.

Though social anxiety disorder and alcohol use disorders commonly co-occur, the mechanisms involved in social anxiety and hazardous drinking among college students are not well understood. The current study contributes to the emerging literature on social anxiety and college drinking as the first known study to test how positive (e.g. “I would feel at ease in social situations”) and negative (e.g. “I would make a fool out of myself”) alcohol outcome expectancies (AOE) specific to social situations (social AOE) impact the association between social anxiety and hazardous alcohol use among 718 undergraduates (61% women; Mage = 19.50, SD = 1.45; 85% White). Results supported the mediation, but not the moderation models. There were positive indirect effects of social anxiety through positive social AOE and negative indirect effects of social anxiety through negative social AOE on both hazardous drinking outcomes (i.e. alcohol consumption and alcohol problems). Findings suggest that there could be competing pathways for increasing (positive social AOE) and decreasing (negative AOE) risk for hazardous alcohol use in socially anxious college students.

OBJECTIVES: To use extensive electronic dental, medical, and pharmacy databases to estimate the prevalence of dental caries in a cohort of new patients during a 5-year period (FY2010-FY2015) and determine whether medication use and medical comorbidities are associated with caries prevalence. METHODS: This was a retrospective analysis of existing data from the Department of Veterans Affairs (VA). The number of teeth treated due to a caries-related diagnosis was determined and outcomes were presented as number of teeth/person and proportion of patients receiving caries-related treatment. Logistic and negative binomial regression modeled teeth/person with caries-related treatment; covariates included age, gender, race, ethnicity, physical and mental comorbidities, and use of prescription medications and prescription drugs with strong anticholinergic properties. RESULTS: The study population included 95,850 dentate dental patients: 92.1 percent were male, mean age of 58.7 ± 12.6 years, 73.2 percent were White/Caucasian, and 21.3 percent were Black/African American. They were taking a mean of 10.6 ± 5.9 VA prescription drug classes, 0.6 ± 0.4 drugs with strong anticholinergic properties, and had 3.6 ± 2.2 physical and 1.4 ± 1.2 mental comorbidities. On average, 2.2 teeth/person received caries-related treatment and 58 percent of the study population received any caries-related treatment. An increase in the rate of caries-related treatment in Veterans was statistically significantly associated with increased prescription medication use; one or more drugs with strong anticholinergic properties and with 1+ mental comorbidities. Increased physical comorbidity was not statistically significantly associated with caries-related treatment. CONCLUSIONS: This study demonstrates a high prevalence of caries among Veteran dental patients, with an increased prevalence in those taking higher numbers of prescription medications.

OBJECTIVE: Insomnia and delirium have gained much attention since the publication of recent guidelines for the management in critically ill adults. Neurologic effects such as sleep disturbance, psychosis, and delirium are commonly cited adverse effects (AEs) of corticosteroids. Steroid use is considered a modifiable risk factor in intensive care unit patients; however, reported mechanisms are often lacking. This focused review will specifically evaluate the effects of steroids on sleep deprivation, psychosis, delirium, and what is known about these effects in a critically ill population. OBSERVATIONS: The medical literature proposes 3 pathways primarily responsible for neurocognitive AEs of steroids: behavior changes through modification of the hypothalamic-pituitary-adrenal axis, changes in natural sleep-wake cycles, and hyperarousal caused by modification in neuroinhibitory pathways. Initial search fields produced 285 articles. Case reports, reviews, letters, and articles pertaining to primary care or palliative populations were excluded, leaving 8 relevant articles for inclusion. CONCLUSIONS: Although steroid therapy often cannot be altered in the critically ill population, research showed that steroid overuse is common in intensive care units. Minimizing dosage and duration are important ways clinicians can mitigate AEs.

Few protocols have been published for the dental management of patients with head and neck cancer to prevent complications from head and neck radiation therapy. Radiation therapy not only affects the tumor cells targeted, but also the dentition, bone, salivary gland, and oral soft tissue structures. A comprehensive dental evaluation prior to head and neck radiation therapy can help prevent many complications. The following clinical guidelines were established by a workgroup of oral health providers within the Department of Veterans Affairs. This workgroup focused on developing a set of recommendations regarding dental care prior to the initiation of head and neck radiation therapy based on the best clinical evidence and expert consensus. A systematic algorithm was developed for the evaluation including pre-exam data gathering, examination, education, and treatment, followed by maintenance and postradiation dental follow-up. This document is evidence-based, patient-centered, consistent with accepted practices of care and safety, and in accordance with applicable statutes and regulations.

OBJECTIVE: United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription. DESIGN: Cross-sectional analysis. METHODS: We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription. RESULTS: Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days' supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%-49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics. CONCLUSIONS: Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.

INTRODUCTION: Ledipasvir/sofosbuvir (Harvoni®) is a fixed-dose tablet indicated for the treatment of chronic hepatitis C virus (HCV) infection. There are currently no data available on the safety and efficacy of crushed ledipasvir/sofosbuvir tablets. CASE SUMMARY: This report describes the first documented case of successful treatment of chronic HCV infection in a patient crushing ledipasvir/sofosbuvir for administration via a percutaneous endoscopic gastrostomy (PEG) tube. The patient was treatment experienced and had evidence of compensated cirrhosis. Treatment duration was 24 weeks, and HCV RNA was undetectable 12 weeks after completion of treatment (SVR12) which is the accepted measure of a clinical cure. DISCUSSION: Issues may arise during or prior to starting HCV treatment that necessitate crushing tablets. Stopping or interrupting HCV treatment could lead to development of resistance or treatment failure. CONCLUSION: This is the first published case in which crushed ledipasvir/sofosbuvir administered via a PEG tube is documented as a safe and effective option for treatment of chronic HCV infection.

INTRODUCTION: Findings from previous studies indicated patients with mental illness feel pharmacists do not provide appropriate care. In addition, many patients with mental illness report not having a strong relationship with their pharmacist. The objective of this study was to determine the level of social distance of student pharmacists toward patients with mental illness. METHODS: Student pharmacists completed an anonymous survey. Data were collected using the Bogardus Social Distance Scale (SDS). Level and correlates of social distancing were examined. RESULTS: = .482). The greatest social distancing was in relation to trusting someone with mental illness to "care for their child," where less than 1 in 5 students (17%) were willing to do this. Most students (88%) were willing to work or be neighbors with someone with mental illness, indicating less social distancing in these domains. Regression analysis indicated a significant change in sum score with knowing someone or having a first-degree relative with mental illness. DISCUSSION: Results indicate social distancing is prominent among pharmacy students. Results may be used in the future to help identify solutions for improving social distancing and increasing pharmacy student interaction to patients with mental illness. Further training related to mental illness may assist with decreasing social distancing among pharmacy students.

PURPOSE: The glucagon-like peptide-1 receptor agonist (GLP-1RA) class of medications are widely prescribed for management of diabetes mellitus as well as obesity or weight management. Although there have been rare reports of skin hypersensitivity associated with GLP-1RA medications, no published reports have documented allodynia or skin pain to the touch. SUMMARY: We report 4 cases of allodynia associated with dose escalation of the GLP-1RA medication semaglutide. Each patient was prescribed semaglutide for management of obesity and developed symptoms of allodynia with the 2.4-mg subcutaneous once-weekly dose. Therapy was stopped in 2 patients, both of whom had resolution of symptoms. Two patients opted to continue semaglutide despite the adverse effect, with one experiencing resolution after 4 months. No pharmacological mechanism was identified for this unique adverse drug reaction. There was a clear temporal and dose-response relationship in each of the 4 cases. CONCLUSION: The 4 cases presented had scores of 5 or 6 (probable) on the Naranjo scale. It is not known whether this is a class effect of the GLP-1RA medications or if the adverse effect will consistently resolve or improve with continuation.

OBJECTIVE: Identify structure and process variables that significantly contributed to dentist productivity across VA Dental Service clinics using multiple VA national datasets from fiscal year 2010. METHODS: A retrospective, longitudinal analysis with the primary outcome of care provided, as measured by relative value units per clinically mapped full-time employee equivalent dentist, per year. Predictor variables included physical plant variables, staffing variables, complexity of the patient population, workplace climate, and environment of care. Predictor variables were initially assessed in a bivariate analysis with the primary outcome and those significant at P < 0.2 were entered into an ordinary least squares regression model. RESULTS: Dentist productivity and several predictor variables were significantly different between sites with and without resident training programs; therefore, two explanatory models were constructed. In both models, increasing the assistant-to-dentist ratio was the most important driver for increasing productivity. Additional drivers include the resident-to-dentist ratio, use of technology, and connectedness and engagement with the medical center as demonstrated by participation in various committees and/or boards. Final models explained over 50 percent of the variance in productivity. CONCLUSIONS: In multiprovider settings, predictors of dentist clinical productivity differ for sites with and without residency training programs. Although the assistant-to-dentist ratio is the most explanatory for each type of setting, other variables such as the resident-to-dentist ratio, use of technology, and connectedness/engagement with the medical center are uniquely significant to the two types of service sites and should also be considered to maximize productivity.

A novel recursive cascaded full-resolution residual network (RCFRR-Net) for abdominal four-dimensional computed tomography (4D-CT) image registration was proposed. The entire network was end-to-end and trained in the unsupervised approach, which meant that the deformation vector field, which presented the ground truth, was not needed during training. The network was designed by cascading three full-resolution residual subnetworks with different architectures. The training loss consisted of the image similarity loss and the deformation vector field regularization loss, which were calculated based on the final warped image and the fixed image, allowing all cascades to be trained jointly and perform the progressive registration cooperatively. Extensive network testing was conducted using diverse datasets, including an internal 4D-CT dataset, a public DIRLAB 4D-CT dataset, and a 4D cone-beam CT (4D-CBCT) dataset. Compared with the iteration-based demon method and two deep learning-based methods (VoxelMorph and recursive cascaded network), the RCFRR-Net achieved consistent and significant gains, which demonstrated that the proposed method had superior performance and generalization capability in medical image registration. The proposed RCFRR-Net was a promising tool for various clinical applications.

BACKGROUND: The Global Burden of Disease Study showed there was a 34.5% increase in years lived with disability due to dental caries from 1990 to 2010. With the aging of 76 million baby boomers, dental caries will continue to pose a significant challenge for older adults. OBJECTIVE: Test the effectiveness of prescription or professionally applied fluoride in the prevention of new dental restorations in a clinical setting where patients are medically compromised and more dentally impaired than the general population. METHODS: A retrospective cohort study, using multiple electronic databases within the Department of Veterans Affairs. Propensity scores were used to adjust for confounding by indication and logistic regression modeled the outcome and included all expected covariates. RESULTS: The study sample included 140,114 high caries risk Veterans with a mean of 3.4 physical comorbidities, 1.2 mental comorbidities, and 11 medication groups per patient. Patients who received clinical fluoride treatments had 17-20% decreased odds of requiring a restoration during the follow-up period. CONCLUSIONS: Prescription self-applied or professionally applied fluoride provided either before or during an episode of care significantly reduced the likelihood of new restorations in high caries risk and medically compromised Veterans.

PURPOSE: Successful use of a 4-drug oral fixed-dose combination therapy to treat chronic hepatitis C in a patient receiving peritoneal dialysis (PD) is reported. SUMMARY: New highly effective treatments for chronic hepatitis C virus (HCV) infection are now available, but safety and efficacy data on the use of anti-HCV therapies in patients with renal failure, particularly those requiring PD, remain limited. A 73-year-old black man with chronic HCV genotype 1a infection and stage 5 chronic renal disease requiring daily automated PD was referred for HCV treatment prior to renal transplantation. HCV treatment was initiated with paritaprevir-ritonavir-ombitasvir- dasabuvir, or "PrOD" (a combination tablet containing paritaprevir 75 mg, ritonavir 50 mg, and ombitasvir 12.5 mg to be taken once daily and a dasabuvir sodium 250-mg tablet to be taken twice daily), in conjunction with ribavirin 200 mg once daily. After a 12-week course of PrOD therapy, during which ribavirin therapy was tapered and then discontinued at week 10 and subcutaneous epoetin alfa was administered for anemia control from weeks 4 to 12, the patient's HCV viral load was undetectable; a sustained virologic response at 12 weeks (SVR12) was noted. CONCLUSION: A patient with end-stage renal disease requiring PD was treated successfully for HCV genotype 1a infection with PrOD fixed-dose combination therapy plus ribavirin therapy. The patient achieved an SVR12 despite withdrawal of ribavirin at treatment week 10, with minimal adverse effects reported.

BACKGROUND: New guidance recommends area under the curve/minimum inhibitory concentration (AUC/MIC) instead of trough-based monitoring for vancomycin therapy. While this transition has demonstrated improved safety and efficacy in large, tertiary centers, this has not been assessed in the primary hospital setting. OBJECTIVE: The primary objectives were to evaluate the efficacy and safety of AUC/MIC monitoring in inpatient veterans treated with intravenous vancomycin for ≥72 hours compared to a historical cohort of trough-based monitoring. METHODS: This was a retrospective, quasi-experimental study over 2 five-month study periods. Efficacy was evaluated by comparing clinical failure rates as defined by a persistent fever, clinical deterioration, or escalation of gram-positive therapy. Safety was determined by the incidence of acute kidney injury (AKI) defined by an acute increase in serum creatinine ≥0.3 mg/dL over 48 hours. RESULTS: 25 patients met the criteria in the before group and 19 in the after group. Efficacy was equivalent between groups; no patients exhibited clinical failure of vancomycin therapy. In the before group, 2 patients (8%) met defined criteria for AKI, while none in the after group experienced AKI (P = 0.21). Total vancomycin exposure was similar between groups (P = 0.56). CONCLUSION: AUC-based monitoring was equally efficacious as trough-based monitoring with similarly low rates of AKI.

INTRODUCTION: Steroid overprescribing is well documented in acute exacerbations of COPD (AECOPD). Given the myriad of unwanted side effects of corticosteroids, facilities should implement steroid stewardship efforts. The objective of this project was to evaluate the prescribing habits of steroids in AECOPD for needs assessment and to tailor interventions in a single centre. METHODS: A questionnaire was developed to evaluate practices and beliefs around steroid dosing in a simplified case of uncomplicated AECOPD. There were 31 total responders: 12 inpatient clinicians, 9 medical residents and 10 emergency department (ED) clinicians. All steroid dosing was converted to prednisone equivalents for reporting. Subgroup analysis was conducted between provider groups. RESULTS: Initial dosing ranged from 40 to 625 mg/day with only four responders (13%) selecting 40 mg/day. Dosing was not significantly different in newer providers ≤4 years' experience: mean 215 mg versus >4 years' experience: mean 312 mg (P = 0.23). Less experienced providers selected shorter treatment durations: median 5 days (IQR 5,6) versus 8.5 days (IQR 6,10.5) (P = 0.015). ED providers selected higher doses than non-ED providers: 447 mg versus 208 mg (P = 0.003). Most responders (81%) selected IV agents over oral steroids. The majority (65%) stated dosing choices were based on prescribing habits/clinical experience, while 36% felt their selections were based on current evidence. Five (16%) of responders correctly identified consensus treatment guidelines and the majority (77%) reported being "very likely" or "somewhat likely" to prescribe lower doses. CONCLUSION: Baseline knowledge was a significant barrier to guideline utilisation. Education will need to focus on the evidence behind using lower doses, oral agents and disease severity.

: Life-threatening bleeds are medical emergencies that require time-sensitive decision making. Patients of the Jehovah's Witness faith can present a challenging conundrum when their beliefs conflict with modern treatment options for haemorrhage. Providers may not be aware of the grades of acceptance of the newer products outside of packed red blood cells. Researchers present a case of using four-factor prothrombin complex concentrate in a Jehovah's Witness patient in a life-threatening gastrointestinal haemorrhage along with a brief review of the literature.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with COPD suffer from persistent chronic cough, sputum production and exacerbations leading to deteriorating lung function, worsening quality of life and loss of independence. While evidence-based interventions exist to improve the well-being of patients with COPD, incorporation of these interventions into routine clinical care is challenging. Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) is a team-based, coordinated care transitions service integrating evidence-based interventions for COPD management within the patient care delivery model to reduce readmissions. This evaluation considers the process of scaling the COPD CARE service across medical facilities using an implementation package designed for service expansion. The implementation package was developed at the United States Veterans Health Administration and implemented at two medical centres. Core dissemination and implementation science methods were applied to guide design and delivery of the implementation package.The aims of this evaluation were to (1) evaluate the impact of the implementation package on use of evidence-based interventions for COPD management and (2) explore clinician perceptions of the implementation package. This prospective mixed-methods quality improvement project included two Plan Do Check Act (PDCA) cycles conducted over a 24-month period. Electronic health record data demonstrated significant improvements in the count of evidence-based interventions incorporated into routine clinical care after training completion (p<0.001), offering preliminary effectiveness of the package to improve uptake of best practices for COPD management. Clinician perceptions of the implementation package, measured by questionnaire at multiple time points, demonstrated significant improvements for all scales at the end of the final PDCA cycle. Clinicians described the implementation package as positively impacting clinician confidence, interprofessional collaboration and patient care delivery.

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