Nightmare disorder and low back pain in veterans: cross-sectional association and effect over time.

Low back pain (LBP) disproportionately impacts US military veterans compared with nonveterans. Although the effect of psychological conditions on LBP is regularly studied, there is little published to date investigating nightmare disorder (NMD) and LBP. The purpose of this study was to (1) investigate whether an association exists between NMD and LBP and (2) estimate the effect of NMD diagnosis on time to LBP. We used a retrospective cohort design with oversampling of those with NMD from the Veterans Health Administration (n = 15 983). We used logistic regression to assess for a cross-sectional association between NMD and LBP and survival analysis to estimate the effect of NMD on time to LBP, up to 60-month follow-up, conditioning on age, sex, race, index year, Charlson Comorbidity Index, depression, anxiety, insomnia, combat exposure, and prisoner of war history to address confounding. Odds ratios (with 95% confidence intervals [CIs]) indicated a cross-sectional association of 1.35 (1.13 to 1.60) and 1.21 (1.02 to 1.42) for NMD and LBP within 6 months and 12 months pre- or post-NMD diagnosis, respectively. Hazard ratios (HRs) indicated the effect of NMD on time to LBP that was time-dependent-HR (with 95% CIs) 1.27 (1.02 to 1.59), 1.23 (1.03 to 1.48), 1.19 (1.01 to 1.40), and 1.10 (0.94 to 1.29) in the first 3, 6, 9, and 12 months post-diagnosis, respectively-approximating the null (1.00) at >12 months. The estimated effect of NMD on LBP suggests that improved screening for NMD among veterans may help clinicians and researchers predict (or intervene to reduce) risk of future back pain.

Cervical Cancer Screening in South Florida Veteran Population, 2014 to 2020: Cytology and High-Risk Human Papillomavirus Correlation and Epidemiology.

Objective This project aims to use our robust women's health patient data to analyze the correlation between cytology and high-risk human papillomavirus (Hr-HPV) testing, study the performance of Hr-HPV testing for detecting cytology lesions, and examine epidemiologic measures of human papillomavirus (HPV) infections in the women's veteran population. Methods We collected patient data from 2014 to 2020 from our computerized patient record system. We performed HPV assays using the cobas® 4800 system (Roche Diagnostics, Basel, Switzerland). The cobas HPV assay detects HPV 16, HPV 18, and 12 other HPV types (31, 33, 35, 39, 45, 51, 56, 58, 59, 66, and 68). We organized cytology results and Hr-HPV assays with Microsoft Access and Microsoft Excel (Microsoft Corporation, Washington, USA) for analysis. Results A total of 9437 cervical specimens were co-tested. High-grade cytology lesions - high-grade intraepithelial lesion (HSIL) or higher and atypical squamous cells, cannot exclude HSIL (ASC-H) - were overwhelmingly positive for Hr-HPV (94.1% and 87.2%, respectively). Low-grade cytology lesions - low-grade squamous intraepithelial lesion ((LSIL) and atypical squamous cells of undetermined significance (ASC-US) - were positive for Hr-HPV in lower percentages (72.6% and 54.9%, respectively). Hr-HPV testing had a sensitivity of 91.3%, a specificity of 93.1%, a positive predictive value of 16.4%, and a negative predictive value of 99.8% for detecting high-grade cytology lesions. Hr-HPV testing had a lower performance for detecting low-grade cytology lesions. Ten cases had high-grade cytology and negative Hr-HPV test. Out of 10 such patients, nine showed no dysplasia (six) or low-grade dysplasia (three) on subsequent biopsy. Overall, 14.4% of tests were positive for Hr-HPV. The highest positive Hr-HPV test rates were in the third and eighth decades of life, 25.1% and 22.0%, respectively. However, the eighth decade consisted of a small sample of only 50 women. In women over 30 years of age with Hr-HPV infections, HPV types 16 and 18 were present in 11.7% and 6.4% of tests, respectively. Other HPV types were present in 82.3% of tests. Conclusions Hr-HPV testing has a high performance in detecting high-grade cytology lesions and a lower performance for detecting low-grade cytology lesions. However, studies show that LSIL rarely progresses to cervical intraepithelial neoplasia grade 3 or higher (CIN3+), suggesting minimal to no impact on cervical cancer screening. We believe our findings are in accordance with recent studies and affirm the guidelines that recommend primary Hr-HPV testing as the preferred screening method. The percentage of positive Hr-HPV tests and rates for age and HPV types 16 and 18 in our women's veteran population suggest similar HPV prevalence to that of the general US population.

"Ask The Pathologist": An Internet Forum Facilitating Communication Between Cancer Registrars and Pathologists.

CONTEXT.­: Cancer registrars should work closely with pathologists to ensure compliance with reporting standards. Many registrars, however, have little contact with pathologists, resulting in a lack of "real-time" interaction that is essential for their professional activities and development. OBJECTIVE.­: To facilitate registrars' case management, as cancer biology becomes more complex, we developed the ATP (Ask the Pathologist) forum as a place to ask pathology-related questions about neoplasms, such as terminology, biology, histologic classification, extent of disease, molecular markers, and prognostic factors. DESIGN.­: Questions posted are reviewed by the ATP multidisciplinary oversight committee, which consists of 3 pathologists, 4 cancer registrars, 1 internal medicine physician, the pathology resident member of the College of American Pathologists Cancer Committee, and 2 medical technologists. The oversight committee may answer the question. Alternatively, the committee may forward the question to a content expert pathologist, determine that the question is better suited for another reference Web site, or both. RESULTS.­: Since September 2013, when the ATP forum became available, users have posted 284 questions, of which 48 (17%) related to gastrointestinal tumors, 43 (15%) to breast tumors, and 37 (13%) to general pathology. The average turnaround time, from question posted to response, is 11.1 days. CONCLUSIONS.­: The ATP forum has had a positive impact in the daily activities of cancer registrars. Of 440 registrars surveyed, more than 90% considered that questions were answered satisfactorily, and one-third reported that ATP answers affected how they managed a given case.

College of American Pathologists Cancer Protocols: Optimizing Format for Accuracy and Efficiency.

CONTEXT: -The data in College of American Pathologists cancer protocols have to be presented effectively to health care providers. There is no consensus on the format of those protocols, resulting in various designs among pathologists. Cancer protocols are independently created by site-specific experts, so there is inconsistent wording and repetition of data. This lack of standardization can be confusing and may lead to interpretation errors. OBJECTIVE: -To define a synopsis format that is effective in delivering essential pathologic information and to evaluate the aesthetic appeal and the impact of varying format styles on the speed and accuracy of data extraction. DESIGN: -We queried individuals from several health care backgrounds using varying formats of the fallopian tube protocol of the College of American Pathologists without content modification to investigate their aesthetic appeal, accuracy, efficiency, and readability/complexity. Descriptive statistics, an item difficulty index, and 3 tests of readability were used. RESULTS: -Columned formats were aesthetically more appealing than justified formats (P < .001) and were associated with greater accuracy and efficiency. Incorrect assumptions were made about items not included in the protocol. Uniform wording and short sentences were associated with better performance by participants. CONCLUSIONS: -Based on these data, we propose standardized protocol formats for cancer resections of the fallopian tube and the more-familiar colon, employing headers, short phrases, and uniform terminology. This template can be easily and minimally modified for other sites, standardizing format and verbiage and increasing user accuracy and efficiency. Principles of human factors engineering should be considered in the display of patient data.

Racial disparity in adherence to positive airway pressure among US veterans.

PURPOSE: Despite advances in continuous positive airway pressure (CPAP) technology, compliance with CPAP therapy remains suboptimal. Studies conducted since the advent of objective CPAP recording have noted that African Americans (AA) may use CPAP less than Whites. We sought to confirm this finding among a large sample of veterans and examine effect modifiers of the differential usage. METHODS: A retrospective cohort of 233 AA and 1939 White Veterans Administration (VA) patients who had a sleep study between January 2003 and October 2006 and received CPAP therapy by the end of 2007. CPAP compliance was summarized at 2 weeks and 6 months post CPAP receipt. RESULTS: AAs were significantly less adherent than Whites even when controlling for age, gender, marital status, median household income for zip code, BMI, comorbidities, and obstructive sleep apnea (OSA) severity. AAs with severe OSA were 3 times more likely to use CPAP than AAs with mild/moderate OSA (p ≤ 0.001); a much smaller but still statistically significant difference was seen for Whites. CONCLUSIONS: CPAP compliance is considerably lower in AAs than in Whites, though severity of OSA modifies this association. These findings are not readily explained by differences in demographics or comorbidity.

Improving identification of fall-related injuries in ambulatory care using statistical text mining.

OBJECTIVES: We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities. METHODS: We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review. RESULTS: STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical. CONCLUSIONS: STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system.

Cancer biomarkers: the role of structured data reporting.

CONTEXT: The College of American Pathologists has been producing cancer protocols since 1986 to aid pathologists in the diagnosis and reporting of cancer cases. Many pathologists use the included cancer case summaries as templates for dictation/data entry into the final pathology report. These summaries are now available in a computer-readable format with structured data elements for interoperability, packaged as "electronic cancer checklists." Most major vendors of anatomic pathology reporting software support this model. OBJECTIVES: To outline the development and advantages of structured electronic cancer reporting using the electronic cancer checklist model, and to describe its extension to cancer biomarkers and other aspects of cancer reporting. DATA SOURCES: Peer-reviewed literature and internal records of the College of American Pathologists. CONCLUSIONS: Accurate and usable cancer biomarker data reporting will increasingly depend on initial capture of this information as structured data. This process will support the standardization of data elements and biomarker terminology, enabling the meaningful use of these datasets by pathologists, clinicians, tumor registries, and patients.

Correlates of a prescription for Bilevel positive airway pressure for treatment of obstructive sleep apnea among veterans.

INTRODUCTION: The acceptance of portable home-based polysomnography together with auto-titrating CPAP has bypassed the need for a laboratory polysomnography. Since bilevel airway pressure (BPAP) is titrated in the sleep lab, patients diagnosed using portable home-based polysomnography may not have the opportunity to receive BPAP. It is unknown whether the patients who would have ordinarily received a BPAP would benefit from it. We determine correlates of receiving BPAP and of being switched from BPAP to CPAP. We examine whether patients with these correlates have better adherence to BPAP versus CPAP. METHODS: Retrospective Cohort Study (Correlates at baseline) of 2,513 VA patients with a sleep study between January 2003 and October 2006 and receiving continuous or bilevel positive airway pressure (CPAP [N = 2,251]) or BPAP [N = 262]) by the end of 2007. PAP adherence up to 30 months was assessed. RESULTS: Significant correlates of BPAP were older age (p < 0.001), higher BMI and CHF (p < 0.01), COPD (p < 0.001), higher blood CO2 (p < 0.05), higher AHI and OSA severity (p < 0.001), lower nadir SpO2 (p < 0.001), and greater sleepiness (ESS) (p < 0.01). Patients on BPAP were more adherent to PAP therapy (p < 0.01), but the association largely disappeared following adjustment for BPAP correlates. There was preliminary evidence that these correlates predict long-term adherence to PAP therapy regardless of mode. CONCLUSIONS: We identified baseline factors that can help clinicians decide whether to prescribe an auto-BPAP as first-line therapy and that predict good long-term PAP adherence.

Improving prostate cancer detection in veterans through the development of a clinical decision rule for prostate biopsy.

BACKGROUND: We sought to improve prostate cancer (PC) detection through developing a prostate biopsy clinical decision rule (PBCDR), based on an elevated PSA and laboratory biomarkers. This decision rule could be used after initial PC screening, providing the patient and clinician information to consider prior to biopsy. METHODS: This case-control study evaluated men from the Tampa, Florida, James A. Haley (JH) Veteran's Administration (VA) (N = 1,378), from January 1, 1998, through April 15, 2005. To assess the PBCDR we did all of the following: 1) Identified biomarkers that are related to PC and have the capability of improving the efficiency of PC screening; 2) Developed statistical models to determine which can best predict the probability of PC; 3) Compared each potential model to PSA alone using Receiver Operator Characteristic (ROC) curves, to evaluate for improved overall effectiveness in PC detection and reduction in (negative) biopsies; and 4) Evaluated dose-response relationships between specified lab biomarkers (surrogates for extra-prostatic disease development) and PC progression. RESULTS: The following biomarkers were related to PC: hemoglobin (HGB) (OR = 1.42 95% CI 1.27, 1.59); red blood cell (RBC) count (OR = 2.52 95% CI 1.67, 3.78); PSA (OR = 1.04 95% CI 1.03, 1.05); and, creatinine (OR = 1.55 95% CI 1.12, 2.15). Comparing all PC stages versus non-cancerous conditions, the ROC curve area under the curve (AUC) enlarged (increasing the probability of correctly classifying PC): PSA (alone) 0.59 (95% CI 0.55, 0.61); PBCDR model 0.68 (95% CI 0.65, 0.71), and the positive predictive value (PPV) increased: PSA 44.7%; PBCDR model 61.8%. Comparing PC (stages II, III, IV) vs. other, the ROC AUC increased: PSA (alone) 0.63 (95% CI 0.58, 0.66); PBCDR model 0.72 (95% CI 0.68, 0.75), and the PPV increased: 20.6% (PSA); PBCDR model 55.3%. CONCLUSIONS: These results suggest evaluating certain common biomarkers in conjunction with PSA may improve PC prediction prior to biopsy. Moreover, these biomarkers may be more helpful in detecting clinically relevant PC. Follow-up studies should begin with replicating the study on different U.S. VA patients involving multiple practices.

Hepatitis C genotype analysis: results in a large veteran population with review of the implications for clinical practice.

CONTEXT: Hepatitis C virus (HCV) infects up to 1.8% of the US general population, although the rate is significantly higher in military veterans at 5.4-20%. Early detection and accurate diagnosis are critical as chronic HCV infection can lead to liver cirrhosis and hepatocellular carcinoma. Genotype analysis has both therapeutic and prognostic importance in patients with HCV infections. OBJECTIVE: We compare two versions of a commonly utilized platform for genotype analysis in HCV infections and review the implications of the results for clinical practice. DESIGN: A retrospective review of 9401 genotype results from 2001-2010 were analyzed. All results were obtained from the James A. Haley VA Medical Center, a large referral veterans' healthcare facility. RESULTS: Genotype 1 was identified in 80.1% of samples, genotype 2 in 11.1%, genotype 3 in 7.4%, and genotype 4 in 1.2%. Genotypes 5 and 6 were rarely present in our patient population. Improvements in diagnostic methodologies over the study period resulted in shifts in genotype subtyping. Specifically, upgrading from the Versant HCV genotype assay (LIPA) (Siemens, Tarrytown, NY) to the newer version 2.0 assay resulted in an increase in identification of genotype 1a by 18.5%. CONCLUSIONS: Improved technologies lead to accurate genotype identification and subtyping, both of which have increasingly important prognostic and therapeutic implications. The clinical importance of these results in patients with HCV infections is reviewed.

Quality of care for veterans with chronic diseases: performance on quality indicators, medication use and adherence, and health care utilization.

This study was conducted to assess and benchmark the quality of care, in terms of adherence to nationally recognized treatment guidelines, for veterans with common chronic diseases (ie, asthma, chronic obstructive pulmonary disease [COPD], coronary artery disease [CAD], diabetes, heart failure, hyperlipidemia [HL]) in a Veterans Health Administration (VHA) system. Patients with at least 1 of the target diagnoses in the period between January 2002 and mid-year 2006 were identified using electronic medical records of patients seen at the James A. Haley Veterans' Hospital in Tampa, Florida. The most common diseases identified were HL (34%), CAD (21%), and diabetes (19%). The percentage of patients filling a prescription for any guidelines-sanctioned pharmacotherapy ranged from 28% (heart failure) to 91% (asthma). Persistence to medication ranged from 21% (HL) to 63% (asthma), while compliance ranged from 49% (COPD) to 85% (CAD). Most patients with diabetes (88%) had at least 1 A1c test in a year, but only 47% of patients had A1c values <7%. This study found that quality of care was generally good for conditions such as cardiovascular disease and diabetes, but quality care for conditions that have not been a primary focus of previous VHA quality improvement efforts, such as asthma and COPD, has room for improvement.

Does warfarin therapy influence the risk of bladder cancer?

There has been growing interest in studying the biological effects of certain drugs and their potential to reduce the risk of various cancers. One study reported a decrease in the incidence of urogenital cancers in a trial with patients who received warfarin for treatment of venous thromboembolism, but a limitation to this study of urogenital cancers was the very small number of bladder cancer cases that developed following warfarin therapy. The objective of the present study is to measure the association between warfarin use and bladder cancer. A total of 330 cases with bladder cancer were identified at the James A. Haley Veterans' Administration (VA) Hospital in Tampa, Florida, using a combination of computerized pathology records and inpatient and outpatient diagnoses. Controls were randomly selected from the VA computerized administrative database and 1293 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of bladder cancer after adjusting for age, gender, and cigarette smoking. Among warfarin users, although there was a 27% elevation in risk, it did not differ significantly from nonusers (OR = 1.27, 95% CI = 0.85, 1.89). No duration-response relationship was observed between anticoagulant use and risk of bladder cancer. The results suggest that warfarin does not protect against bladder cancer, at least in male smokers, the highest risk population for bladder cancer.

Analgesic therapy and the prevention of bladder cancer.

The aim of this study was to measure the association between analgesic use and risk of bladder cancer among patients seen at the James A. Haley Veterans' Administration (VA) Hospital in Tampa, FL. A total of 330 cases were obtained using a combination of computerized pathology records, and inpatient and outpatient diagnoses. Controls were randomly selected from the VA computerized administrative database, and 1293 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of bladder cancer after adjusting for age, gender, and cigarette smoking. Among analgesic users, we were able to identify a nearly 20% reduction in risk potentially consistent with a protective role (OR = 0.81, 95% CI = 0.63, 1.05). Nonsmokers had a 43% decrease in risk (OR = 0.57, 95% CI = 0.33, 0.98). While smoking is a strong and recognized cause of bladder cancer, 50% of bladder cancer cases are not attributable to tobacco consumption. Given that nonsmokers prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) were observed to have a 43% reduction in risk, it is important to study whether nonsmokers may benefit from therapy with NSAIDs.

Thromboembolism preceding cancer: a correlation study.

Thromboembolic (TE) events preceding cancer have been observed. Some studies failed to find this correlation. We retrospectively examined the cancer incidence following thromboembolic events in patients at our medical center. Medical records of 183 patients with established thromboembolic events documented in their records were selected and reviewed. Time interval between primary, secondary, and recurrent TE events preceding cancer diagnosis was analyzed. Two hundred age- and sex-matched controls seen during the same period and without any evidence of TE were randomly selected and charts reviewed for malignancy. Cancer occurred after TE in 48 of 183 patients (26.2%). In controls, cancer was diagnosed in 23 (11.5%). This was statistically significant with an odds ratio of 2.736 (1.586, 4.720). In the 64 primary TE patients, the cancer incidence was 37.5%. The 63 patients with recurrent TE had an incidence of 35.4%, and 56 secondary TE patients had an incidence of 27.1%. Time between initial TE and cancer diagnosis was <6 months in 27 (56.3%) patients, between 6 months and 1 year in 12 (25.0%), 1-5 years in 5 (10.4%), and >5 years in 4 (8.3%). Fourteen (31.1%) TE patients presented with metastatic cancer. This study indicates that thromboembolic events are important predictors of cancer. Cancer in this population occurs within a year in the majority of patients. Cancer screening in patients without identifiable risk factors for thrombosis could be helpful for early detection, diagnosis, and management of cancer.

Pancreatitis-associated ascitic fluid induces hepatocyte death independent of local cytokines.

INTRODUCTION: Kupffer-cell-derived cytokines mediate liver injury, yet macrophage pacification does not abolish hepatocyte injury. We undertook this study to examine the role of pancreatitis-associated ascitic fluid (PAAF) in liver injury. METHODS: Pathogen-free PAAF was perfused into healthy rat livers in situ for 60 min (n = 5, sham = 5, LPS = 5). AST, ALT, LDH, and TNF were measured in the effluent. Primary cultures of rat Kupffer cells or hepatocytes were treated with PAAF; AST, ALT, LDH, and TNF were measured and cell proliferation was determined by MTT assay. A hepatocyte human cell line (CCL-13) was treated with PAAF and apoptosis was measured by flow cytometry. RESULTS: Liver perfusion with PAAF induced a >15-fold increase in AST/ALT/LDH (P < 0.001 PAAF vs sham), but not in TNF. In vitro, Kupffer cell viability was sharply reduced by PAAF in a dose-dependent manner; however, 5% PAAF (50% viability) did not induce TNF production from Kupffer cells. PAAF induced a multifold increase in AST/ALT/LDH from fresh hepatocytes (P < 0.001 vs control), which was not attenuated by a protease inhibitor. The CCL-13 cell population was reduced to 15 +/- 2% of baseline by PAAF (P < 0.001 vs control), whereas elastase, trypsin, or TNF had no effect. PAAF increased the percentage of nonviable CCL-13 cells (78 +/- 4% vs 28 +/- 1%, P < 0.001 vs control). Neither protease inhibitor nor heat inactivation of PAAF altered this pattern of hepatocyte death. CONCLUSION: PAAF induces direct hepatocyte injury and death by heat-stable factors other than pancreatic enzymes but not via local production of Kupffer-cell-derived cytokines.