VA Maryland Healthcare System

Maryland, United States

VA Maryland Healthcare System

Maryland, United States
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Coon E.R.,University of Utah | Young P.C.,University of Utah | Quinonez R.A.,Baylor College of Medicine | Morgan D.J.,University of Maryland, Baltimore | And 4 more authors.
Pediatrics | Year: 2017

As concerns over health care-related harms and costs continue to mount, efforts to identify and combat medical overuse are needed. Although much of the recent attention has focused on health care for adults, children are also harmed by overuse. Using a structured PubMed search and manual tables of contents review, we identified important articles on pediatric overuse published in 2015. These articles were evaluated according to the quality of the methods, the magnitude of clinical effect, and the number of patients potentially affected and were categorized into overdiagnosis, overtreatment, and overutilization. Overdiagnosis: Findings included evidence for overdiagnosis of hypoxemia in children with bronchiolitis and skull fractures in children suffering minor head injuries. Overtreatment: Findings included evidence that up to 85% of hospitalized children with radiographic pneumonia may not have a bacterial etiology; many children are receiving prolonged intravenous antibiotic therapy for osteomyelitis although oral therapy is equally effective; antidepressant medication for adolescents and nebulized hypertonic saline for bronchiolitis appear to be ineffective; and thresholds for treatment of hyperbilirubinemia may be too low. Overutilization: Findings suggested that the frequency of head circumference screening could be relaxed; large reductions in abdominal computed tomography testing for appendicitis appear to have been safe and effective; and overreliance on C-reactive protein levels in neonatal early onset sepsis appears to extend hospital length-of-stay. © 2017 by the American Academy of Pediatrics.


Morgan D.J.,University of Maryland, Baltimore | Morgan D.J.,VA Maryland Healthcare System | Okeke I.N.,Haverford College | Laxminarayan R.,Center for Disease Dynamics | And 4 more authors.
The Lancet Infectious Diseases | Year: 2011

In much of the world antimicrobial drugs are sold without prescription or oversight by health-care professionals. The scale and effect of this practice is unknown. We systematically reviewed published works about non-prescription antimicrobials from 1970-2009, identifying 117 relevant articles. 35 community surveys from five continents showed that non-prescription use occurred worldwide and accounted for 19-100% of antimicrobial use outside of northern Europe and North America. Safety issues associated with non-prescription use included adverse drug reactions and masking of underlying infectious processes. Non-prescription use was common for non-bacterial disease, and antituberculosis drugs were available in many areas. Antimicrobial-resistant bacteria are common in communities with frequent non-prescription use. In a few settings, control efforts that included regulation decreased antimicrobial use and resistance. Non-prescription antimicrobial and antituberculosis use is common outside of North America and northern Europe and must be accounted for in public health efforts to reduce antimicrobial resistance. © 2011 Elsevier Ltd.


Braykov N.P.,Center for Disease Dynamics | Eber M.R.,University of Southern California | Klein E.Y.,Center for Disease Dynamics | Klein E.Y.,Johns Hopkins University | And 5 more authors.
Infection Control and Hospital Epidemiology | Year: 2013

Objective. Multidrug-resistant Enterobacteriaceae pose a serious infection control challenge and have emerged as a public health threat. We examined national trends in the proportion of Klebsiella pneumoniae isolates resistant to carbapenems (CRKP) and third-generation cephalosporins (G3CRKP). Design and Setting. Retrospective analysis of approximately 500,000 K. pneumoniae isolates cultured between January 1999 and July 2010 at 287 clinical laboratories throughout the United States. Methods. Isolates were defined as CRKP if they were nonsusceptible to 1 or more carbapenems and were defined as G3CRKP if they were nonsusceptible to ceftazidime, ceftriaxone, or related antibiotics. A multivariable analysis examined trends in the proportion of resistant isolates, adjusting for age, sex, isolate source, patient location, and geographic region. Results. The crude proportion of CRKP increased from less than 0.1% to 4.5% between 2002 and 2010; the frequency of G3CRKP increased from 5.3% to 11.5% between 1999 and 2010. G3CRKP and CRKP were more common among elderly patients (those greater than 65 years of age); the adjusted odds ratio (aOR) relative to pediatric patients (those less than 18 years of age) was 1.2 for G3CRKP (95% confidence interval [CI], 1.2-1.3) and 3.3 for CRKP (95% CI, 2.6-4.2). G3CRKP and CRKP were also more common among patients from the northeastern United States (aOR, 2.9 [95% CI, 2.8-3.0] and 9.0 [95% CI, 7.9-10.4]) than among those from the western United States. The prevalence of outpatient CRKP isolates increased after 2006, reaching 1.9% of isolates in our sample in 2010 (95% CI, 1.6%- 2.1%). Conclusions. The frequency of G3CRKP and CRKP is increasing in all regions of the United States, and resistance is emerging among isolates recovered in the outpatient setting. This underscores the need for enhanced laboratory capacity and coordinated surveillance strategies to contain the further spread of these emerging pathogens. © 2013 by The Society for Healthcare Epidemiology of America. All rights reserved.


Rubin D.L.,Stanford University | Flanders A.,Thomas Jefferson University | Kim W.,University of Pennsylvania | Siddiqui K.M.,VA Maryland Healthcare System | And 2 more authors.
Journal of Digital Imaging | Year: 2011

Radiologists frequently search the Web to find information they need to improve their practice, and knowing the types of information they seek could be useful for evaluating Web resources. Our goal was to develop an automated method to categorize unstructured user queries using a controlled terminology and to infer the type of information users seek. We obtained the query logs from two commonly used Web resources for radiology. We created a computer algorithm to associate RadLex-controlled vocabulary terms with the user queries. Using the RadLex hierarchy, we determined the high-level category associated with each RadLex term to infer the type of information users were seeking. To test the hypothesis that the term category assignments to user queries are non-random, we compared the distributions of the term categories in RadLex with those in user queries using the chi square test. Of the 29,669 unique search terms found in user queries, 15,445 (52%) could be mapped to one or more RadLex terms by our algorithm. Each query contained an average of one to two RadLex terms, and the dominant categories of RadLex terms in user queries were diseases and anatomy. While the same types of RadLex terms were predominant in both RadLex itself and user queries, the distribution of types of terms in user queries and RadLex were significantly different (p<0.0001). We conclude that RadLex can enable processing and categorization of user queries of Web resources and enable understanding the types of information users seek from radiology knowledge resources on the Web. © 2010 Society for Imaging Informatics in Medicine.


Dixon L.B.,Columbia University | Glynn S.M.,Mental Illness Research | Cohen A.N.,Mental Illness Research | Drapalski A.L.,VA Maryland Healthcare System | And 4 more authors.
Psychiatric Services | Year: 2014

Objective: The Recovery-Oriented Decisions for Relatives' Support (REORDER) intervention is an innovative, manualized protocol utilizing shared decision-making principles with persons who have seriousmental illnesses to promote recovery and encourage consideration of family involvement in care. This study compared REORDER to enhanced treatment as usual in a randomized design. Methods: Participants included 226 veterans with serious mental illness whose relatives had low rates of contact with treatment staff. REORDER involved up to three consumer sessions followed by up to three relative educational sessions if the consumer and relative consented. Individuals were assessed at baseline and six months later. Results: Eighty-five percent of the 111 randomly assigned REORDER participants attended at least one REORDER consumer session; of those, 59% had at least one family session. REORDER participants had significantly reduced paranoid ideation and increased recovery at follow-up. Conclusions: Participation in REORDER led to marked increases in family participation and improved consumer outcomes.


Seliger S.L.,University of Maryland Baltimore County | Seliger S.L.,VA Maryland Healthcare System | Zhang A.D.,University of Maryland Baltimore County | Weir M.R.,University of Maryland Baltimore County | And 6 more authors.
Kidney International | Year: 2011

Erythropoiesis-stimulating agents (ESAs) are effective in ameliorating anemia in chronic kidney disease (CKD). A recent trial in diabetic patients with CKD, however, suggested a greater risk of stroke associated with full correction of anemia with ESAs. Using national Veterans Affairs data we performed a case-control study examining the association of incident ESA use with acute stroke in patients with estimated glomerular filtration rate 60 cm 3/min per 1.73 m 2 and outpatient hemoglobin 12 g/dl. Using diagnosis codes, we identified 2071 acute hospitalized stroke cases and matched them 1:5 with controls without stroke, resulting in 12,426 total patients for analysis. Conditional logistic regression was used to estimate the association of ESA use with stroke, adjusting for potential confounders. After multivariate adjustment, ESA use in 1026 patients was associated with greater odds of stroke (odds ratio 1.30). There was significant interaction between ESA use and cancer, with greater odds of stroke among ESA-treated cancer patients (odds ratio 1.85), but not in ESA-treated patients without cancer (odds ratio 1.07). ESA-treated patients with cancer received a median initial dose 2.5-4 times greater than ESA-treated patients without cancer, but pre-ESA hemoglobin and its rate of change did not differ between these groups. Hence, in a large national sample of anemic patients with CKD, ESA treatment was associated with an increased risk of acute stroke with the greatest effect among patients with cancer. © 2011 International Society of Nephrology.


Day H.R.,University of Maryland, Baltimore | Morgan D.J.,University of Maryland, Baltimore | Morgan D.J.,VA Maryland Healthcare System | Himelhoch S.,University of Maryland Baltimore County | And 3 more authors.
American Journal of Infection Control | Year: 2011

Contact Precautions (CP) have been associated with depression and anxiety. We enrolled 103 patients on admission to a VA hospital and administered the Hospital Depression and Anxiety Scale (HADS). The mean unadjusted HADS score was 10% higher in patients on CP (14.3 vs 13.0; P = .47), and the association was stronger after adjusting for other variables (mean difference, 2.2; P = .21). Although underpowered, in the largest study to date, patients on CP tended toward more depression and anxiety. Copyright © 2011 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.


Arnold R.,University of Maryland, Baltimore | Rock C.,University of Maryland, Baltimore | Croft L.,University of Maryland, Baltimore | Gilliam B.L.,University of Maryland, Baltimore | And 2 more authors.
Antimicrobial Agents and Chemotherapy | Year: 2014

Patients with vertebral osteomyelitis may require instrumentation for spinal stabilization. Determining the optimal duration and type of antimicrobial therapy for these patients is challenging. The aim of this study was to examine risk factors for treatment failure, in particular antimicrobial duration, in a cohort of patients requiring spinal instrumentation for vertebral osteomyelitis. We conducted a retrospective cohort study of all patients with vertebral osteomyelitis who had spinal instrumentation between January 2002 and January 2012 at the University of Maryland Medical Center. The primary outcome measure was treatment failure>4 weeks postoperatively. We identified 131 patients with vertebral osteomyelitis requiring spinal instrumentation, 94 of whom had>4 weeks of follow-up and were included in the primary analysis. Treatment failure occurred in 22 of the 94 patients (23%) at a median of 4 months after surgery. Among patients who failed therapy, 20 of 22 failed within 1 year of surgery. Cervical and thoracic infection sites and the presence of negative cultures were associated with fewer treatment failures. Addition of rifampin and the use of chronic suppressive antimicrobials did not affect treatment failure rate. Twenty-three percent of patients with spinal instrumentation for vertebral osteomyelitis experienced treatment failure. Treatment failure almost always occurred within the first year of spinal instrumentation. Copyright © 2014, American Society for Microbiology. All Rights Reserved.


PubMed | University of Central Florida, VA Maryland Healthcare System and DCI Corporate Quality Management
Type: Journal Article | Journal: LGBT health | Year: 2016

Men who have sex with men (MSM) continue to be overrepresented in rates of incidence and prevalence of human immunodeficiency virus (HIV). Both HIV-diagnosed (HIV-D) and HIV-nondiagnosed (HIV-N) MSM report a variety of reasons for intentional and unintentional nonuse of condoms. Elucidating and comparing reasons for continued engagement in condomless anal sex specific to both HIV-D and HIV-N MSM likely is important to identifying effective prevention.This study employed meta-analytic methods to evaluate and compare correlates to condomless anal sex in both HIV-D and HIV-N MSM from primary studies from 1993 to February 2013.Of the 19 individual correlates assessed within the subgroup of HIV-D MSM, variables that achieved significant effect were alcohol, mind-altering substance use, sexual-enhancement medication, intentional condom nonuse, self-efficacy, attitudes toward condom use, social support, gay identity, compulsivity, trading sex, and number of sex partners. Those that were statistically non-significant were intention to use a condom, perceived risk, perceived norms, perceived responsibility, HIV medical management, treatment optimism, mental health, and setting. Of the 12 correlates assessed within the subgroup of HIV-N MSM, variables that achieved significant effect were alcohol, mind-altering substance use, intentional condom nonuse, attitudes toward condom use, perceived risk, and setting. Those observed as statistically non-significant were perceived norms, social support, gay identity, mental health, trading sex, and number of sex partners.Study results have clinical implications that may guide future prevention research and practice by highlighting risk variables shared between HIV-N and HIV-D MSM, as well as variables observed to be unique to each group that may warrant more tailored intervention. Further investigation is recommended to elucidate the relationships among these variables such that optimal intervention can be determined.


BACKGROUND: Metformin can result in vitamin B12deficiency, potentially leading to complications such as neuropathy. Annual monitoring of vitamin B12has been suggested; however, it is unknown whether current practice reflects this recommendation. OBJECTIVE: To identify vitamin B12monitoring patterns in patients on long-term, highdose metformin. Secondary objective was to determine the frequency of new vitamin B12deficiency, anemia, and neuropathy documented after initiation of highdose metformin. METHODS: Electronic medical records of veterans treated at the Veterans Affairs Maryland Healthcare System with high-dose metformin (≥2000 mg/day) as of November 1, 2010, were reviewed. Data regarding metformin treatment, vitamin B12measurements, and documentation of vitamin B12deficiency, cyanocobalamin supplementation, anemia, and neuropathy were collected. Subjects treated with metformin for less than 1 year or those with documented peripheral neuropathy, megaloblastic anemia, vitamin B12deficiency, or a condition associated with vitamin B12malabsorption prior to metformin initiation were excluded. RESULTS: Subjects (N = 235) had a mean metformin dose of 2050 mg/day and mean duration of treatment of 5.2 years. Sixty percent did not have vitamin B12measured. Of subjects receiving metformin for 10 years or more, nearly half (46%) never had vitamin B12measured. New documentation of vitamin B12deficiency or cyanocobalamin supplementation was found in 5.5% of the population, and anemia was found in 12%. Of the 14% with new neuropathy, 42% did not have vitamin B12measured. CONCLUSIONS: Vitamin B12was not routinely monitored in patients on high-dose metformin, even in those at highest risk (≥10 years of therapy), or in those with potential manifestations of vitamin B12deficiency (neuropathy). Cases of vitamin B12deficiency and resulting anemia or neuropathy may be undiagnosed and untreated because of lack of monitoring. Prospective studies examining the effect of increased vitamin B12monitoring on identification and treatment of vitamin B12deficiency in patients on metformin are warranted.

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