Trauma

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

Background: Venous thromboembolism and pulmonary embolism are common after major trauma. Anticoagulant prophylaxis usually is not considered because of the increased risk of bleeding. Despite the limited data, many trauma centers use inferior vena cava (IVC) filters as a primary means to prevent pulmonary embolism.

Study design: Randomized, controlled, and multicenter trial.

Setting: Four tertiary hospitals in Australia.

Synopsis: 240 major trauma patients were randomly assigned to receive either IVC filter or no IVC filter within 72 hours after admission. The primary endpoint was a composite of 90-day mortality or symptomatic pulmonary embolism confirmed on imaging. There was no difference in the rate of composite outcome in those with IVC filter, compared with those with no IVC filter.

Bottom line: After major trauma, early prophylactic placement of IVC filter did not reduce the 90-day mortality or incidence of symptomatic pulmonary embolism.

Citation: Ho KM et al. A multicenter trial of vena cava filters in severely injured patients. N Engl J Med. 2019 Jul 25;381:328-37.

Dr. Hoque Sharmy is a hospitalist and assistant professor of medicine in the division of hospital medicine at St. Louis University School of Medicine.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

A group of experts representing various international professional societies has drafted a consensus statement on the determination of brain death or death by neurologic criteria (BD/DNC). The document, a result of the World Brain Death Project, surveys the clinical aspects of this determination, such as clinical testing, apnea testing, and the number of examinations required, as well as its social and legal aspects, including documentation, qualifications for making the determination, and religious attitudes toward BD/DNC.

The recommendations are the minimum criteria for BD/DNC, and countries and professional societies may choose to adopt stricter criteria, the authors noted. Seventeen supplements to the consensus statement contain detailed reports on topics the statement examines, including focuses on both adults and children.

“Perhaps the most important points of this project are, first, to show the worldwide acceptance of the concept of BD/DNC and what the minimum requirements are for BD/DNC,” said corresponding author Gene Sung, MD, MPH, director of the neurocritical care and stroke division at the University of Southern California, Los Angeles. Second, “this standard is centered around a clinical determination without the need for other testing.”

The consensus document and supplements were published online Aug. 3 in JAMA.

Comprehensive review

A lack of rigor has led to many differences in the determination of BD/DNC, said Dr. Sung. “Some of the variance that is common are the numbers of exams and examiners that are required and whether ancillary tests are required for determination of BD/DNC. In addition, a lot of guidelines and protocols that are in use are not thorough in detailing how to do the examinations and what to do in different circumstances.”

Professional societies such as the World Federation of Intensive and Critical Care recruited experts in BD/DNC to develop recommendations, which were based on relevant articles that they identified during a literature search. “We wanted to develop a fairly comprehensive document that, along with the 17 supplements, builds a foundation to show how to determine BD/DNC – what the minimum clinical criteria needed are and what to do in special circumstances,” Dr. Sung said.

Major sections of the statement include recommendations for the minimum clinical standards for the determination of BD/DNC in adults and children.

Determination must begin by establishing that the patient has sustained an irreversible brain injury that resulted in the loss of all brain function, according to the authors. Confounders such as pharmacologic paralysis and the effect of CNS depressant medications should be ruled out.

In addition, clinical evaluation must include an assessment for coma and an evaluation for brain stem areflexia. Among other criteria, the pupils should be fixed and nonresponsive to light, the face should not move in response to noxious cranial stimulation, and the gag and cough reflexes should be absent. Apnea testing is recommended to evaluate the responsiveness of respiratory centers in the medulla.

Although the definition of BD/DNC is the same in children as in adults, less evidence is available for the determination of BD/DNC in the very young. The authors thus advised a cautious approach to the evaluation of infants and younger children.

Recommendations vary by age and often require serial examinations, including apnea testing, they noted.

Ancillary testing

The consensus statement also reviews ancillary testing, which the authors recommend be required when the minimum clinical examination, including the apnea test, cannot be completed and when it is in the presence of confounding conditions that cannot be resolved.

The authors recommended digital subtraction angiography, radionuclide studies, and transcranial Doppler ultrasonography as ancillary tests based on blood flow in the brain. However, CT angiography and magnetic resonance angiography not be used.

A lack of guidance makes performing an apnea test in patients receiving extracorporeal membrane oxygenation (ECMO) challenging, according to the authors. Nevertheless, they recommended that the same principles of BD/DNC be applied to adults and children receiving ECMO.

They further recommended a period of preoxygenation before the apnea test, and the document describes in detail the method for administering this test to people receiving ECMO.

Another potentially challenging situation pointed out in the consensus document is the determination of BD/DNC in patients who have been treated with targeted temperature management. Therapeutic hypothermia, particularly if it is preceded or accompanied by sedation, can temporarily impair brain stem reflexes, thus mimicking BD/DNC.

The new document includes a flowchart and step-by-step recommendations as well as suggestions for determining BD/DNC under these circumstances.

Among document limitations acknowledged by the authors is the lack of high-quality data from randomized, controlled trials on which to base their recommendations.

In addition, economic, technological, or personnel limitations may reduce the available options for ancillary testing, they added. Also, the recommendations do not incorporate contributions from patients or social or religious groups, although the authors were mindful of their concerns.

To promote the national and international harmonization of BD/DNC criteria, “medical societies and countries can evaluate their own policies in relation to this document and fix any deficiencies,” Dr. Sung said.

“Many countries do not have any BD/DNC policies and can use the documents from this project to create their own. There may need to be discussions with legal, governmental, religious, and societal leaders to help understand and accept BD/DNC and to help enact policies in different communities,” he added.

Divergent definitions

The determination of death is not simply a scientific question, but also a philosophical, religious, and cultural question, wrote Robert D. Truog, MD, director of the Harvard Center for Bioethics, Boston, and colleagues in an accompanying editorial. Future research should consider cultural differences over these questions.

“Most important is that there be a clear and logical consistency between the definition of death and the tests that are used to diagnose it,” Dr. Truog said.

The concept of whole brain death was advanced as an equivalent to biological death, “such that, when the brain dies, the body literally disintegrates, just as it does after cardiac arrest,” but evidence indicates that this claim is untrue, Dr. Truog said. Current tests also do not diagnose the death of the whole brain.

Another hypothesis is that brain stem death represents the irreversible loss of consciousness and the capacity for spontaneous respiration.

“Instead of focusing on biology, [this definition] focuses on values and is based on the claim that when a person is in a state of irreversible apneic unconsciousness, we may consider them to be dead,” said Dr. Truog. He and his coeditorialists argued that the concept of whole brain death should be replaced with that of brain stem death.

“This report should be a call for our profession, as well as for federal and state lawmakers, to reform our laws so that they are consistent with our diagnostic criteria,” Dr. Truog said.

“The most straightforward way of doing this would be to change U.S. law and adopt the British standard of brain stem death, and then refine our testing to make the diagnosis of irreversible apneic unconsciousness as reliable and safe as possible,” he concluded.

The drafting of the consensus statement was not supported by outside funding. Dr. Sung reported no relevant financial relationships. Dr. Truog reported receiving compensation from Sanofi and Covance for participating in data and safety monitoring boards unrelated to the consensus document.

A version of this article originally appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Concentrations of neurofilament light (NfL) chain in blood can detect concussion, its severity and help predict recovery in patients with mild traumatic brain injury (TBI), new research indicates.

“Blood NfL may be used to aid in the diagnosis of patients with concussion or mild TBI [and] to identify individuals at increased risk of developing persistent postconcussive symptoms following TBI,” said lead author Pashtun Shahim, MD, PhD, National Institutes of Health Clinical Center, Bethesda, Md.

“This study is the first to do a detailed assessment of serum NfL chain and advanced brain imaging in multiple cohorts, brain injury severities, and time points after injury. The cohorts included professional athletes and nonathletes, and over time up to 5 years after TBI,” Dr. Shahim added.

The study was published online July 8 in Neurology.
 

Rapid indicator of neuronal damage

The researchers studied two cohorts of patients with head injuries. In the first, they determined serum and CSF NfL chain levels in professional Swedish ice hockey players (median age, 27 years), including 45 with acute concussion, 31 with repetitive concussions and persistent post-concussive symptoms (PCS), 28 who contributed samples during preseason with no recent concussion, and 14 healthy nonathletes.

CSF and serum NfL concentrations were closely correlated (r = 0.71; P < .0001). Serum NfL distinguished players with persistent PCS due to repetitive concussions from preseason concussion-free players, with an area under the receiver operating characteristic curve of 0.97. Higher CSF and serum NfL levels were associated with a higher number of concussions and severity of PCS after 1 year.

The second cohort involved 230 clinic-based adults (mean age, 43 years), including 162 with TBI and 68 healthy controls. In this cohort, patients with TBI had increased serum NfL concentrations compared with controls for up to 5 years, and these concentrations were able to distinguish between mild, moderate, and severe TBI. Serum NfL also correlated with measures of functional outcome, MRI brain atrophy, and diffusion tensor imaging estimates of traumatic axonal injury.

“Our findings suggest that NfL concentrations in serum offer rapid and accessible means of assessing and predicting neuronal damage in patients with TBI,” the investigators wrote.

What’s needed going forward, said Dr. Shahim, is “validation in larger cohorts for determining what levels of NfL in blood may be associated with a specific type of TBI, and what the levels are in healthy individuals of different ages.”

Not ready for prime time

In an accompanying editorial, Christopher Filley, MD, University of Colorado at Denver, Aurora, noted that NfL “may prove useful in identifying TBI patients at risk for prolonged symptoms and in enabling more focused treatment for these individuals.”

“These reports are richly laden with acute and longitudinal data that not only support the use of NfL as a convenient diagnostic test for TBI, but plausibly correlate with the neuropathology of TBI that is thought to play a major role in immediate and lasting cognitive disability,” he wrote.

Although the origin of TBI-induced cognitive decline is not entirely explained by traumatic axonal injury, “NfL appears to have much promise as a blood test that relates directly to the ubiquitous white matter damage of TBI, revealing a great deal about not only whether a TBI occurred, but also the extent of injury sustained, and how this injury may affect patient outcome for years thereafter,” Dr. Filley wrote.

However, he cautioned more research is needed before the blood test can be routinely applied to TBI diagnosis in clinical practice. “Among the hurdles still ahead are the standardization of measurement techniques across analytical platforms, and the determination of precise cutoffs between normal and abnormal values in different ages groups and at varying levels of TBI severity,” Dr. Filley noted.

The research was supported by the National Institutes of Health, the Department of Defense, the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University, and the Swedish Research Council. Dr. Shahim and Dr. Filley have reported no relevant financial relationships.

This article first appeared on Medscape.com.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

COVID-19 has created stressors that are unprecedented in our modern era, prompting health care systems to adapt rapidly. Demand for telehealth has skyrocketed, and clinicians, many of whom had planned to adopt virtual practices in the future, have been pressured to do so immediately.¹ In March 2020, the Centers for Medicare and Medicaid Services (CMS) expanded telehealth services, removing many barriers to virtual care.² Similar remedy was not necessary for the Veterans Health Administration (VHA) which reported more than 2.6 million episodes of telehealth care in 2019.³ By the time the pandemic was underway in the US, use of telehealth was widespread across the agency. In late March 2020, VHA released a COVID-19 Response Plan, in which telehealth played a critical role in safe, uninterrupted delivery of services.⁴ While telehealth has been widely used in VHA, the call for replacement of most in-person outpatient visits with telehealth visits was a fundamental paradigm shift for many patients and clinicians.⁴

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (HR 748) gave the US Department of Veterans Affairs (VA) funding to expand coronavirus-related telehealth services, including the purchase of mobile devices and broadband expansion. CARES authorized the agency to expand telemental health services, enter into short-term agreements with telecommunications companies to provide temporary broadband services to veterans, temporarily waived an in-person home visit requirement (accepting video and phone calls as an alternative), and provided means to make telehealth available for homeless veterans and case managers through the HUD-VASH (US Department of Housing and Urban Development-VA Supportive Housing) program.

VHA is a national telehealth exemplar, initiating telehealth by use of closed-circuit televisions as early as 1968, and continuing to expand through 2017 with the implementation of the Veterans Video Connect (VVC) platform.⁵ VVC has enabled veterans to participate in virtual visits from distant locations, including their homes. VVC was used successfully during hurricanes Sandy, Harvey, Irma, and Maria and is being widely deployed in the current crisis.^6-8

While telehealth can take many forms, the current discussion will focus on live (synchronous) videoconferencing: a 2-way audiovisual link between a patient and clinician, such as VVC, which enables patients to maintain a safe and social distance from others while connecting with the health care team and receiving urgent as well as ongoing medical care for both new and established conditions.⁹ VHA has developed multiple training resources for use of VVC across many settings, including primary care, mental health, and specialties. In this review, we will make the novel case for applying a trauma-informed lens to telehealth care across VHA and beyond to other health care systems.

Trauma-Informed Care

Although our current focus is rightly on mitigating the health effects of a pandemic, we must recognize that stressful phenomena like COVID-19 occur against a backdrop of widespread physical, sexual, psychological, and racial trauma in our communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁰ Trauma exposure is both ubiquitous worldwide and inequitably distributed, with vulnerable populations disproportionately impacted.^11,12

Veterans as a population are often highly trauma exposed, and while VHA routinely screens for experiences of trauma, such as military sexual trauma (MST) and intimate partner violence (IPV), and potential mental health sequelae of trauma, including posttraumatic stress disorder (PTSD) and suicidality, veterans may experience other forms of trauma or be unwilling or unable to talk about past exposures.¹³ One common example is that of adverse childhood experiences (ACEs), which include household dysfunction, neglect, and physical and sexual abuse before the age of 18 years.¹⁴ ACEs have been associated with a wide range of risk behaviors and poor health outcomes in adulthood.¹⁴ In population-based data, both male and female veterans have reported higher ACE scores.¹⁵ In addition, ACE scores are higher overall for those serving in the all-volunteer era (after July 1, 1973).¹⁶ Because trauma may be unseen, unmeasured, and unnamed, it is important to deliver all medical care with sensitivity to its potential presence.

It is important to distinguish the concept of trauma-informed care (TIC) from trauma-focused services. Trauma-focused or trauma-specific treatment refers to evidence-based and best practice treatment models that have been proven to facilitate recovery from problems resulting from the experience of trauma, such as PTSD.¹⁷ These treatments directly address the emotional, behavioral, and physiologic impact of trauma on an individual’s life and facilitate improvement in related symptoms and functioning: They are designed to treat the consequences of trauma. VHA offers a wide range of trauma-specific treatments, and considerable experience in delivering evidence-based trauma-focused treatment through telehealth exists.^18,19 Given the range of possible responses to the experience of trauma, not all veterans with trauma histories need to, chose to, or feel ready to access trauma-specific treatments.²⁰

In contrast, TIC is a global, universal precautions approach to providing quality care that can be applied to all aspects of health care and to all patients.²¹ TIC is a strengths-based service delivery framework that is grounded in an understanding of, and responsiveness to, the disempowering impact of experiencing trauma. It seeks to maximize physical, psychological, and emotional safety in all health care encounters, not just those that are specifically trauma-focused, and creates opportunities to rebuild a sense of control and empowerment while fostering healing through safe and collaborative patient-clinician relationships.²² TIC is not accomplished through any single technique or checklist but through continuous appraisal of approaches to care delivery. SAMHSA has elucidated 6 fundamental principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment; voice and choice; and sensitivity to cultural, historical, and gender issues.¹⁰

TIC is based on the understanding that often traditional service delivery models of care may trigger, silence, or disempower survivors of trauma, exacerbating physical and mental health symptoms and potentially increasing disengagement from care and poorer outcomes.²³ Currier and colleagues aptly noted, “TIC assumes that trustworthiness is not something that an organization creates in a veteran client, but something that he or she will freely grant to an organization.”²⁴ Given the global prevalence of trauma, its well-established and deleterious impact on lifelong health, and the potential for health care itself to be traumatizing, TIC is a fundamental construct to apply universally with any patient at any time, especially in the context of a large-scale community trauma, such as a pandemic.¹²

Trauma-Informed COVID-19 Care

Catastrophic events, such as natural disasters and pandemics, may serve as both newly traumatic and as potential triggers for survivors who have endured prior trauma.^25,26 Increases in depression, PTSD, and substance use disorder (SUD) are common sequalae, occurring during the event, the immediate aftermath, and beyond.^25,27 In 2003, quarantine contained the spread of Severe acute respiratory syndrome (SARS) but resulted in a high prevalence of psychological distress, including PTSD and depression.²⁷ Many veterans may have deployed in support of humanitarian assistance/disaster relief missions, which typically do not involve armed combat but may expose service members to warlike situations, including social insecurity and suffering populations.²⁸ COVID-19 may be reminiscent of some of these deployments as well.

The impact of the current COVID-19 pandemic on patients is pervasive. Those with preexisting financial insecurity now face additional economic hardship and health challenges, which are amplified by loneliness and loss of social support networks.²⁶ Widespread unemployment and closures of many businesses add to stress and may exacerbate preexisting mental and physical health concerns for many; some veterans also may be at increased risk.²⁹ While previous postdisaster research suggests that psychopathology in the general population will significantly remit over time, high-risk groups remain vulnerable to PTSD and bear the brunt of social and economic consequences associated with the crisis.²⁵ Veterans with preexisting trauma histories and mental health conditions are at increased risk for being retraumatized by the current pandemic and impacted by isolation and unplanned job or wage loss from it.²⁹ Compounding this, social distancing serves to protect communities but may amplify isolation and danger in abusive relationships or exacerbate underlying mental illness.^26,30

Thus, as we expand our use of telehealth, replacing our face-to-face visits with virtual encounters, it is critical for clinicians to be mindful that the pandemic and public health responses to it may result in trauma and retraumatization for veterans and other vulnerable patients, which in turn can impact both access and response to care. The application of trauma-informed principles to our virtual encounters has the potential to mitigate some of these health impacts, increase engagement in care, and provide opportunities for protective, healing connections.

In the setting of the continued fear and uncertainty of the COVID-19 pandemic, we believe that application of a trauma-informed lens to telehealth efforts is timely. While virtual visits may seem to lack the warmth and immediacy of traditional medical encounters, accumulated experience suggests otherwise.¹⁹ Telehealth is fundamentally more patient-focused than traditional encounters, overcomes service delivery barriers, offers a greater range of options for treatment engagement, and can enhance clinician-patient partnerships.^6,31,32 Although the rapid transition to telehealth may be challenging for those new to it, experienced clinicians and patients express high degrees of satisfaction with virtual care because direct communication is unhampered by in-office challenges and travel logistics.³³

While it may feel daunting to integrate principles of TIC into telehealth during a crisis-driven scale-up, a growing practice and body of research can inform these efforts. To help better understand how trauma-exposed patients respond to telehealth, we reviewed findings from trauma-focused telemental health (TMH) treatment. This research demonstrates that telehealth promotes safety and collaboration—fundamental principles of TIC—that can, in turn, be applied to telehealth visits in primary care and other medical and surgical specialties. When compared with traditional in-person treatment, studies of both individual and group formats of TMH found no significant differences in satisfaction, acceptability, or outcomes (such as reduction in PTSD symptom severity scores³⁴), and TMH did not impede development of rapport.^19,35

Although counterintuitive, the virtual space created by the combined physical and psychological distance of videoconferencing has been shown to promote safety and transparency. In TMH, patients have reported greater honesty due to the protection afforded by this virtual space.³¹ Engaging in telehealth visits from the comfort of one’s home can feel emotionally safer than having to travel to a medical office, resulting in feeling more at ease during encounters.³¹ In one TMH study, veterans with PTSD described high comfort levels and ability to let their guard down during virtual treatment.¹⁹ Similarly, in palliative telehealth care, patients reported that clinicians successfully nurtured an experience of intimacy, expressed empathy verbally and nonverbally, and responded to the patient’s unique situation and emotions.³³

Trauma-Informed Telehealth

We have discussed how telehealth’s greater flexibility may create an ideal environment in which to implement principles of TIC. It may allow increased collaboration and closeness between patients and clinicians, empowering patients to codesign their care.^31,33 The Table reviews 6 core SAMHSA principles of TIC and offers examples of their application to telehealth visits. The following case illustrates the application of trauma-informed telehealth care.

Case Presentation

S is a 45-year-old male veteran of Operation Enduring Freedom (OEF) who served as a combat medic. He has a history of osteoarthritis and PTSD related to combat experiences like caring for traumatic amputees. Before the pandemic began, he was employed as a server at a local restaurant but was laid off as the business transitioned to takeout orders only. The patient worked near a VA primary care clinic and frequently dropped by to see the staff and to pick up prescriptions. He had never agreed to video visits despite receiving encouragement from his medical team. He was reluctant to try telehealth, but he had developed a painful, itchy rash on his lower leg and was concerned about getting care.

For patients like S who may be reluctant to try telehealth, it is important to understand the cause. Potential barriers to telehealth may include lack of Internet access or familiarity with technology, discomfort with being on video, shame about the appearance of one’s home, or a strong cultural preference for face-to-face medical visits. Some may miss the social support benefit of coming into a clinic, particularly in VHA, which is designed specifically for veteran patients. For these reasons it is important to offer the patient a choice and to begin with a supportive phone call that explores and strives to address the patient’s concerns about videoconferencing.

The clinic nurse called S who agreed to try a VVC visit with gentle encouragement. He shared that he was embarrassed about the appearance of his apartment and fearful about pictures being recorded of his body due to “a bad experience in my past.” The patient was reassured that visits are private and will not be recorded. The nurse also reminded him that he can choose the location in which the visit will take place and can turn his camera off at any time. Importantly, the nurse did not ask him to recount additional details of what happened in his past. Next, the nurse verified his location and contact information and explained why obtaining this information was necessary. Next, she asked his consent to proceed with the visit, reminding him that the visit can end at any point if he feels uncomfortable. After finishing this initial discussion, the nurse told him that his primary care physician (PCP) would join the visit and address his concerns with his leg.

S was happy to see his PCP despite his hesitations about video care. The PCP noticed that he seemed anxious and was avoiding talking about the rash. Knowing that he was anxious about this VVC visit, the PCP was careful to look directly at the camera to make eye contact and to be sure her face was well lit and not in shadows. She gave him some time to acclimate to the virtual environment and thanked him for joining the visit. Knowing that he was a combat veteran, she warned him that there have been sudden, loud construction noises outside her window. Although the PCP was pressed for time, she was aware that S may have had a previous difficult experience around images of his body or even combat-related trauma. She gently brought up the rash and asked for permission to examine it, avoiding commands or personalizing language such as “show me your leg” or “take off your pants for me.”³⁶After some hesitation, the patient revealed his leg that appeared to have multiple excoriations and old scars from picking. After the examination, the PCP waited until the patient’s leg was fully covered before beginning a discussion of the care plan. Together they collaboratively reviewed treatments that would soothe the skin. They decided to virtually consult a social worker to obtain emergency economic assistance and to speak with the patient’s care team psychologist to reduce some of the anxiety that may be leading to his leg scratching.

Case Discussion

This case illustrates the ways in which TIC can be applied to telehealth for a veteran with combat-related PTSD who may have experienced additional interpersonal trauma. It was not necessary to know more detail about the veteran’s trauma history to conduct the visit in a trauma-informed manner. Connecting to patients at home while considering these principles may thus foster mutuality, mitigate retraumatization, and cultivate enhanced collaboration with health care teams in this era of social distancing.

While a virtual physical examination creates both limitations and opportunity in telehealth, patients may find the greater degree of choice over their clothing and surroundings to be empowering. Telehealth also can allow for a greater portion of time to be dedicated to quality discussion and collaborative planning, with the clinician hearing and responding to the patient’s needs with reduced distraction. This may include opportunities to discuss mental health concerns openly, normalize emotional reactions, and offer connection to mental health and support services available through telehealth, including for patients who have not previously engaged in such care.

Conclusions

Telehealth expansion is occurring out of necessity in a time of crisis. While VHA is expanding its already robust telehealth program to replace some in-person visits, many other health care systems are just beginning to use telehealth. Trauma-informed virtual care during the COVID-19 pandemic has the potential to ensure and even expand continuity of medical care, offer connection and support to trauma survivors, and enhance patient and clinician resilience in this time of need. Clinicians have a unique opportunity in this pandemic to apply TIC principles early on and to envision how telehealth may contribute to a more meaningful care experience for all and a more equitable future for those we care for.

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.
 

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.
 

A quality initiative to restrict the use of Foley catheters in middle-aged and geriatric trauma patients with hip fracture reduced the risk of urinary tract infections (UTI) and led to earlier discharge, findings from a study revealed. The results of the study were reported in an abstract scheduled for release at the annual meeting of the American Academy of Orthopaedic Surgeons. The meeting was canceled because of COVID-19.

“We reduced the use of Foley catheters in our target population by more than 50%, which led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes,” reported Sanjit R. Konda, MD, an orthopedic surgeon with New York University Langone Health.

The quality initiative was introduced about 2 years ago specifically to reduce the risk of UTI in older patients admitted for femur or hip fractures. Previously at the level 1 trauma center where this quality initiative was introduced, placement of Foley catheters in these types of patients had been routine.

After the policy change, Foley catheters were only offered to these trauma patients 55 years of age or older when more than three episodes or urinary retention had been documented with a bladder scan. Urinary retention was defined as a volume of at least 600 mL.

When outcomes in 184 patients treated in the 15 months after the policy change were compared with 393 treated in the prior 38 months, Foley catheter use was substantially and significantly reduced (43.5% vs. 95.5%; P < .001), Dr. Konda said in an interview.

Although the lower rate of UTI following the policy change fell short of statistical significance (10.33% vs. 14.5%; P = .167), the policy change was associated with a decreased time to surgery (33.27 vs. 38.54 hours; P = .001), shorter length of stay (6.89 vs. 8.34 days; P < .001), and higher rate of home discharge (22.8% vs. 15.6%; P = .038).

When those who avoided a Foley catheter were compared with those who did not after the policy change, there was a significant reduction in UTI (4.81% vs. 17.4%; P = .014). In addition, patients who avoided a Foley catheter had a decreased time to surgery (P = .014), shorter length of stay (P < .001) and an almost 900% greater likelihood of home discharge (odds ratio, 9.9; P < .001).

“This quality initiative does increase the number of bladder scans required, meaning more work for nurses, but the program was developed in collaboration with our nursing staff, who were supportive of the goals,” Dr. Konda reported.

Reducing the incidence of UTI is an important initiative because the Centers for Medicare & Medicaid Services and other third-party payers employ this as a quality metric, according to Dr. Konda. This explains why hospital administrators generally embrace effective strategies to reduce UTI rates.

The improvement in outcomes, including the reduction in UTIs and length of stay, has cost implications, which will be evaluated in a future analysis, according to Dr. Konda.

Although this quality initiative was undertaken in a level 1 trauma center, Dr. Konda believes the same principles can be applied to other settings.

Jennifer A. Meddings, MD, an associate professor of medicine at the University of Michigan, Ann Arbor, agreed. Active in the evaluation of strategies to reduce hospital-acquired complications, Dr. Meddings published a study of procedural appropriateness ratings to guide strategies for improving the likelihood that catheters are employed only when needed (BMJ Qual Saf. 2019;28:56-66).

“In addition to avoiding UTI, reducing unnecessary placement of Foley catheters also eliminates the risk of trauma to the urinary tract,” Dr. Meddings said. This is a complication that is not well appreciated because the trauma is not always documented, according to Dr. Meddings, who believes increased risk of both UTI and urinary tract trauma should discourage use of Foley catheters when there is not a specific indication.

Although there are criteria other than excess bladder volume to determine when to consider a Foley catheter, Dr. Meddings encourages any systematic approach that increases the likelihood that catheters are not placed unnecessarily. She emphasized that a hip fracture by itself “is not a criterion for catheterization.”

Dr. Konda reported a financial relationship with Stryker.
 

Among patients who had an out-of-hospital cardiac arrest, intravenous sodium nitrite given by paramedics during resuscitation did not significantly improve their chances of being admitted to or discharged from the hospital alive.

The study was presented at the recent “virtual” American College of Cardiology 2020 Scientific Session (ACC.20)/World Congress of Cardiology (WCC).

Lead investigator Francis Kim, MD, professor of medicine at the University of Washington, Seattle, explained that sodium nitrate is an antioxidant; animal studies have suggested that under conditions of hypoxia, it is converted into the vasodilator nitric oxide, which can increase blood flow to the brain and heart tissues.

In animal models of cardiac arrest, the use of sodium nitrite during resuscitation increased survival by almost 50%.

For the current study, 1,502 patients who had an out-of-hospital cardiac arrest were randomly assigned to receive either a low dose (45 mg) or a high dose (60 mg) of sodium nitrite or a placebo. The average age of the patients who were included in the study was 64 years, and 66% were male; 22% had ventricular fibrillation, 43% had asystole, and 29% had pulseless electrical activity.

Results showed no statistically significant differences between the groups who received placebo, low-dose sodium nitrite, or high-dose sodium nitrite on survival to hospital admission (the primary endpoint) or on hospital discharge (the secondary endpoint). There was also no difference in either endpoint in the subgroup with ventricular fibrillation.

“Our results are disappointing, especially after the promising findings in animal studies, but we feel this trial shuts the door on using this drug in this indication,” Kim said.

Discussing the study at an ACC press conference, Dhanunjaya Lakkireddy, MD, University of Kansas Hospital and Medical Center and ACC Electrophysiology Council chair, said this was “an excellent trial in the unending quest to try to improve survival in out-of-hospital cardiac arrest.

“As we all aware, if we don’t get blood circulation to the brain for more than 5 seconds, we pass out, and if don’t get blood circulation to the brain for more than 5 minutes, brain death occurs. When people suffer out-of-hospital cardiac arrest, the rate of survival is therefore dramatically lower when the ability to resuscitate goes beyond 5 minutes,” Lakkireddy noted.

He questioned why the current trial showed no effect when there had been significant early promise in animal studies. He suggested factors that could have been relevant included the time to intervention ― which was an average of 22 minutes from call to randomization ― perfusion of the brain, whether the drug cleared the blood-brain barrier, whether nitric oxide levels in the brain were sufficient, and the patient population that was included in the study.

“A large percentage of patients had asystole or pulseless electrical activity ― these are known to have worse outcomes ― and 60% of patients in the study did not have a witnessed arrest and could have been down for much longer and therefore could have had a significantly higher level of irreversible brain damage,” Lakkireddy pointed out.

“If we can understand some of the issues, we may be able to do another trial in a different subset of patients in whom the duration of arrest is significantly lower,” he commented.

The study was funded by the National Heart, Lung, and Blood Institute. Kim has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Among patients who had an out-of-hospital cardiac arrest, intravenous sodium nitrite given by paramedics during resuscitation did not significantly improve their chances of being admitted to or discharged from the hospital alive.

The study was presented at the recent “virtual” American College of Cardiology 2020 Scientific Session (ACC.20)/World Congress of Cardiology (WCC).

Lead investigator Francis Kim, MD, professor of medicine at the University of Washington, Seattle, explained that sodium nitrate is an antioxidant; animal studies have suggested that under conditions of hypoxia, it is converted into the vasodilator nitric oxide, which can increase blood flow to the brain and heart tissues.

In animal models of cardiac arrest, the use of sodium nitrite during resuscitation increased survival by almost 50%.

For the current study, 1,502 patients who had an out-of-hospital cardiac arrest were randomly assigned to receive either a low dose (45 mg) or a high dose (60 mg) of sodium nitrite or a placebo. The average age of the patients who were included in the study was 64 years, and 66% were male; 22% had ventricular fibrillation, 43% had asystole, and 29% had pulseless electrical activity.

Results showed no statistically significant differences between the groups who received placebo, low-dose sodium nitrite, or high-dose sodium nitrite on survival to hospital admission (the primary endpoint) or on hospital discharge (the secondary endpoint). There was also no difference in either endpoint in the subgroup with ventricular fibrillation.

“Our results are disappointing, especially after the promising findings in animal studies, but we feel this trial shuts the door on using this drug in this indication,” Kim said.

Discussing the study at an ACC press conference, Dhanunjaya Lakkireddy, MD, University of Kansas Hospital and Medical Center and ACC Electrophysiology Council chair, said this was “an excellent trial in the unending quest to try to improve survival in out-of-hospital cardiac arrest.

“As we all aware, if we don’t get blood circulation to the brain for more than 5 seconds, we pass out, and if don’t get blood circulation to the brain for more than 5 minutes, brain death occurs. When people suffer out-of-hospital cardiac arrest, the rate of survival is therefore dramatically lower when the ability to resuscitate goes beyond 5 minutes,” Lakkireddy noted.

He questioned why the current trial showed no effect when there had been significant early promise in animal studies. He suggested factors that could have been relevant included the time to intervention ― which was an average of 22 minutes from call to randomization ― perfusion of the brain, whether the drug cleared the blood-brain barrier, whether nitric oxide levels in the brain were sufficient, and the patient population that was included in the study.

“A large percentage of patients had asystole or pulseless electrical activity ― these are known to have worse outcomes ― and 60% of patients in the study did not have a witnessed arrest and could have been down for much longer and therefore could have had a significantly higher level of irreversible brain damage,” Lakkireddy pointed out.

“If we can understand some of the issues, we may be able to do another trial in a different subset of patients in whom the duration of arrest is significantly lower,” he commented.

The study was funded by the National Heart, Lung, and Blood Institute. Kim has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Among patients who had an out-of-hospital cardiac arrest, intravenous sodium nitrite given by paramedics during resuscitation did not significantly improve their chances of being admitted to or discharged from the hospital alive.

The study was presented at the recent “virtual” American College of Cardiology 2020 Scientific Session (ACC.20)/World Congress of Cardiology (WCC).

Lead investigator Francis Kim, MD, professor of medicine at the University of Washington, Seattle, explained that sodium nitrate is an antioxidant; animal studies have suggested that under conditions of hypoxia, it is converted into the vasodilator nitric oxide, which can increase blood flow to the brain and heart tissues.

In animal models of cardiac arrest, the use of sodium nitrite during resuscitation increased survival by almost 50%.

For the current study, 1,502 patients who had an out-of-hospital cardiac arrest were randomly assigned to receive either a low dose (45 mg) or a high dose (60 mg) of sodium nitrite or a placebo. The average age of the patients who were included in the study was 64 years, and 66% were male; 22% had ventricular fibrillation, 43% had asystole, and 29% had pulseless electrical activity.

Results showed no statistically significant differences between the groups who received placebo, low-dose sodium nitrite, or high-dose sodium nitrite on survival to hospital admission (the primary endpoint) or on hospital discharge (the secondary endpoint). There was also no difference in either endpoint in the subgroup with ventricular fibrillation.

“Our results are disappointing, especially after the promising findings in animal studies, but we feel this trial shuts the door on using this drug in this indication,” Kim said.

Discussing the study at an ACC press conference, Dhanunjaya Lakkireddy, MD, University of Kansas Hospital and Medical Center and ACC Electrophysiology Council chair, said this was “an excellent trial in the unending quest to try to improve survival in out-of-hospital cardiac arrest.

“As we all aware, if we don’t get blood circulation to the brain for more than 5 seconds, we pass out, and if don’t get blood circulation to the brain for more than 5 minutes, brain death occurs. When people suffer out-of-hospital cardiac arrest, the rate of survival is therefore dramatically lower when the ability to resuscitate goes beyond 5 minutes,” Lakkireddy noted.

He questioned why the current trial showed no effect when there had been significant early promise in animal studies. He suggested factors that could have been relevant included the time to intervention ― which was an average of 22 minutes from call to randomization ― perfusion of the brain, whether the drug cleared the blood-brain barrier, whether nitric oxide levels in the brain were sufficient, and the patient population that was included in the study.

“A large percentage of patients had asystole or pulseless electrical activity ― these are known to have worse outcomes ― and 60% of patients in the study did not have a witnessed arrest and could have been down for much longer and therefore could have had a significantly higher level of irreversible brain damage,” Lakkireddy pointed out.

“If we can understand some of the issues, we may be able to do another trial in a different subset of patients in whom the duration of arrest is significantly lower,” he commented.

The study was funded by the National Heart, Lung, and Blood Institute. Kim has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Since the beginning of the American Republic, servicemen have been captured and held as prisoners of war (POWs), including > 130,000 in World War II , > 7,100 in the Korean War, > 700 in the Vietnam War, and 37 in Operation Desert Storm and recent conflicts.^1,2 Also, > 80 servicewomen have been held during these conflicts.^1-3 Of those living former POWs (FPOWs), almost all are geriatric (aged > 65 years) with a significant portion aged ≥ 85 years.

The physical hardships and psychological stress endured by FPOWs have lifelong deleterious sequelae on health and social functioning.^3-5 The experiences of FPOWs are associated with higher prevalence of chronic diseases and diminished functional performance in later life as demonstrated by a survey of FPOWs from World War II.⁴ The survey assessed health and functional status in a random sample of 101 FPOWs and a group of 107 non-POW combatants from the same military operations. FPOWs reported a higher mean number of somatic symptoms than did non-POWs (7.2 vs 5.4, respectively; P = .002), a higher mean number of diagnosed health conditions (9.4 vs 7.7, respectively; P < .001), and used a greater mean number of medications (4.5 vs 3.4, respectively; P = .001). Among 15 broad categories of diagnoses, differences were found in gastrointestinal disorders (FPOWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (FPOWs 76% vs non-POWs 60%, P = .001), and cognitive disorders (FPOWs 31% vs non-POWs 15%, P = .006). FPOWs had a significantly higher proportion of 7 extrapyramidal signs and 6 signs relating to ataxia. On the Instrumental Activities of Daily Living scale, FPOWs were more likely to be impaired than were non-POWs (33% vs 17%, respectively; P = .01). In addition, FPOWs have an increased risk of developing dementia, and this risk is doubled in FPOWs with posttraumatic stress disorder (PTSD) compared with non-FPOWs without PTSD.⁵

These data indicate that FPOW status is associated with increased risk of disability and loss of independence. Federal statutes established the presumption of a relationship between FPOW status and many comorbidities for VA disability determinations in recognition of such data and to overcome lack of medical records during POW confinement and to accord benefit of the doubt where medical science cannot conclusively link disease etiology to FPOW status, to FPOWs.

Service-Connected Conditions

The historical development of conditions with a presumption of service connection for adjudication of VA compensation/disability claims began in 1921 with the Act to Establish a Veterans’ Bureau and to Improve the Facilities.¹ The act simplified and streamlined the claims adjudication process by eliminating the need to obtain evidence on the part of the veteran. The presumption of service connection also facilitated increased accuracy and consistency in adjudications by requiring similar treatment for similar claims. This “presumptive” process relieved claimants and VA of the necessity of producing direct evidence when it was impractical to do so.

In 1970, the first presumptives specific to FPOWs were legislatively established and covered 17 diseases for a FPOW who had been confined for ≥ 30 days (Pub. L. 91-376). The 30-day confinement requirement was later relaxed, and additional presumptives were established that related to diseases that were more common among FPOWs than they were among non-FPOWs. These disorders included traumatic arthritis, stroke, heart disease, osteoporosis, peripheral neuropathy, cold injuries, as well as a variety of digestive and neuropsychiatric disorders. If a FPOW is diagnosed as having ≥ 1 of these conditions and it is judged to be ≥ 10% disabling, the condition is presumed to be a sequelae of the POW experience, and it is classified as a service-connected disability (Table).

FPOW Care And Benefits Teams

Several Veterans Health Administration (VHA) directives have been issued, including the recent VHA directive 1650, which requires that each VHA medical facility have a special Care and Benefits Team (CBT) that is charged with the evaluation and treatment of FPOWs to ensure that “FPOWs receive the highest quality care and benefit services.”⁶ CBTs must be composed of a clinician trained in internal medicine or family practice; a clinician who is certified through the VA Office of Disability and Medical Assessment to conduct General Medical Compensation and Pension evaluations; a FPOW advocate who typically is a VHA clinical social worker; and a Veterans Benefits Administration (VBA) FPOW coordinator appointed by the local VBA regional office. CBTs can be expanded to include other members as needed. The CBTs are tasked with facilitating interactions between FPOWs, the VHA, and the VBA.

CBTs face several challenges in meeting their responsibilities. For example, the POW experience often results in psychological trauma that foments denial and distrust; hence, thoughtful sensitivity to the sequelae of captivity when approaching FPOWs about personal issues, such as health care, is required. Establishing trusting relationships with FPOWs is necessary if their needs are to be effectively addressed.

While the VHA is mandated to provide priority treatment for FPOWs, including hospital, nursing home, dental, and outpatient treatment, a significant number of FPOWs do not avail themselves of benefits to which they are entitled. Often these FPOWs have not used VA programs and facilities because they are uninformed or confused about VA benefits for FPOWs. As a result, referrals of eligible FPOWs to appropriate programs can be overlooked. Maximizing the service-connected disability rating of FPOWs not only impacts the disability pensions received by these veterans, but also impacts their eligibility for VHA programs, including long-term care and Dependency and Indemnity Compensation, a monthly benefit paid to spouses, children, and/or surviving parents.

In 2013, the FPOW Committee of the South Texas Veterans Health Care System (STVHCS) noted that 40% of FPOWs in our region had no VA primary care or clinic assignment. In consideration of the commitment of the VA to care for FPOWs, the unique POW-related medical and psychological issues, the geriatric age of many FPOWs, and the surprising number of FPOWs currently not receiving VA care, we expanded the concept of the CBT team to create a specialized interdisciplinary FPOW Clinic to address the unique needs of this predominantly elderly population and to involve more FPOWs in the VA system.

The main purpose of this clinic was to advise FPOWs of all VA benefits and services to which they may be entitled by identifying overlooked FPOW presumptives. As the number of FPOWs continues to decrease, outreach to FPOWs and family members has become critical, especially as increased benefits and special services might be available to this increasingly dependent older population. An informal survey of FPOW advocates across the nation found that 21% of FPOWs had disability ratings from the VA of ≤ 60%, including some who had no VA disability rating at all. Thus, an additional goal of the project was to develop a clinic model that could be disseminated throughout the VHA.

Design

The design of the FPOW Clinic team is based on an interdisciplinary model that has proven successful in geriatric medicine.⁷ The team comprises a physician, a social worker, and a registered nurse.⁸ All members have expertise in geriatric medicine and specific training in FPOW-related issues by completing a VA employee education training session on FPOW case management. Completion of this training ensured that team members were:

• Familiar with the experiences of FPOWs as well as about the medical, psychosocial, and mental health conditions that affect FPOWs;
• Knowledgeable about FPOW presumptive conditions;
• Familiar with the VBA process for rating FPOW disability claims; and
• Capable of FPOW case coordination, workflow, and communications between the FPOW Clinic team and the VBA to avail FPOWs and their families of all eligible benefits.

In-person FPOW clinic visits and chart reviews helped identify overlooked FPOW benefits. To facilitate case management, a representative of the VBA attended the initial evaluation of each FPOW in the clinic to confirm any overlooked presumptive benefits and to familiarize FPOWs with the claims process. FPOWs were also given the choice to officially enroll in the FPOW clinic for primary care or to remain with their current health care provider. Special efforts were made to enroll those FPOWs who had no STVHCS assigned primary care clinic.

The clinic was scheduled for 4 hours every week. Initial patient visits were 2 hours each and consisted of separate evaluations by each of the 3 FPOW Clinic team members who then met as a team with the addition of the VBA representative. The purpose of this meeting was to discuss overlooked benefits, address any other specific issues noted, and to devise an appropriate interdisciplinary plan. Findings of overlooked benefits and other relevant outcomes then were conveyed to the FPOW. For FPOWs who opted to continue in the clinic for their primary care, subsequent appointments were 1 hour.

Implementation 

STVHCS FPOW advocates identified and sent letters to FPOWs announcing the opening of the clinic and its goals. Phone calls were made to each FPOW to address questions and to ascertain their interest. The FPOW advocates then worked directly with schedulers to make clinic appointments. Forty-one FPOWs responded to this initial invitation and attended the new clinic. Subsequently, this number increased through FPOW consults placed by STVHCS primary care providers.

The service-connected disability rating of clinic patients ranged from none (6% of attendees) to 100% (28% of attendees). For 34% of patients, clinic attendance resulted in identification application for overlooked presumptives. VBA evaluation resulted in increased service-connected disability ratings for nearly one-third of clinic patients. All clinic patients without a service-connected disability prior to FPOW clinic evaluation received an increased service-connected disability rating. Overall, 60% of the FPOWs who attended the clinic opted to receive their primary care at the FPOW clinic.

The FPOW Clinic successfully identified overlooked presumptives and facilitated the determination of appropriate service-connected disabilities. Interestingly, the FPOW Clinic encountered an unanticipated challenge to identifying overlooked FPOW benefits—veterans’ medical conditions that are listed by the VHA as being service-connected in the Computerized Patient Record System did not always reflect those listed officially in VBA records. This led to occasional identification of apparently overlooked FPOW presumptives that were already recognized by the VBA but not reflected in VHA records. This issue was addressed by ensuring that VBA representatives attended postclinic meetings with clinic staff and avoided the need to pursue supposedly unrecognized benefits that were recognized.

Telehealth 

At present, FPOWs from World War II outnumber those of all other conflicts; however, this group is rapidly dwindling in numbers. World War II FPOWs are aged > 85 years, and therefore among the most frail and dependent of veterans. Often they are homebound and unable to physically travel to clinics for assessment. To serve these veterans, we are modifying the FPOW Clinic to utilize telehealth. The Telehealth FPOW Clinic will obtain relevant data from review of the electronic health record and telehealth-based clinic visits. Telehealth also may be used for assessments of Vietnam War veterans (eg, Agent Orange exposure), atomic veterans, and Gulf War veterans. Once fully designed and implemented, we believe that telehealth will prove to be a cost-effective way to provide clinic benefits to rural and older veterans.

Conclusions

The VHA provides priority medical treatment to FPOWs as well as timely and appropriate assessment of their eligibility for veterans’ benefits. The complexities benefit programs established for FPOWs is often beyond the ken of VHA physicians, social workers, and nurses. Because of this unfamiliarity, referrals of eligible FPOWs to appropriate programs can be overlooked. We established a clinic-based interdisciplinary team (FPOW Clinic) that was fully trained in FPOW benefit programs to identify overlooked benefits for FPOWs and were able to increase the disability rating on approximately one-third of the FPOWs seen in the FPOW Clinic. A telehealth-based version of the FPOW clinic is now being developed.

Since the beginning of the American Republic, servicemen have been captured and held as prisoners of war (POWs), including > 130,000 in World War II , > 7,100 in the Korean War, > 700 in the Vietnam War, and 37 in Operation Desert Storm and recent conflicts.^1,2 Also, > 80 servicewomen have been held during these conflicts.^1-3 Of those living former POWs (FPOWs), almost all are geriatric (aged > 65 years) with a significant portion aged ≥ 85 years.

The physical hardships and psychological stress endured by FPOWs have lifelong deleterious sequelae on health and social functioning.^3-5 The experiences of FPOWs are associated with higher prevalence of chronic diseases and diminished functional performance in later life as demonstrated by a survey of FPOWs from World War II.⁴ The survey assessed health and functional status in a random sample of 101 FPOWs and a group of 107 non-POW combatants from the same military operations. FPOWs reported a higher mean number of somatic symptoms than did non-POWs (7.2 vs 5.4, respectively; P = .002), a higher mean number of diagnosed health conditions (9.4 vs 7.7, respectively; P < .001), and used a greater mean number of medications (4.5 vs 3.4, respectively; P = .001). Among 15 broad categories of diagnoses, differences were found in gastrointestinal disorders (FPOWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (FPOWs 76% vs non-POWs 60%, P = .001), and cognitive disorders (FPOWs 31% vs non-POWs 15%, P = .006). FPOWs had a significantly higher proportion of 7 extrapyramidal signs and 6 signs relating to ataxia. On the Instrumental Activities of Daily Living scale, FPOWs were more likely to be impaired than were non-POWs (33% vs 17%, respectively; P = .01). In addition, FPOWs have an increased risk of developing dementia, and this risk is doubled in FPOWs with posttraumatic stress disorder (PTSD) compared with non-FPOWs without PTSD.⁵

These data indicate that FPOW status is associated with increased risk of disability and loss of independence. Federal statutes established the presumption of a relationship between FPOW status and many comorbidities for VA disability determinations in recognition of such data and to overcome lack of medical records during POW confinement and to accord benefit of the doubt where medical science cannot conclusively link disease etiology to FPOW status, to FPOWs.

Service-Connected Conditions

The historical development of conditions with a presumption of service connection for adjudication of VA compensation/disability claims began in 1921 with the Act to Establish a Veterans’ Bureau and to Improve the Facilities.¹ The act simplified and streamlined the claims adjudication process by eliminating the need to obtain evidence on the part of the veteran. The presumption of service connection also facilitated increased accuracy and consistency in adjudications by requiring similar treatment for similar claims. This “presumptive” process relieved claimants and VA of the necessity of producing direct evidence when it was impractical to do so.

In 1970, the first presumptives specific to FPOWs were legislatively established and covered 17 diseases for a FPOW who had been confined for ≥ 30 days (Pub. L. 91-376). The 30-day confinement requirement was later relaxed, and additional presumptives were established that related to diseases that were more common among FPOWs than they were among non-FPOWs. These disorders included traumatic arthritis, stroke, heart disease, osteoporosis, peripheral neuropathy, cold injuries, as well as a variety of digestive and neuropsychiatric disorders. If a FPOW is diagnosed as having ≥ 1 of these conditions and it is judged to be ≥ 10% disabling, the condition is presumed to be a sequelae of the POW experience, and it is classified as a service-connected disability (Table).

FPOW Care And Benefits Teams

Several Veterans Health Administration (VHA) directives have been issued, including the recent VHA directive 1650, which requires that each VHA medical facility have a special Care and Benefits Team (CBT) that is charged with the evaluation and treatment of FPOWs to ensure that “FPOWs receive the highest quality care and benefit services.”⁶ CBTs must be composed of a clinician trained in internal medicine or family practice; a clinician who is certified through the VA Office of Disability and Medical Assessment to conduct General Medical Compensation and Pension evaluations; a FPOW advocate who typically is a VHA clinical social worker; and a Veterans Benefits Administration (VBA) FPOW coordinator appointed by the local VBA regional office. CBTs can be expanded to include other members as needed. The CBTs are tasked with facilitating interactions between FPOWs, the VHA, and the VBA.

CBTs face several challenges in meeting their responsibilities. For example, the POW experience often results in psychological trauma that foments denial and distrust; hence, thoughtful sensitivity to the sequelae of captivity when approaching FPOWs about personal issues, such as health care, is required. Establishing trusting relationships with FPOWs is necessary if their needs are to be effectively addressed.

While the VHA is mandated to provide priority treatment for FPOWs, including hospital, nursing home, dental, and outpatient treatment, a significant number of FPOWs do not avail themselves of benefits to which they are entitled. Often these FPOWs have not used VA programs and facilities because they are uninformed or confused about VA benefits for FPOWs. As a result, referrals of eligible FPOWs to appropriate programs can be overlooked. Maximizing the service-connected disability rating of FPOWs not only impacts the disability pensions received by these veterans, but also impacts their eligibility for VHA programs, including long-term care and Dependency and Indemnity Compensation, a monthly benefit paid to spouses, children, and/or surviving parents.

In 2013, the FPOW Committee of the South Texas Veterans Health Care System (STVHCS) noted that 40% of FPOWs in our region had no VA primary care or clinic assignment. In consideration of the commitment of the VA to care for FPOWs, the unique POW-related medical and psychological issues, the geriatric age of many FPOWs, and the surprising number of FPOWs currently not receiving VA care, we expanded the concept of the CBT team to create a specialized interdisciplinary FPOW Clinic to address the unique needs of this predominantly elderly population and to involve more FPOWs in the VA system.

The main purpose of this clinic was to advise FPOWs of all VA benefits and services to which they may be entitled by identifying overlooked FPOW presumptives. As the number of FPOWs continues to decrease, outreach to FPOWs and family members has become critical, especially as increased benefits and special services might be available to this increasingly dependent older population. An informal survey of FPOW advocates across the nation found that 21% of FPOWs had disability ratings from the VA of ≤ 60%, including some who had no VA disability rating at all. Thus, an additional goal of the project was to develop a clinic model that could be disseminated throughout the VHA.

Design

The design of the FPOW Clinic team is based on an interdisciplinary model that has proven successful in geriatric medicine.⁷ The team comprises a physician, a social worker, and a registered nurse.⁸ All members have expertise in geriatric medicine and specific training in FPOW-related issues by completing a VA employee education training session on FPOW case management. Completion of this training ensured that team members were:

• Familiar with the experiences of FPOWs as well as about the medical, psychosocial, and mental health conditions that affect FPOWs;
• Knowledgeable about FPOW presumptive conditions;
• Familiar with the VBA process for rating FPOW disability claims; and
• Capable of FPOW case coordination, workflow, and communications between the FPOW Clinic team and the VBA to avail FPOWs and their families of all eligible benefits.

In-person FPOW clinic visits and chart reviews helped identify overlooked FPOW benefits. To facilitate case management, a representative of the VBA attended the initial evaluation of each FPOW in the clinic to confirm any overlooked presumptive benefits and to familiarize FPOWs with the claims process. FPOWs were also given the choice to officially enroll in the FPOW clinic for primary care or to remain with their current health care provider. Special efforts were made to enroll those FPOWs who had no STVHCS assigned primary care clinic.

The clinic was scheduled for 4 hours every week. Initial patient visits were 2 hours each and consisted of separate evaluations by each of the 3 FPOW Clinic team members who then met as a team with the addition of the VBA representative. The purpose of this meeting was to discuss overlooked benefits, address any other specific issues noted, and to devise an appropriate interdisciplinary plan. Findings of overlooked benefits and other relevant outcomes then were conveyed to the FPOW. For FPOWs who opted to continue in the clinic for their primary care, subsequent appointments were 1 hour.

Implementation 

STVHCS FPOW advocates identified and sent letters to FPOWs announcing the opening of the clinic and its goals. Phone calls were made to each FPOW to address questions and to ascertain their interest. The FPOW advocates then worked directly with schedulers to make clinic appointments. Forty-one FPOWs responded to this initial invitation and attended the new clinic. Subsequently, this number increased through FPOW consults placed by STVHCS primary care providers.

The service-connected disability rating of clinic patients ranged from none (6% of attendees) to 100% (28% of attendees). For 34% of patients, clinic attendance resulted in identification application for overlooked presumptives. VBA evaluation resulted in increased service-connected disability ratings for nearly one-third of clinic patients. All clinic patients without a service-connected disability prior to FPOW clinic evaluation received an increased service-connected disability rating. Overall, 60% of the FPOWs who attended the clinic opted to receive their primary care at the FPOW clinic.

The FPOW Clinic successfully identified overlooked presumptives and facilitated the determination of appropriate service-connected disabilities. Interestingly, the FPOW Clinic encountered an unanticipated challenge to identifying overlooked FPOW benefits—veterans’ medical conditions that are listed by the VHA as being service-connected in the Computerized Patient Record System did not always reflect those listed officially in VBA records. This led to occasional identification of apparently overlooked FPOW presumptives that were already recognized by the VBA but not reflected in VHA records. This issue was addressed by ensuring that VBA representatives attended postclinic meetings with clinic staff and avoided the need to pursue supposedly unrecognized benefits that were recognized.

Telehealth 

At present, FPOWs from World War II outnumber those of all other conflicts; however, this group is rapidly dwindling in numbers. World War II FPOWs are aged > 85 years, and therefore among the most frail and dependent of veterans. Often they are homebound and unable to physically travel to clinics for assessment. To serve these veterans, we are modifying the FPOW Clinic to utilize telehealth. The Telehealth FPOW Clinic will obtain relevant data from review of the electronic health record and telehealth-based clinic visits. Telehealth also may be used for assessments of Vietnam War veterans (eg, Agent Orange exposure), atomic veterans, and Gulf War veterans. Once fully designed and implemented, we believe that telehealth will prove to be a cost-effective way to provide clinic benefits to rural and older veterans.

Conclusions

The VHA provides priority medical treatment to FPOWs as well as timely and appropriate assessment of their eligibility for veterans’ benefits. The complexities benefit programs established for FPOWs is often beyond the ken of VHA physicians, social workers, and nurses. Because of this unfamiliarity, referrals of eligible FPOWs to appropriate programs can be overlooked. We established a clinic-based interdisciplinary team (FPOW Clinic) that was fully trained in FPOW benefit programs to identify overlooked benefits for FPOWs and were able to increase the disability rating on approximately one-third of the FPOWs seen in the FPOW Clinic. A telehealth-based version of the FPOW clinic is now being developed.

Since the beginning of the American Republic, servicemen have been captured and held as prisoners of war (POWs), including > 130,000 in World War II , > 7,100 in the Korean War, > 700 in the Vietnam War, and 37 in Operation Desert Storm and recent conflicts.^1,2 Also, > 80 servicewomen have been held during these conflicts.^1-3 Of those living former POWs (FPOWs), almost all are geriatric (aged > 65 years) with a significant portion aged ≥ 85 years.

The physical hardships and psychological stress endured by FPOWs have lifelong deleterious sequelae on health and social functioning.^3-5 The experiences of FPOWs are associated with higher prevalence of chronic diseases and diminished functional performance in later life as demonstrated by a survey of FPOWs from World War II.⁴ The survey assessed health and functional status in a random sample of 101 FPOWs and a group of 107 non-POW combatants from the same military operations. FPOWs reported a higher mean number of somatic symptoms than did non-POWs (7.2 vs 5.4, respectively; P = .002), a higher mean number of diagnosed health conditions (9.4 vs 7.7, respectively; P < .001), and used a greater mean number of medications (4.5 vs 3.4, respectively; P = .001). Among 15 broad categories of diagnoses, differences were found in gastrointestinal disorders (FPOWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (FPOWs 76% vs non-POWs 60%, P = .001), and cognitive disorders (FPOWs 31% vs non-POWs 15%, P = .006). FPOWs had a significantly higher proportion of 7 extrapyramidal signs and 6 signs relating to ataxia. On the Instrumental Activities of Daily Living scale, FPOWs were more likely to be impaired than were non-POWs (33% vs 17%, respectively; P = .01). In addition, FPOWs have an increased risk of developing dementia, and this risk is doubled in FPOWs with posttraumatic stress disorder (PTSD) compared with non-FPOWs without PTSD.⁵

These data indicate that FPOW status is associated with increased risk of disability and loss of independence. Federal statutes established the presumption of a relationship between FPOW status and many comorbidities for VA disability determinations in recognition of such data and to overcome lack of medical records during POW confinement and to accord benefit of the doubt where medical science cannot conclusively link disease etiology to FPOW status, to FPOWs.

Service-Connected Conditions

The historical development of conditions with a presumption of service connection for adjudication of VA compensation/disability claims began in 1921 with the Act to Establish a Veterans’ Bureau and to Improve the Facilities.¹ The act simplified and streamlined the claims adjudication process by eliminating the need to obtain evidence on the part of the veteran. The presumption of service connection also facilitated increased accuracy and consistency in adjudications by requiring similar treatment for similar claims. This “presumptive” process relieved claimants and VA of the necessity of producing direct evidence when it was impractical to do so.

In 1970, the first presumptives specific to FPOWs were legislatively established and covered 17 diseases for a FPOW who had been confined for ≥ 30 days (Pub. L. 91-376). The 30-day confinement requirement was later relaxed, and additional presumptives were established that related to diseases that were more common among FPOWs than they were among non-FPOWs. These disorders included traumatic arthritis, stroke, heart disease, osteoporosis, peripheral neuropathy, cold injuries, as well as a variety of digestive and neuropsychiatric disorders. If a FPOW is diagnosed as having ≥ 1 of these conditions and it is judged to be ≥ 10% disabling, the condition is presumed to be a sequelae of the POW experience, and it is classified as a service-connected disability (Table).

FPOW Care And Benefits Teams

Several Veterans Health Administration (VHA) directives have been issued, including the recent VHA directive 1650, which requires that each VHA medical facility have a special Care and Benefits Team (CBT) that is charged with the evaluation and treatment of FPOWs to ensure that “FPOWs receive the highest quality care and benefit services.”⁶ CBTs must be composed of a clinician trained in internal medicine or family practice; a clinician who is certified through the VA Office of Disability and Medical Assessment to conduct General Medical Compensation and Pension evaluations; a FPOW advocate who typically is a VHA clinical social worker; and a Veterans Benefits Administration (VBA) FPOW coordinator appointed by the local VBA regional office. CBTs can be expanded to include other members as needed. The CBTs are tasked with facilitating interactions between FPOWs, the VHA, and the VBA.

CBTs face several challenges in meeting their responsibilities. For example, the POW experience often results in psychological trauma that foments denial and distrust; hence, thoughtful sensitivity to the sequelae of captivity when approaching FPOWs about personal issues, such as health care, is required. Establishing trusting relationships with FPOWs is necessary if their needs are to be effectively addressed.

While the VHA is mandated to provide priority treatment for FPOWs, including hospital, nursing home, dental, and outpatient treatment, a significant number of FPOWs do not avail themselves of benefits to which they are entitled. Often these FPOWs have not used VA programs and facilities because they are uninformed or confused about VA benefits for FPOWs. As a result, referrals of eligible FPOWs to appropriate programs can be overlooked. Maximizing the service-connected disability rating of FPOWs not only impacts the disability pensions received by these veterans, but also impacts their eligibility for VHA programs, including long-term care and Dependency and Indemnity Compensation, a monthly benefit paid to spouses, children, and/or surviving parents.

In 2013, the FPOW Committee of the South Texas Veterans Health Care System (STVHCS) noted that 40% of FPOWs in our region had no VA primary care or clinic assignment. In consideration of the commitment of the VA to care for FPOWs, the unique POW-related medical and psychological issues, the geriatric age of many FPOWs, and the surprising number of FPOWs currently not receiving VA care, we expanded the concept of the CBT team to create a specialized interdisciplinary FPOW Clinic to address the unique needs of this predominantly elderly population and to involve more FPOWs in the VA system.

The main purpose of this clinic was to advise FPOWs of all VA benefits and services to which they may be entitled by identifying overlooked FPOW presumptives. As the number of FPOWs continues to decrease, outreach to FPOWs and family members has become critical, especially as increased benefits and special services might be available to this increasingly dependent older population. An informal survey of FPOW advocates across the nation found that 21% of FPOWs had disability ratings from the VA of ≤ 60%, including some who had no VA disability rating at all. Thus, an additional goal of the project was to develop a clinic model that could be disseminated throughout the VHA.

Design

The design of the FPOW Clinic team is based on an interdisciplinary model that has proven successful in geriatric medicine.⁷ The team comprises a physician, a social worker, and a registered nurse.⁸ All members have expertise in geriatric medicine and specific training in FPOW-related issues by completing a VA employee education training session on FPOW case management. Completion of this training ensured that team members were:

• Familiar with the experiences of FPOWs as well as about the medical, psychosocial, and mental health conditions that affect FPOWs;
• Knowledgeable about FPOW presumptive conditions;
• Familiar with the VBA process for rating FPOW disability claims; and
• Capable of FPOW case coordination, workflow, and communications between the FPOW Clinic team and the VBA to avail FPOWs and their families of all eligible benefits.

In-person FPOW clinic visits and chart reviews helped identify overlooked FPOW benefits. To facilitate case management, a representative of the VBA attended the initial evaluation of each FPOW in the clinic to confirm any overlooked presumptive benefits and to familiarize FPOWs with the claims process. FPOWs were also given the choice to officially enroll in the FPOW clinic for primary care or to remain with their current health care provider. Special efforts were made to enroll those FPOWs who had no STVHCS assigned primary care clinic.

The clinic was scheduled for 4 hours every week. Initial patient visits were 2 hours each and consisted of separate evaluations by each of the 3 FPOW Clinic team members who then met as a team with the addition of the VBA representative. The purpose of this meeting was to discuss overlooked benefits, address any other specific issues noted, and to devise an appropriate interdisciplinary plan. Findings of overlooked benefits and other relevant outcomes then were conveyed to the FPOW. For FPOWs who opted to continue in the clinic for their primary care, subsequent appointments were 1 hour.

Implementation 

STVHCS FPOW advocates identified and sent letters to FPOWs announcing the opening of the clinic and its goals. Phone calls were made to each FPOW to address questions and to ascertain their interest. The FPOW advocates then worked directly with schedulers to make clinic appointments. Forty-one FPOWs responded to this initial invitation and attended the new clinic. Subsequently, this number increased through FPOW consults placed by STVHCS primary care providers.

The service-connected disability rating of clinic patients ranged from none (6% of attendees) to 100% (28% of attendees). For 34% of patients, clinic attendance resulted in identification application for overlooked presumptives. VBA evaluation resulted in increased service-connected disability ratings for nearly one-third of clinic patients. All clinic patients without a service-connected disability prior to FPOW clinic evaluation received an increased service-connected disability rating. Overall, 60% of the FPOWs who attended the clinic opted to receive their primary care at the FPOW clinic.

The FPOW Clinic successfully identified overlooked presumptives and facilitated the determination of appropriate service-connected disabilities. Interestingly, the FPOW Clinic encountered an unanticipated challenge to identifying overlooked FPOW benefits—veterans’ medical conditions that are listed by the VHA as being service-connected in the Computerized Patient Record System did not always reflect those listed officially in VBA records. This led to occasional identification of apparently overlooked FPOW presumptives that were already recognized by the VBA but not reflected in VHA records. This issue was addressed by ensuring that VBA representatives attended postclinic meetings with clinic staff and avoided the need to pursue supposedly unrecognized benefits that were recognized.

Telehealth 

At present, FPOWs from World War II outnumber those of all other conflicts; however, this group is rapidly dwindling in numbers. World War II FPOWs are aged > 85 years, and therefore among the most frail and dependent of veterans. Often they are homebound and unable to physically travel to clinics for assessment. To serve these veterans, we are modifying the FPOW Clinic to utilize telehealth. The Telehealth FPOW Clinic will obtain relevant data from review of the electronic health record and telehealth-based clinic visits. Telehealth also may be used for assessments of Vietnam War veterans (eg, Agent Orange exposure), atomic veterans, and Gulf War veterans. Once fully designed and implemented, we believe that telehealth will prove to be a cost-effective way to provide clinic benefits to rural and older veterans.

Conclusions

The VHA provides priority medical treatment to FPOWs as well as timely and appropriate assessment of their eligibility for veterans’ benefits. The complexities benefit programs established for FPOWs is often beyond the ken of VHA physicians, social workers, and nurses. Because of this unfamiliarity, referrals of eligible FPOWs to appropriate programs can be overlooked. We established a clinic-based interdisciplinary team (FPOW Clinic) that was fully trained in FPOW benefit programs to identify overlooked benefits for FPOWs and were able to increase the disability rating on approximately one-third of the FPOWs seen in the FPOW Clinic. A telehealth-based version of the FPOW clinic is now being developed.

A 17% surge in mortality from fall-related traumatic brain injuries from 2008 to 2017 was driven largely by increases among those aged 75 years and older, according to investigators from the Centers for Disease Control and Prevention.

Nationally, the rate of deaths from traumatic brain injuries (TBIs) caused by unintentional falls rose from 3.86 per 100,000 population in 2008 to 4.52 per 100,000 in 2017, as the number of deaths went from 12,311 to 17,408, said Alexis B. Peterson, PhD, and Scott R. Kegler, PhD, of the CDC’s National Center for Injury Prevention and Control in Atlanta.

“This increase might be explained by longer survival following the onset of common diseases such as stroke, cancer, and heart disease or be attributable to the increasing population of older adults in the United States,” they suggested in the Mortality and Morbidity Weekly Report.

The rate of fall-related TBI among Americans aged 75 years and older increased by an average of 2.6% per year from 2008 to 2017, compared with 1.8% in those aged 55-74. Over that same time, death rates dropped for those aged 35-44 (–0.3%), 18-34 (–1.1%), and 0-17 (–4.3%), they said, based on data from the National Vital Statistics System’s multiple cause-of-death database.

The death rate increased fastest in residents of rural areas (2.9% per year), but deaths from fall-related TBI were up at all levels of urbanization. The largest central cities and fringe metro areas were up by 1.4% a year, with larger annual increases seen in medium-size cities (2.1%), small cities (2.2%), and small towns (2.1%), Dr. Peterson and Dr. Kegler said.

Rates of TBI-related mortality in general are higher in rural areas, they noted, and “heterogeneity in the availability and accessibility of resources (e.g., access to high-level trauma centers and rehabilitative services) can result in disparities in postinjury outcomes.”

State-specific rates increased in 45 states, although Alaska was excluded from the analysis because of its small number of cases (less than 20). Increases were significant in 29 states, but none of the changes were significant in the 4 states with lower rates at the end of the study period, the investigators reported.

“In older adults, evidence-based fall prevention strategies can prevent falls and avert costly medical expenditures,” Dr. Peterson and Dr. Kegler said, suggesting that health care providers “consider prescribing exercises that incorporate balance, strength and gait activities, such as tai chi, and reviewing and managing medications linked to falls.”

[email protected]

SOURCE: Peterson AB, Kegler SR. MMWR. 2019 Mar 6;69(9):225-30.

A 17% surge in mortality from fall-related traumatic brain injuries from 2008 to 2017 was driven largely by increases among those aged 75 years and older, according to investigators from the Centers for Disease Control and Prevention.

Nationally, the rate of deaths from traumatic brain injuries (TBIs) caused by unintentional falls rose from 3.86 per 100,000 population in 2008 to 4.52 per 100,000 in 2017, as the number of deaths went from 12,311 to 17,408, said Alexis B. Peterson, PhD, and Scott R. Kegler, PhD, of the CDC’s National Center for Injury Prevention and Control in Atlanta.

“This increase might be explained by longer survival following the onset of common diseases such as stroke, cancer, and heart disease or be attributable to the increasing population of older adults in the United States,” they suggested in the Mortality and Morbidity Weekly Report.

The rate of fall-related TBI among Americans aged 75 years and older increased by an average of 2.6% per year from 2008 to 2017, compared with 1.8% in those aged 55-74. Over that same time, death rates dropped for those aged 35-44 (–0.3%), 18-34 (–1.1%), and 0-17 (–4.3%), they said, based on data from the National Vital Statistics System’s multiple cause-of-death database.

The death rate increased fastest in residents of rural areas (2.9% per year), but deaths from fall-related TBI were up at all levels of urbanization. The largest central cities and fringe metro areas were up by 1.4% a year, with larger annual increases seen in medium-size cities (2.1%), small cities (2.2%), and small towns (2.1%), Dr. Peterson and Dr. Kegler said.

Rates of TBI-related mortality in general are higher in rural areas, they noted, and “heterogeneity in the availability and accessibility of resources (e.g., access to high-level trauma centers and rehabilitative services) can result in disparities in postinjury outcomes.”

State-specific rates increased in 45 states, although Alaska was excluded from the analysis because of its small number of cases (less than 20). Increases were significant in 29 states, but none of the changes were significant in the 4 states with lower rates at the end of the study period, the investigators reported.

“In older adults, evidence-based fall prevention strategies can prevent falls and avert costly medical expenditures,” Dr. Peterson and Dr. Kegler said, suggesting that health care providers “consider prescribing exercises that incorporate balance, strength and gait activities, such as tai chi, and reviewing and managing medications linked to falls.”

[email protected]

SOURCE: Peterson AB, Kegler SR. MMWR. 2019 Mar 6;69(9):225-30.

A 17% surge in mortality from fall-related traumatic brain injuries from 2008 to 2017 was driven largely by increases among those aged 75 years and older, according to investigators from the Centers for Disease Control and Prevention.

Nationally, the rate of deaths from traumatic brain injuries (TBIs) caused by unintentional falls rose from 3.86 per 100,000 population in 2008 to 4.52 per 100,000 in 2017, as the number of deaths went from 12,311 to 17,408, said Alexis B. Peterson, PhD, and Scott R. Kegler, PhD, of the CDC’s National Center for Injury Prevention and Control in Atlanta.

“This increase might be explained by longer survival following the onset of common diseases such as stroke, cancer, and heart disease or be attributable to the increasing population of older adults in the United States,” they suggested in the Mortality and Morbidity Weekly Report.

The rate of fall-related TBI among Americans aged 75 years and older increased by an average of 2.6% per year from 2008 to 2017, compared with 1.8% in those aged 55-74. Over that same time, death rates dropped for those aged 35-44 (–0.3%), 18-34 (–1.1%), and 0-17 (–4.3%), they said, based on data from the National Vital Statistics System’s multiple cause-of-death database.

The death rate increased fastest in residents of rural areas (2.9% per year), but deaths from fall-related TBI were up at all levels of urbanization. The largest central cities and fringe metro areas were up by 1.4% a year, with larger annual increases seen in medium-size cities (2.1%), small cities (2.2%), and small towns (2.1%), Dr. Peterson and Dr. Kegler said.

Rates of TBI-related mortality in general are higher in rural areas, they noted, and “heterogeneity in the availability and accessibility of resources (e.g., access to high-level trauma centers and rehabilitative services) can result in disparities in postinjury outcomes.”

State-specific rates increased in 45 states, although Alaska was excluded from the analysis because of its small number of cases (less than 20). Increases were significant in 29 states, but none of the changes were significant in the 4 states with lower rates at the end of the study period, the investigators reported.

“In older adults, evidence-based fall prevention strategies can prevent falls and avert costly medical expenditures,” Dr. Peterson and Dr. Kegler said, suggesting that health care providers “consider prescribing exercises that incorporate balance, strength and gait activities, such as tai chi, and reviewing and managing medications linked to falls.”

[email protected]

SOURCE: Peterson AB, Kegler SR. MMWR. 2019 Mar 6;69(9):225-30.

More than half of patients who undergo prolonged mechanical ventilation experience an acute laryngeal injury (ALgI), and the injury is associated with worse breathing and speaking at 10 weeks, according to a study published in Critical Care Medicine (2019 Dec;47[12]:1669-1706). The researchers, led by Alexander Gelbard, MD, of Vanderbilt Medical Center, Nashville, Tenn., found that higher body mass index, diabetes, and larger endotracheal tube (ETT) size were all associated with heightened risk.

The investigators assert that comparatively scarce data are available about how patients fare after receiving mechanical ventilation, and how adverse effects might interfere with recovery and return to daily activity. The larynx is rarely examined after extubation, and laryngeal injury may initially appear to be minor. Restricted glottic mobility therefore tends to be diagnosed after discharge, leaving critical care specialists unaware of the long-term impact.

The findings of the study should be a wake-up call for the development of guidelines for recognition and management of laryngeal injuries, according to John Robert Gowardman, MD, of Royal Brisbane (Australia) and Women’s Hospital, who wrote an accompanying editorial (Crit Care Med, 2019 Dec;47[12]:1802-04).

In addition, findings that ETT size, diabetes, and BMI represent risk factors for injury should help identify patients at risk, and the “practice of ‘putting in the biggest ETT just in case’ needs to be balanced against the dangers of an undersized ETT ... we should ask, ‘can my patient be safely managed with a smaller ETT?’ ” wrote Dr. Gowardman.

The researchers followed 100 consecutive adult patients who were examined with nasolaryngoscopy following an intubation of greater than 12 hours at Vanderbilt University Medical Center. They recorded baseline comorbidities and other factors. Fifty seven patients had an ALgI, defined as having glottic mucosal ulceration/granulation or subglottic granulation tissue/stenosis at the time of endoscopy. Nineteen patients had granulation tissue, 48 had posterior glottic ulceration, and 8 had subglottic mucosal ulceration.

Ten weeks after extubation, all patients were contacted by phone and asked to answer the Voice Handicap Index (VHI)-10 and the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ). The questioner did not know the results of the patient’s endoscopy. Patients with ALgI were heavier on average (mean difference, 14 kg; BMI difference, 3.8 kg/m²), were more likely to have type 2 diabetes (46% versus 21%), and had more severe illness (median Charlson Comorbidity Index, 3.00 versus 2.00).

Sixty-seven patients completed the 10-week questionnaires, including 40 patients with ALgI and 27 without ALgI. Injury was associated with reports of worse breathing (median CCQ, 1.05 versus 0.20; P less than .001), as well as worse patient-reported voice outcomes (median VHI, 2 versus 0; P = .005).

ETT size appeared to be an important factor, according to multivariate analyses. Use of a 7.0 ETT was associated with lower frequency of injury than 7.5 (adjusted odds ratio, 0.04; P = .004) and 8.0 (OR, 0.03; P = .004). There was no significant difference between the 7.5 and 8.0 sizes.

The presence of type 2 diabetes altered the risk associated with BMI (P = .003 for interaction). Among patients who did not have type 2 diabetes, ALgI went up as a function of increasing BMI. Still, injury risk was higher in the presence of type 2 diabetes across all BMI ranges.

The Vanderbilt Institute for Clinical and Translational Research funded the study. Dr. Gowardman has no relevant disclosures.

SOURCE: Shinn JR et al. Crit Care Med;2019 Dec;47(12):1669-1706 .

More than half of patients who undergo prolonged mechanical ventilation experience an acute laryngeal injury (ALgI), and the injury is associated with worse breathing and speaking at 10 weeks, according to a study published in Critical Care Medicine (2019 Dec;47[12]:1669-1706). The researchers, led by Alexander Gelbard, MD, of Vanderbilt Medical Center, Nashville, Tenn., found that higher body mass index, diabetes, and larger endotracheal tube (ETT) size were all associated with heightened risk.

The investigators assert that comparatively scarce data are available about how patients fare after receiving mechanical ventilation, and how adverse effects might interfere with recovery and return to daily activity. The larynx is rarely examined after extubation, and laryngeal injury may initially appear to be minor. Restricted glottic mobility therefore tends to be diagnosed after discharge, leaving critical care specialists unaware of the long-term impact.

The findings of the study should be a wake-up call for the development of guidelines for recognition and management of laryngeal injuries, according to John Robert Gowardman, MD, of Royal Brisbane (Australia) and Women’s Hospital, who wrote an accompanying editorial (Crit Care Med, 2019 Dec;47[12]:1802-04).

In addition, findings that ETT size, diabetes, and BMI represent risk factors for injury should help identify patients at risk, and the “practice of ‘putting in the biggest ETT just in case’ needs to be balanced against the dangers of an undersized ETT ... we should ask, ‘can my patient be safely managed with a smaller ETT?’ ” wrote Dr. Gowardman.

The researchers followed 100 consecutive adult patients who were examined with nasolaryngoscopy following an intubation of greater than 12 hours at Vanderbilt University Medical Center. They recorded baseline comorbidities and other factors. Fifty seven patients had an ALgI, defined as having glottic mucosal ulceration/granulation or subglottic granulation tissue/stenosis at the time of endoscopy. Nineteen patients had granulation tissue, 48 had posterior glottic ulceration, and 8 had subglottic mucosal ulceration.

Ten weeks after extubation, all patients were contacted by phone and asked to answer the Voice Handicap Index (VHI)-10 and the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ). The questioner did not know the results of the patient’s endoscopy. Patients with ALgI were heavier on average (mean difference, 14 kg; BMI difference, 3.8 kg/m²), were more likely to have type 2 diabetes (46% versus 21%), and had more severe illness (median Charlson Comorbidity Index, 3.00 versus 2.00).

Sixty-seven patients completed the 10-week questionnaires, including 40 patients with ALgI and 27 without ALgI. Injury was associated with reports of worse breathing (median CCQ, 1.05 versus 0.20; P less than .001), as well as worse patient-reported voice outcomes (median VHI, 2 versus 0; P = .005).

ETT size appeared to be an important factor, according to multivariate analyses. Use of a 7.0 ETT was associated with lower frequency of injury than 7.5 (adjusted odds ratio, 0.04; P = .004) and 8.0 (OR, 0.03; P = .004). There was no significant difference between the 7.5 and 8.0 sizes.

The presence of type 2 diabetes altered the risk associated with BMI (P = .003 for interaction). Among patients who did not have type 2 diabetes, ALgI went up as a function of increasing BMI. Still, injury risk was higher in the presence of type 2 diabetes across all BMI ranges.

The Vanderbilt Institute for Clinical and Translational Research funded the study. Dr. Gowardman has no relevant disclosures.

SOURCE: Shinn JR et al. Crit Care Med;2019 Dec;47(12):1669-1706 .

More than half of patients who undergo prolonged mechanical ventilation experience an acute laryngeal injury (ALgI), and the injury is associated with worse breathing and speaking at 10 weeks, according to a study published in Critical Care Medicine (2019 Dec;47[12]:1669-1706). The researchers, led by Alexander Gelbard, MD, of Vanderbilt Medical Center, Nashville, Tenn., found that higher body mass index, diabetes, and larger endotracheal tube (ETT) size were all associated with heightened risk.

The investigators assert that comparatively scarce data are available about how patients fare after receiving mechanical ventilation, and how adverse effects might interfere with recovery and return to daily activity. The larynx is rarely examined after extubation, and laryngeal injury may initially appear to be minor. Restricted glottic mobility therefore tends to be diagnosed after discharge, leaving critical care specialists unaware of the long-term impact.

The findings of the study should be a wake-up call for the development of guidelines for recognition and management of laryngeal injuries, according to John Robert Gowardman, MD, of Royal Brisbane (Australia) and Women’s Hospital, who wrote an accompanying editorial (Crit Care Med, 2019 Dec;47[12]:1802-04).

In addition, findings that ETT size, diabetes, and BMI represent risk factors for injury should help identify patients at risk, and the “practice of ‘putting in the biggest ETT just in case’ needs to be balanced against the dangers of an undersized ETT ... we should ask, ‘can my patient be safely managed with a smaller ETT?’ ” wrote Dr. Gowardman.

The researchers followed 100 consecutive adult patients who were examined with nasolaryngoscopy following an intubation of greater than 12 hours at Vanderbilt University Medical Center. They recorded baseline comorbidities and other factors. Fifty seven patients had an ALgI, defined as having glottic mucosal ulceration/granulation or subglottic granulation tissue/stenosis at the time of endoscopy. Nineteen patients had granulation tissue, 48 had posterior glottic ulceration, and 8 had subglottic mucosal ulceration.

Ten weeks after extubation, all patients were contacted by phone and asked to answer the Voice Handicap Index (VHI)-10 and the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ). The questioner did not know the results of the patient’s endoscopy. Patients with ALgI were heavier on average (mean difference, 14 kg; BMI difference, 3.8 kg/m²), were more likely to have type 2 diabetes (46% versus 21%), and had more severe illness (median Charlson Comorbidity Index, 3.00 versus 2.00).

Sixty-seven patients completed the 10-week questionnaires, including 40 patients with ALgI and 27 without ALgI. Injury was associated with reports of worse breathing (median CCQ, 1.05 versus 0.20; P less than .001), as well as worse patient-reported voice outcomes (median VHI, 2 versus 0; P = .005).

ETT size appeared to be an important factor, according to multivariate analyses. Use of a 7.0 ETT was associated with lower frequency of injury than 7.5 (adjusted odds ratio, 0.04; P = .004) and 8.0 (OR, 0.03; P = .004). There was no significant difference between the 7.5 and 8.0 sizes.

The presence of type 2 diabetes altered the risk associated with BMI (P = .003 for interaction). Among patients who did not have type 2 diabetes, ALgI went up as a function of increasing BMI. Still, injury risk was higher in the presence of type 2 diabetes across all BMI ranges.

The Vanderbilt Institute for Clinical and Translational Research funded the study. Dr. Gowardman has no relevant disclosures.

SOURCE: Shinn JR et al. Crit Care Med;2019 Dec;47(12):1669-1706 .

CHICAGO – Individuals who sustain gunshot wounds have an increased risk for rehospitalization years, and even decades, after their initial injury.

Kateywhat/ThinkStock

A study of individuals at a single institution who were hospitalized and had a prior history of gunshot wound found some patterns of injury that set patients up for a greater likelihood of readmission.

In particular, patients who sustained visceral gunshot wounds were over six times more likely to be readmitted to the hospital, Corbin Pomeranz, MD, a radiology resident at Thomas Jefferson University, Philadelphia, said in an interview at the annual meeting of the Radiological Society of North America. Dr. Pomeranz led the retrospective study that begins to fill a knowledge gap about what happens over the long term to those who sustain gunshot wounds.

“There continues to be profound lack of substantial information related to gun violence, particularly in predicting long-term outcomes,” Dr. Pomeranz and coauthors wrote in the abstract accompanying the presentation.

The researchers performed a single-site retrospective analysis over 3 months in 2018, tapping into an imaging database and looking for inpatient imaging exams that were nonacute, but related to gunshot wounds. From this information, the researchers went back to the original gunshot wound injury imaging, and recorded the pattern of injury, classifying wounds as neurologic, vascular, visceral, musculoskeletal, or involving multiple systems.

The investigators were able to glean additional information including the initial admitting hospital unit, information about interval admissions or surgeries, and demographic data. Regarding the nature of the gunshot injury itself, Dr. Pomeranz and coauthors went back to the earlier imaging studies to note bullet morphology, recording whether the bullet was intact, deformed, or had splintered into shrapnel within injured tissues.

In all, 174 imaging studies involving 110 patients were examined. Men made up 92% of the study population; the average age was 49.7 years. Neurologic and visceral gunshot wounds were moderately correlated with subsequent readmission (r = .436; P less than .001). However, some of this effect was blunted when patient age was controlled for in the statistical analysis.

Patients who were initially admitted to the intensive care unit, and who presumably had more severe injuries, were also more likely to be readmitted (r = .494, P less than .001). Here, “controlling for age had very little effect on the strength of the relationship between these two variables,” noted Dr. Pomeranz and coauthors.

A more elaborate statistical model incorporated several independent variables including age, type of injury, and body region involved, as well as bullet morphology. In this model, visceral injury was the strongest predictor for readmission, with an odds ratio of 6.44.

Dr. Pomeranz said that both the initial gunshot wound and subsequent gaps in care can contribute to readmissions. A patient who has a spinal cord injury may not be reimbursed adequately for supportive cushioning, or an appropriate wheelchair, and so may require admission for decubitus ulcers.

The number of admissions for osteomyelitis, which made up more than half of the subsequent admissions, initially surprised Dr. Pomeranz, until he realized that lack of mobility and sensory losses from gunshot-induced spinal cord injuries could easily lead to nonhealing lower extremity wounds, with osteomyelitis as a sequela.

Several patients were admitted for small bowel obstructions with no interval surgery since treatment for the gunshot wound. These readmissions, said Dr. Pomeranz, were assessed as related to the gunshot wound since it’s extremely rare for a patient with no history of abdominal surgery and no malignancy to have a small bowel obstruction. Exploratory laparotomies are common in the context of abdominal trauma caused by gunshot wounds, and either the gunshot itself or the laparotomy was the likely cause of adhesions.

Dr. Pomeranz acknowledged the many limitations of the study, but pointed out that some will be addressed when he and his coauthors conduct a larger study they have planned to look at readmissions from gunshot wounds at multiple hospitals in the Philadelphia area. The small sample size in the current study meant that the impact of socioeconomic status and other lifestyle and social variables and comorbidities couldn’t be adequately addressed in the statistical analysis. By casting a wider net within the greater Philadelphia area, the investigators should be able to track patients who receive care in more than one hospital system, increasing participant numbers, he said.

“Morbidity and outcomes from gun violence can only be assessed after a firm understanding of injury patterns on imaging,” noted Dr. Pomeranz. He said that interdisciplinary research investigating individual and societal short- and long-term costs of gun violence is sorely needed to inform public policy.

Dr. Pomeranz reported no outside sources of funding and reported that he had no conflicts of interest.

[email protected]

SOURCE: Pomeranz C et al. RSNA 2019, Presentation HP226-SD-THA3.

CHICAGO – Individuals who sustain gunshot wounds have an increased risk for rehospitalization years, and even decades, after their initial injury.

Kateywhat/ThinkStock

A study of individuals at a single institution who were hospitalized and had a prior history of gunshot wound found some patterns of injury that set patients up for a greater likelihood of readmission.

In particular, patients who sustained visceral gunshot wounds were over six times more likely to be readmitted to the hospital, Corbin Pomeranz, MD, a radiology resident at Thomas Jefferson University, Philadelphia, said in an interview at the annual meeting of the Radiological Society of North America. Dr. Pomeranz led the retrospective study that begins to fill a knowledge gap about what happens over the long term to those who sustain gunshot wounds.

“There continues to be profound lack of substantial information related to gun violence, particularly in predicting long-term outcomes,” Dr. Pomeranz and coauthors wrote in the abstract accompanying the presentation.

The researchers performed a single-site retrospective analysis over 3 months in 2018, tapping into an imaging database and looking for inpatient imaging exams that were nonacute, but related to gunshot wounds. From this information, the researchers went back to the original gunshot wound injury imaging, and recorded the pattern of injury, classifying wounds as neurologic, vascular, visceral, musculoskeletal, or involving multiple systems.

The investigators were able to glean additional information including the initial admitting hospital unit, information about interval admissions or surgeries, and demographic data. Regarding the nature of the gunshot injury itself, Dr. Pomeranz and coauthors went back to the earlier imaging studies to note bullet morphology, recording whether the bullet was intact, deformed, or had splintered into shrapnel within injured tissues.

In all, 174 imaging studies involving 110 patients were examined. Men made up 92% of the study population; the average age was 49.7 years. Neurologic and visceral gunshot wounds were moderately correlated with subsequent readmission (r = .436; P less than .001). However, some of this effect was blunted when patient age was controlled for in the statistical analysis.

Patients who were initially admitted to the intensive care unit, and who presumably had more severe injuries, were also more likely to be readmitted (r = .494, P less than .001). Here, “controlling for age had very little effect on the strength of the relationship between these two variables,” noted Dr. Pomeranz and coauthors.

A more elaborate statistical model incorporated several independent variables including age, type of injury, and body region involved, as well as bullet morphology. In this model, visceral injury was the strongest predictor for readmission, with an odds ratio of 6.44.

Dr. Pomeranz said that both the initial gunshot wound and subsequent gaps in care can contribute to readmissions. A patient who has a spinal cord injury may not be reimbursed adequately for supportive cushioning, or an appropriate wheelchair, and so may require admission for decubitus ulcers.

The number of admissions for osteomyelitis, which made up more than half of the subsequent admissions, initially surprised Dr. Pomeranz, until he realized that lack of mobility and sensory losses from gunshot-induced spinal cord injuries could easily lead to nonhealing lower extremity wounds, with osteomyelitis as a sequela.

Several patients were admitted for small bowel obstructions with no interval surgery since treatment for the gunshot wound. These readmissions, said Dr. Pomeranz, were assessed as related to the gunshot wound since it’s extremely rare for a patient with no history of abdominal surgery and no malignancy to have a small bowel obstruction. Exploratory laparotomies are common in the context of abdominal trauma caused by gunshot wounds, and either the gunshot itself or the laparotomy was the likely cause of adhesions.

Dr. Pomeranz acknowledged the many limitations of the study, but pointed out that some will be addressed when he and his coauthors conduct a larger study they have planned to look at readmissions from gunshot wounds at multiple hospitals in the Philadelphia area. The small sample size in the current study meant that the impact of socioeconomic status and other lifestyle and social variables and comorbidities couldn’t be adequately addressed in the statistical analysis. By casting a wider net within the greater Philadelphia area, the investigators should be able to track patients who receive care in more than one hospital system, increasing participant numbers, he said.

“Morbidity and outcomes from gun violence can only be assessed after a firm understanding of injury patterns on imaging,” noted Dr. Pomeranz. He said that interdisciplinary research investigating individual and societal short- and long-term costs of gun violence is sorely needed to inform public policy.

Dr. Pomeranz reported no outside sources of funding and reported that he had no conflicts of interest.

[email protected]

SOURCE: Pomeranz C et al. RSNA 2019, Presentation HP226-SD-THA3.

CHICAGO – Individuals who sustain gunshot wounds have an increased risk for rehospitalization years, and even decades, after their initial injury.

Kateywhat/ThinkStock

A study of individuals at a single institution who were hospitalized and had a prior history of gunshot wound found some patterns of injury that set patients up for a greater likelihood of readmission.

In particular, patients who sustained visceral gunshot wounds were over six times more likely to be readmitted to the hospital, Corbin Pomeranz, MD, a radiology resident at Thomas Jefferson University, Philadelphia, said in an interview at the annual meeting of the Radiological Society of North America. Dr. Pomeranz led the retrospective study that begins to fill a knowledge gap about what happens over the long term to those who sustain gunshot wounds.

“There continues to be profound lack of substantial information related to gun violence, particularly in predicting long-term outcomes,” Dr. Pomeranz and coauthors wrote in the abstract accompanying the presentation.

The researchers performed a single-site retrospective analysis over 3 months in 2018, tapping into an imaging database and looking for inpatient imaging exams that were nonacute, but related to gunshot wounds. From this information, the researchers went back to the original gunshot wound injury imaging, and recorded the pattern of injury, classifying wounds as neurologic, vascular, visceral, musculoskeletal, or involving multiple systems.

The investigators were able to glean additional information including the initial admitting hospital unit, information about interval admissions or surgeries, and demographic data. Regarding the nature of the gunshot injury itself, Dr. Pomeranz and coauthors went back to the earlier imaging studies to note bullet morphology, recording whether the bullet was intact, deformed, or had splintered into shrapnel within injured tissues.

In all, 174 imaging studies involving 110 patients were examined. Men made up 92% of the study population; the average age was 49.7 years. Neurologic and visceral gunshot wounds were moderately correlated with subsequent readmission (r = .436; P less than .001). However, some of this effect was blunted when patient age was controlled for in the statistical analysis.

Patients who were initially admitted to the intensive care unit, and who presumably had more severe injuries, were also more likely to be readmitted (r = .494, P less than .001). Here, “controlling for age had very little effect on the strength of the relationship between these two variables,” noted Dr. Pomeranz and coauthors.

A more elaborate statistical model incorporated several independent variables including age, type of injury, and body region involved, as well as bullet morphology. In this model, visceral injury was the strongest predictor for readmission, with an odds ratio of 6.44.

Dr. Pomeranz said that both the initial gunshot wound and subsequent gaps in care can contribute to readmissions. A patient who has a spinal cord injury may not be reimbursed adequately for supportive cushioning, or an appropriate wheelchair, and so may require admission for decubitus ulcers.

The number of admissions for osteomyelitis, which made up more than half of the subsequent admissions, initially surprised Dr. Pomeranz, until he realized that lack of mobility and sensory losses from gunshot-induced spinal cord injuries could easily lead to nonhealing lower extremity wounds, with osteomyelitis as a sequela.

Several patients were admitted for small bowel obstructions with no interval surgery since treatment for the gunshot wound. These readmissions, said Dr. Pomeranz, were assessed as related to the gunshot wound since it’s extremely rare for a patient with no history of abdominal surgery and no malignancy to have a small bowel obstruction. Exploratory laparotomies are common in the context of abdominal trauma caused by gunshot wounds, and either the gunshot itself or the laparotomy was the likely cause of adhesions.

Dr. Pomeranz acknowledged the many limitations of the study, but pointed out that some will be addressed when he and his coauthors conduct a larger study they have planned to look at readmissions from gunshot wounds at multiple hospitals in the Philadelphia area. The small sample size in the current study meant that the impact of socioeconomic status and other lifestyle and social variables and comorbidities couldn’t be adequately addressed in the statistical analysis. By casting a wider net within the greater Philadelphia area, the investigators should be able to track patients who receive care in more than one hospital system, increasing participant numbers, he said.

“Morbidity and outcomes from gun violence can only be assessed after a firm understanding of injury patterns on imaging,” noted Dr. Pomeranz. He said that interdisciplinary research investigating individual and societal short- and long-term costs of gun violence is sorely needed to inform public policy.

Dr. Pomeranz reported no outside sources of funding and reported that he had no conflicts of interest.

[email protected]

SOURCE: Pomeranz C et al. RSNA 2019, Presentation HP226-SD-THA3.