Clement blocki Va Medical Center

Milwaukee, WI, United States

Clement blocki Va Medical Center

Milwaukee, WI, United States
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Garbelman J.,Clement blocki Va Medical Center
Psychological Injury and Law | Year: 2017

Former service-members are barred from veteran benefits if their character of discharge is other-than-honorable due to willful and persistent misconduct. One exception is if it is determined that the service-member was legally insane at the time of the behaviors resulting in discharge. Offering an expert opinion on a mental state years or decades in the past is complicated. Yet, cases involving such opinions are assigned to veterans affairs-based mental health professionals without additional training or resources. This article fills this gap by discussing the unique legal statutes that define insanity for the purpose of benefit eligibility. In addition, it shares available resources and highlights themes resulting from having opined in such cases and having reviewed 30 Board of Veterans Appeals decisions involving claimed insanity. © 2017 Springer Science+Business Media New York

Garbelman J.L.,Clement blocki Va Medical Center
Psychological Injury and Law | Year: 2017

Forms of financial compensation have been paid to the beneficiaries of deceased service members since the Revolutionary War. In its current version, Dependency and Indemnity Compensation (DIC) is a tax-free monetary benefit paid to eligible survivors of veterans whose death resulted from a service-related disability. Mental health professionals are called upon to provide medico-legal opinions in DIC claims involving questions of whether a veteran’s service-connected mental illness contributed substantially to their death. The U.S. Department of Veterans Affairs (VA) does not currently employ training programs, competency standards, or best practice recommendations for these specialized evaluations. This article seeks to fill this gap and provide a resource for mental health professionals providing medical opinions in DIC claims. © 2017 Springer Science+Business Media New York

Hayes J.,Clement blocki Va Medical Center | Jackson J.L.,Clement blocki Va Medical Center | McNutt G.M.,William S Middleton Memorial Veterans Hospital | Hertz B.J.,Hines Medical Center | And 2 more authors.
JAMA - Journal of the American Medical Association | Year: 2014

IMPORTANCE: American Board of Internal Medicine (ABIM) initiatives encourage internists with time-unlimited certificates to recertify. However, there are limited data evaluating differences in performance between internists with time-limited or time-unlimited board certification. OBJECTIVE: To determine whether there are differences in primary care quality between physicians holding time-limited or time-unlimited certification. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of performance data from 1 year (2012-2013) at 4 Veterans Affairs (VA) medical centers. Participants were internists with time-limited (n = 71) or time-unlimited (n = 34) ABIM certification providing primary care to 68 213 patients. Median physician panel size was 610 patients (range, 19-1316), with no differences between groups (P = .90). MAIN OUTCOMES AND MEASURES: Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90mmHg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100mg/dL; hypertension with blood pressure less than 140/90mmHg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100mg/dL; post-myocardial infarction use of aspirin; post-myocardial infarction use of β-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor. RESULTS: After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure: colorectal screening (odds ratio [OR], 0.95 [95%CI, 0.89-1.01]); diabetes with HbA1c level less than 9.0% (OR, 0.96 [95%CI, 0.74-1.2]); blood pressure control (OR, 0.99 [95%CI, 0.69-1.4]); LDL-C level less than 100mg/dL (OR, 1.1 [95%CI, 0.79-1.5]); hypertension with blood pressure less than 140/90mmHg (OR, 1.0 [95%CI, 0.92-1.2]); thiazide use (OR, 1.0 [95%CI, 0.8-1.3]); atherosclerotic coronary artery disease with LDL-C level less than 100mg/dL (OR, 1.1 [95%CI, 0.75-1.7]); post-myocardial infarction use of aspirin (OR, 0.98 [95%CI, 0.58-1.68]) or β-blockers (OR, 1.0 [95%CI, 0.57-1.9]); CHF with use of ACE inhibitor (OR, 0.98 [95%CI, 0.61-1.6]). CONCLUSIONS AND RELEVANCE: Among internists providing primary care at 4 VA medical centers, there were no significant differences between those with time-limited ABIM certification and those with time-unlimited ABIM certification on 10 primary care performance measures. Additional research to examine the difference in patient outcomes among holders of time-limited and time-unlimited certificates in non-VA and nonacademic settings and the association with other ABIM goals may help clarify the potential benefit of Maintenance of Certification participation. Copyright 2014 American Medical Association. All rights reserved.

Kidambi S.,Medical College of Wisconsin | Kidambi S.,Clement blocki Va Medical Center | Kotchen T.A.,Medical College of Wisconsin
American Journal of Cardiovascular Drugs | Year: 2013

Obesity is a global pandemic and with its rise, its associated co-morbidities are increasing in prevalence, particularly uncontrolled hypertension. Lifestyle changes should be an anchor for the management of obesity-related hypertension; however, they are difficult to sustain. Drug therapy is often necessary to achieve blood pressure control. Diuretics, inhibitors of the renin-angiotensin system, and dihydropyridine calcium channel blockers are often used as first trio, with subsequent additions of mineralocorticoid receptor antagonists and/or dual alpha/beta blocking agents. While a number of agents are currently available, 50 % of hypertensive patients remain uncontrolled. A number of novel drug and invasive therapies are in development and hold significant potential for the effective management of obesity-related hypertension. © 2013 Springer International Publishing Switzerland.

Kennedy S.P.,Clement blocki Va Medical Center | Barnas G.P.,Clement blocki Va Medical Center | Schmidt M.J.,Clement blocki Va Medical Center | Glisczinski M.S.,Clement blocki Va Medical Center | Paniagua A.C.,Clement blocki Va Medical Center
Journal of Clinical Lipidology | Year: 2011

Background: Many patients who could benefit from hydroxymethylglutaryl coenzyme-A reductase inhibitors (statins) are unable to take statins because of myalgias while taking previous statin therapy. Objective: The primary objective was to assess the efficacy and tolerability of once-weekly rosuvastatin in patients with documented myalgias on statins who were not currently taking a statin and not at low-density lipoprotein (LDL) goal. Methods: In this randomized, double-blind, placebo-controlled crossover study we enrolled a total of 17 Clement J. Zablocki Veterans Affairs (VA) primary care patients with a diagnosis of hyperlipidemia and a history of myalgias on statin therapy who were not currently on a statin and not at LDL goal. Two 8-week treatment phases consisted of rosuvastatin 5 mg once-weekly or matching placebo, with a dose titration to 10 mg once-weekly if not at LDL goal at week 4. The primary efficacy outcome was the difference in the mean percentage change in LDL from baseline between rosuvastatin and placebo. Results: A significant difference in the mean percentage change in LDL from baseline for rosuvastatin vs. placebo was identified (12.2% reduction vs. 0.4% reduction, respectively; P =.002). Two of the 17 patients (11.8%) in the placebo treatment phase and three of the 15 patients (20%) in the rosuvastatin treatment phase experienced myalgias requiring cessation of therapy. In addition, three patients (20%) were able to attain LDL goal on rosuvastatin compared with zero patients (0%) on placebo. Conclusion: Once-weekly low-dose rosuvastatin is an effective and well-tolerated lipid-lowering therapy option for patients not at LDL goal and previously unable to tolerate statins because of a history of myalgias. © 2011 National Lipid Association. All rights reserved.

Kumar G.,Medical College of Wisconsin | Kumar N.,Clement blocki Va Medical Center | Taneja A.,Medical College of Wisconsin | Kaleekal T.,Medical College of Wisconsin | And 9 more authors.
Chest | Year: 2011

Background: Severe sepsis is common and often fatal. The expanding armamentarium of evidence-based therapies has improved the outcomes of persons with this disease. However, the existing national estimates of the frequency and outcomes of severe sepsis were made before many of the recent therapeutic advances. Therefore, it is important to study the outcomes of this disease in an aging US population with rising comorbidities. Methods: We used the Healthcare Costs and Utilization Project's Nationwide Inpatient Sample (NIS) to estimate the frequency and outcomes of severe sepsis hospitalizations between 2000 and 2007. We identified hospitalizations for severe sepsis using International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating the presence of sepsis and organ system failure. Using weights from NIS, we estimated the number of hospitalizations for severe sepsis in each year. We combined these with census data to determine the number of severe sepsis hospitalizations per 100,000 persons. We used discharge status to identify in-hospital mortality and compared mortality rates in 2000 with those in 2007 after adjusting for demographics, number of organ systems failing, and presence of comorbid conditions. Results: The number of severe sepsis hospitalizations per 100,000 persons increased from 143 in 2000 to 343 in 2007. The mean number of organ system failures during admission increased from 1.6 to 1.9 (P < .001). The mean length of hospital stay decreased from 17.3 to 14.9 days. The mortality rate decreased from 39% to 27%. However, more admissions ended with discharge to a long-term care facility in 2007 than in 2000 (35% vs 27%, P < .001). Conclusions: An increasing number of admissions for severe sepsis combined with declining mortality rates contribute to more individuals surviving to hospital discharge. Importantly, this leads to more survivors being discharged to skilled nursing facilities and home with in-home care. Increased attention to this phenomenon is warranted. © 2011 American College of Chest Physicians.

Riess M.L.,Medical College of Wisconsin | Riess M.L.,Clement blocki Va Medical Center | Ulrichs J.G.,Medical College of Wisconsin | Pagel P.S.,Clement blocki Va Medical Center | Woehlck H.J.,Medical College of Wisconsin
Anesthesia and Analgesia | Year: 2011

Intramyometrial vasopressin injection reduces bleeding during myomectomy. Subsequent loss of peripheral pulses and nonmeasurable arterial blood pressure have been attributed to cardiovascular collapse or hypotension. When interpreted as global hypotension, treatment with vasopressors or according to Advanced Cardiac Life Support resuscitation protocols has been associated with cardiac complications. We describe a patient who developed loss of peripheral pulses and nonmeasurable blood pressure by noninvasive means after myometrial administration of 60 U vasopressin, with documented severe peripheral arterial vasospasm and elevated proximal blood pressure. We discuss the pathophysiology and emphasize the danger of misinterpreting pulselessness as global hypotension instead of vasospasm in this setting. Copyright © 2011 International Anesthesia Research Society.

Kumar G.,Medical College of Wisconsin | Majumdar T.,Medical College of Wisconsin | Jacobs E.R.,Medical College of Wisconsin | Jacobs E.R.,Clement blocki Va Medical Center | And 5 more authors.
Chest | Year: 2013

Background: Critically ill, morbidly obese patients (BMI > 40 kg/m 2) are at high risk of respiratory failure requiring invasive mechanical ventilation (IMV). It is not clear if outcomes of critically ill, obese patients are affected by obesity. Due to limited cardiopulmonary reserve, they may have poor outcomes. However, literature to this effect is limited and conflicted. Methods: We used the Nationwide Inpatient Sample from 2004 to 2008 to examine the outcomes of morbidly obese people receiving IMV and compared them to nonobese people. We identified hospitalizations requiring IMV and morbid obesity using International Classification of Diseases, 9th Revision, Clinical Modification codes. Primary outcomes studied were inhospital mortality, rates of prolonged mechanical ventilation (> 96 h), and tracheostomy. Multivariable logistic regression was used to adjust for potential confounding variables. We also examined outcomes stratified by number of organs failing. Results: Of all hospitalized, morbidly obese people, 2.9% underwent IMV. Mean age, comorbidity score, and severity of illness were lower in morbidly obese people. The adjusted mortality was not significantly different in morbidly obese people (OR 0.89; 95% CI, 0.74-1.06). When stratified by severity of disease, there was a stepwise increase in risk for mortality among morbidly obese people relative to nonobese people (range: OR, 0.77; 95% CI, 0.58-1.01 for only respiratory failure, to OR, 4.14; 95% CI, 1.11-15.3 for four or more organs failing). Rates of prolonged mechanical ventilation were similar, but rate of tracheostomy (OR 2.19; 95% CI, 1.77-2.69) was significantly higher in patients who were morbidly obese. Conclusions: Morbidly obese people undergoing IMV have a similar risk for death as nonobese people if only respiratory failure is present. When more organs fail, morbidly obese people have increased risk for mortality compared with nonobese people. © 2013 American College of Chest Physicians.

Santana-Davila R.,Clement blocki Va Medical Center | Szabo A.,Medical College of Wisconsin | Arce-Lara C.,Clement blocki Va Medical Center | Williams C.D.,Durham Medical Center | And 2 more authors.
Journal of Thoracic Oncology | Year: 2014

BACKGROUND:: While platinum-based doublet chemotherapy is standard of care for patients presenting with metastatic non-small-cell lung cancer, the optimal platinum agent (cisplatin versus carboplatin) is unclear. We therefore compared survival and toxicity among persons receiving these agents at Department of Veterans Affairs hospitals. METHODS:: We used the Veterans Affairs Central Cancer Registry to identify veterans presented between 2001 and 2008 with metastatic non-small-cell lung cancer, then selected those receiving initial platinum doublet chemotherapy. We compared survival between those receiving cisplatin and carboplatin using multivariable Cox proportional hazards models and propensity score analyses to adjust for imbalances in demographics and clinical characteristics. RESULTS:: We identified 4352 eligible persons; 4061 (93%) received carboplatin. Patients treated with cisplatin were younger (median age 61 versus 63, p < 0.01) and had less comorbidities (summary comorbidity score > 2, 7.7% versus 12.8%, p = 0.01) and higher eGFR (87 versus 84 mL/min/1.73 m). Median survival was similar for persons receiving cisplatin and carboplatin (8.1 versus 7.5 months, p = 0.54). In an adjusted survival analyses, the use of cisplatin was not associated with a better survival (hazard ratio 0.98, 95% confidence interval 0.84-1.14, p = 0.79). We performed subgroup analysis defined by histology and second agent, the hazard ratio for mortality ranged spanned 1 and none of these approached statistical significance (all p values > 0.20). Cisplatin-treated patients were more likely to have more hospitalization (1.7 versus 1.3, p < 0.01) and outpatient visits (11 versus 9.6, p < 0.01). Cisplatin-treated patient had more subsequent encounters for infection (41.6% versus 34.3%, p < 0.01) and acute kidney injury/dehydration (29.2% versus 15.5%, p < 0.01) CONCLUSIONS:: Patients receiving cisplatin and carboplatin-based doublets did not have significantly different survival, but cisplatin use was associated with an increase morbidity and healthcare use. © 2014 by the International Association for the Study of Lung Cancer.

Kumar G.,Medical College of Wisconsin | Taneja A.,Medical College of Wisconsin | Majumdar T.,Medical College of Wisconsin | Jacobs E.R.,Medical College of Wisconsin | And 3 more authors.
Critical Care Medicine | Year: 2014

OBJECTIVE:: Patients with severe sepsis have high mortality that is improved by timely, often expensive, treatments. Patients without insurance are more likely to delay seeking care; they may also receive less intense care. DESIGN:: We performed a retrospective analysis of administrative database -Healthcare Costs and Utilization Project's Nationwide Inpatient Sample -to test whether mortality is more likely among uninsured patients hospitalized for severe sepsis. PATIENTS:: None. INTERVENTIONS:: We used International Classification of Diseases -9th Revision, Clinical Modification, codes indicating sepsis and organ system failure to identify hospitalizations for severe sepsis among patients aged 18-64 between 2000 and 2008. We excluded patients with end-stage renal disease or solid organ transplants because very few are uninsured. We performed multivariate logistic regression modeling to examine the association of insurance status and in-hospital mortality, adjusted for patient and hospital characteristics. We performed subgroup analysis to examine whether the impact of insurance status varied by geographical region; by patient age, sex, or race; or by hospital characteristics such as teaching status, size, or ownership. We used similar methods to examine the impact of insurance status on the use of certain procedures, length of stay, and discharge destination. MEASUREMENTS AND MAIN RESULTS:: There were 1,600,269 discharges with severe sepsis from 2000 through 2008 in the age group 18-64 years. Uninsured people, who accounted for 7.5% of admissions with severe sepsis, had higher adjusted odds of mortality (odds ratio, 1.43; 95% CI, 1.37-1.47) than privately insured people. The higher mortality in uninsured was present in all subgroups and was similar in each year from 2000 to 2008. After adjustment, uninsured individuals had a slightly shorter length of stay than insured people and were less likely to receive five of the six interventions we examined. They were also less likely to be discharged to skilled nursing facilities or with home healthcare after discharge. CONCLUSIONS:: Uninsured are more likely to die following admission for severe sepsis than patients with insurance, even after adjusting for potential confounders. This was not due to a hospital effect or demographic or clinical factors available in our administrative database. Further research should examine the mechanisms that lead to this association. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

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