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Noel P.H.,VERDICT South Texas Veterans Health Care System | Noel P.H.,University of Texas Health Science Center at San Antonio | Wang C.-P.,VERDICT South Texas Veterans Health Care System | Wang C.-P.,University of Texas Health Science Center at San Antonio | And 12 more authors.
Obesity | Year: 2012

We examined 5-year trends in BMI among obese primary care patients to determine whether obesity-related education such as nutrition counseling or a weight management program was associated with declines in BMI. Veterans with BMI 30 kg/m 2 and 1 primary care visits in fiscal year 2002 were identified from the Veterans Health Administration's (VHA) national databases. Outpatient visits from fiscal year 2002-2006 for nutrition counseling, exercise, or weight management were grouped into five categories varying in intensity and duration: (i) intense-and-sustained, (ii) intense-only, (iii) irregular, (iv) limited, and (v) no counseling. Generalized estimating equation assessed associations between obesity-related counseling and BMI trend (annual rate of BMI change fiscal year 2002-2006) among cohort members with complete race/ethnic data (N = 179,881). Multinomial logistic regression compared intensity and duration of counseling among patients whose net BMI increased or decreased by ≥10% vs. remained stable. Compared with patients receiving intense-and-sustained counseling, the BMI trend of those receiving intense-only or irregular counseling was not significantly different, but patients receiving no counseling or limited counseling had significantly higher rates of decreasing BMI (0.12 and 0.08 BMI per year; P<0.01, respectively). This was especially true for veterans in their 50-60s, compared with the oldest veterans who were most likely to lose weight. In contrast, younger veterans (18-35 years) were least likely to lose weight; their BMI tended to increase regardless of counseling intensity and duration. Enhanced efforts are needed to detect and combat increasing weight trajectories among veterans who are already obese, especially among those aged 18-35 who are at greatest risk. © 2011 The Obesity Society.


Restrepo M.I.,University of Texas Health Science Center at San Antonio | Restrepo M.I.,VERDICT South Texas Veterans Health Care System | Frei C.R.,University of Texas Health Science Center at San Antonio | Frei C.R.,University of Texas at Austin
American Journal of Medicine | Year: 2010

Respiratory diseases account for approximately 10% of all hospital admissions in the United States. Pneumonia constitutes 35% of these cases, with an average length of stay (LOS) of 5.1 days. It is estimated that $8.4 billion to $10 billion of all annual US hospital expenditures are attributable to community-acquired pneumonia (CAP). As such, medical decisions, including empiric antibiotic choice, potentially exert an impact on hospital LOS and associated costs. In this review, we focus on the empiric antibiotic choices and associated costs of treatment for hospitalized patients with CAP, focusing on the use of fluoroquinolone therapy as recommended by the CAP guidelines. © 2010.


King P.,University of Texas Health Science Center at San Antonio | Mortensen E.M.,University of Texas Health Science Center at San Antonio | Mortensen E.M.,VERDICT South Texas Veterans Health Care System | Mortensen E.M.,Dallas Medical Center General Internal Medicine 111E | And 11 more authors.
European Respiratory Journal | Year: 2013

Obesity is an increasing problem in the USA, and research into the association between obesity and pneumonia has yielded conflicting results. Using Department of Veterans Affairs administrative data from fiscal years 2002-2006, we examined a cohort of patients hospitalised with a discharge diagnosis of pneumonia. Body mass index was categorised as underweight (<18.5 kg.m -2), normal (18.5-24.9 kg.m-2, reference group), overweight (25-29.9 kg.m-2), obese (30-39.9 kg.m-2) and morbidly obese (≥40 kg.m-2). Our primary analyses were multi level regression models with the outcomes of 90-day mortality, intensive care unit (ICU) admission, need for mechanical ventilation and vasopressor utilisation. The cohort comprised 18 746 subjects: 3% were underweight, 30% were normal, 36% were overweight, 27% were obese and 4% were morbidly obese. In the regression models, after adjusting for potential confounders, morbid obesity was not associated with mortality (OR 0.96, 95% CI 0.72-1.28), but obesity was associated with decreased mortality (OR 0.86, 95% CI 0.74- 0.99). Neither obesity nor morbid obesity was associated with ICU admission, use of mechanical ventilation or vasopressor utilisation. Underweight patients had increased 90-day mortality (OR 1.40, 95% CI 1.14-1.73). Although obesity is a growing health epidemic, it appears to have little impact on clinical outcomes and may reduce mortality for veterans hospitalised with pneumonia.


Keyt H.,University of Texas Health Science Center at San Antonio | Faverio P.,University of Texas Health Science Center at San Antonio | Faverio P.,University of Milan Bicocca | Restrepo M.I.,University of Texas Health Science Center at San Antonio | Restrepo M.I.,VERDICT South Texas Veterans Health Care System
Indian Journal of Medical Research | Year: 2014

Ventilator-associated pneumonia (VAP) is one of the most commonly encountered hospital-acquired infections in intensive care units and is associated with significant morbidity and high costs of care. The pathophysiology, epidemiology, treatment and prevention of VAP have been extensively studied for decades, but a clear prevention strategy has not yet emerged. In this article we will review recent literature pertaining to evidence-based VAP-prevention strategies that have resulted in clinically relevant outcomes. A multidisciplinary strategy for prevention of VAP is recommended. Those interventions that have been shown to have a clinical impact include the following: (i) Non-invasive positive pressure ventilation for able patients, especially in immunocompromised patients, with acute exacerbation of chronic obstructive pulmonary disease or pulmonary oedema, (ii) Sedation and weaning protocols for those patients who do require mechanical ventilation, (iii) Mechanical ventilation protocols including head of bed elevation above 30 degrees and oral care, and (iv) Removal of subglottic secretions. Other interventions, such as selective digestive tract decontamination, selective oropharyngeal decontamination and antimicrobial-coated endotracheal tubes, have been tested in different studies. However, the evidence for the efficacy of these measures to reduce VAP rates is not strong enough to recommend their use in clinical practice. In numerous studies, the implementation of VAP prevention bundles to clinical practice was associated with a significant reduction in VAP rates. Future research that considers clinical outcomes as primary endpoints will hopefully result in more detailed prevention strategies.


Perry T.W.,VERDICT South Texas Veterans Health Care System | Pugh M.J.V.,VERDICT South Texas Veterans Health Care System | Pugh M.J.V.,University of Texas Health Science Center at San Antonio | Waterer G.W.,University of Western Australia | And 11 more authors.
American Journal of Medicine | Year: 2011

Objective: Several studies have suggested an increased risk of cardiovascular events, primarily acute myocardial infarction, around the time of hospital admission for pneumonia. Therefore, we examined cardiovascular events, including myocardial infarction, congestive heart failure, unstable angina, stroke, and serious cardiac arrhythmias, within 90 days after hospitalization for pneumonia. Methods: By using data from the administrative databases of the Department of Veterans Affairs, we examined a cohort of subjects hospitalized with pneumonia between October 2001 and September 2007. Subjects were at least 65 years of age. We examined the incidence of myocardial infarction, congestive heart failure, cardiac arrhythmias, unstable angina, and stroke by International Classification of Diseases, Ninth Revision codes, excluding those with a diagnosis before the admission for pneumonia. Results: The cohort comprised 50,119 subjects with a mean age of 77.5 years (standard deviation 6.7 years), 98% of whom were male. The 90-day incidence of cardiovascular events was 1.5% for myocardial infarction, 10.2% for congestive heart failure, 9.5% for arrhythmia, 0.8% for unstable angina, and 0.2% for stroke. The majority of events occurred during the hospitalization for pneumonia. Conclusion: A clinically important number of subjects in this cohort had a cardiovascular event within 90 days of hospital admission, suggesting that such events may have an important role in post-pneumonia mortality. Additional research is needed to determine whether interventions may reduce the number of cardiovascular events after pneumonia. © 2011 Elsevier Inc. All rights reserved.


Noel P.H.,VERDICT South Texas Veterans Health Care System | Noel P.H.,University of Texas Health Science Center at San Antonio | Copeland L.A.,VERDICT South Texas Veterans Health Care System | Copeland L.A.,University of Texas Health Science Center at San Antonio | And 11 more authors.
Journal of General Internal Medicine | Year: 2010

Background: In response to dramatic increases in obesity prevalence, clinical guidelines urge health care providers to prevent and treat obesity more aggressively. OBJECTIVE: To describe the proportion of obese primary care patients receiving obesity care over a 5-year period and identify factors predicting receipt of care. DESIGN: Retrospective cohort study utilizing VHA administrative data from 6 of 21 VA administrative regions. PATIENTS: Veterans seen in primary care in FY2002 with a body mass index (BMI) ≥30 kg/m 2 based on heights and weights recorded in the electronic medical record (EMR), survival through FY2006, and active care (1 or more visits in at least 3 follow-up years FY2003-2006). MAIN MEASURES: Receipt of outpatient visits for individual or group education or instruction in nutrition, exercise, or weight management; receipt of prescriptions for any FDA-approved medications for weight reduction; and receipt of bariatric surgery. KEY Results: Of 933,084 (88.6%) of 1,053,228 primary care patients who had recorded heights and weights allowing calculation of BMI, 330,802 (35.5%) met criteria for obesity. Among obese patients who survived and received active care (N=264,667), 53.5% had a recorded obesity diagnosis, 34.1% received at least one outpatient visit for obesity-related education or counseling, 0.4% received weight-loss medications, and 0.2% had bariatric surgery between FY2002-FY2006. In multivariable analysis, patients older than 65 years (OR=0.62; 95% CI: 0.60-0.64) were less likely to receive obesity-related education, whereas those prescribed 5-7 or 8 or more medication classes (OR= 1.41; 1.38-1.45; OR=1.94; 1.88-2.00, respectively) or diagnosed with obesity (OR=4.0; 3.92-4.08) or diabetes (OR=2.23; 2.18-2.27) were more likely to receive obesity-related education. Conclusions: Substantial numbers of VHA primary care patients did not have sufficient height or weight data recorded to calculate BMI or have recorded obesity diagnoses when warranted. Receipt of obesity education varied by sociodemographic and clinical factors; providers may need to be cognizant of these when engaging patients in treatment. © 2010 Society of General Internal Medicine.


Soto-Gomez N.,University of Texas Health Science Center at San Antonio | Anzueto A.,University of Texas Health Science Center at San Antonio | Waterer G.W.,University of Western Australia | Waterer G.W.,Northwestern University | And 4 more authors.
American Journal of Medicine | Year: 2013

Background: Recent studies suggest that there is an increase in cardiovascular disease after pneumonia; however, there is little information on cardiac arrhythmias after pneumonia. The aims of this study were to assess the incidence of, and examine risk factors for, cardiac arrhythmias after hospitalization for pneumonia. Methods: We conducted a national cohort study using Department of Veterans Affairs administrative data including patients aged ≥65 years hospitalized with pneumonia in fiscal years 2002-2007, receiving antibiotics within 48 hours of admission, having no prior diagnosis of a cardiac arrhythmia, and having at least 1 year of Veterans Affairs care. We included only the first pneumonia-related hospitalization, and follow-up was for the 90 days after admission. Cardiac arrhythmias included atrial fibrillation, ventricular tachycardia/fibrillation, cardiac arrest, and symptomatic bradycardia. We used a multilevel regression model, adjusting for hospital of admission, to examine risk factors for cardiac arrhythmias. Results: We identified 32,689 patients who met the inclusion criteria. Of these, 3919 (12%) had a new diagnosis of cardiac arrhythmia within 90 days of admission. Variables significantly associated with increased risk of cardiac arrhythmia included increasing age, history of congestive heart failure, and a need for mechanical ventilation or vasopressors. Beta-blocker use was associated with a decreased incidence of events. Conclusion: An important number of patients have new cardiac arrhythmia during and after hospitalization for pneumonia. Additional research is needed to determine whether use of cardioprotective medications will improve outcomes for patients hospitalized with pneumonia. At-risk patients hospitalized with pneumonia should be monitored for cardiac arrhythmias during the hospitalization. © 2013 Elsevier Inc.


PubMed | VERDICT South Texas Veterans Health Care System
Type: Journal Article | Journal: Journal of general internal medicine | Year: 2010

In response to dramatic increases in obesity prevalence, clinical guidelines urge health care providers to prevent and treat obesity more aggressively.To describe the proportion of obese primary care patients receiving obesity care over a 5-year period and identify factors predicting receipt of care.Retrospective cohort study utilizing VHA administrative data from 6 of 21 VA administrative regions.Veterans seen in primary care in FY2002 with a body mass index (BMI) > or =30 kg/m(2) based on heights and weights recorded in the electronic medical record (EMR), survival through FY2006, and active care (1 or more visits in at least 3 follow-up years FY2003-2006).Receipt of outpatient visits for individual or group education or instruction in nutrition, exercise, or weight management; receipt of prescriptions for any FDA-approved medications for weight reduction; and receipt of bariatric surgery.Of 933,084 (88.6%) of 1,053,228 primary care patients who had recorded heights and weights allowing calculation of BMI, 330,802 (35.5%) met criteria for obesity. Among obese patients who survived and received active care (N = 264,667), 53.5% had a recorded obesity diagnosis, 34.1% received at least one outpatient visit for obesity-related education or counseling, 0.4% received weight-loss medications, and 0.2% had bariatric surgery between FY2002-FY2006. In multivariable analysis, patients older than 65 years (OR = 0.62; 95% CI: 0.60-0.64) were less likely to receive obesity-related education, whereas those prescribed 5-7 or 8 or more medication classes (OR = 1.41; 1.38-1.45; OR = 1.94; 1.88-2.00, respectively) or diagnosed with obesity (OR = 4.0; 3.92-4.08) or diabetes (OR = 2.23; 2.18-2.27) were more likely to receive obesity-related education.Substantial numbers of VHA primary care patients did not have sufficient height or weight data recorded to calculate BMI or have recorded obesity diagnoses when warranted. Receipt of obesity education varied by sociodemographic and clinical factors; providers may need to be cognizant of these when engaging patients in treatment.


PubMed | VERDICT South Texas Veterans Health Care System
Type: Journal Article | Journal: The American journal of medicine | Year: 2011

Several studies have suggested an increased risk of cardiovascular events, primarily acute myocardial infarction, around the time of hospital admission for pneumonia. Therefore, we examined cardiovascular events, including myocardial infarction, congestive heart failure, unstable angina, stroke, and serious cardiac arrhythmias, within 90 days after hospitalization for pneumonia.By using data from the administrative databases of the Department of Veterans Affairs, we examined a cohort of subjects hospitalized with pneumonia between October 2001 and September 2007. Subjects were at least 65 years of age. We examined the incidence of myocardial infarction, congestive heart failure, cardiac arrhythmias, unstable angina, and stroke by International Classification of Diseases, Ninth Revision codes, excluding those with a diagnosis before the admission for pneumonia.The cohort comprised 50,119 subjects with a mean age of 77.5 years (standard deviation 6.7 years), 98% of whom were male. The 90-day incidence of cardiovascular events was 1.5% for myocardial infarction, 10.2% for congestive heart failure, 9.5% for arrhythmia, 0.8% for unstable angina, and 0.2% for stroke. The majority of events occurred during the hospitalization for pneumonia.A clinically important number of subjects in this cohort had a cardiovascular event within 90 days of hospital admission, suggesting that such events may have an important role in post-pneumonia mortality. Additional research is needed to determine whether interventions may reduce the number of cardiovascular events after pneumonia.

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