Faculty Bibliography

BACKGROUND:Obesity is a worldwide epidemic, and its prevalence is higher among Veterans in the United States. Based on our prior research, primary care teams at a Veterans Affairs (VA) hospital do not feel well-equipped to deliver effective weight management counseling and often lack sufficient time. Further, effective and intensive lifestyle-based weight management programs (e.g. VA MOVE! program) are underutilized despite implementation of systematic screening and referral at all VA sites. The 5As behavior change model (Assess, Advise, Agree, Assist, Arrange) is endorsed by the United States Preventive Service Task Force for use in counseling patients about weight management in primary care and reimbursed by Medicare. In this paper, we describe the iterative development of a technology-assisted intervention designed to provide primary care-based 5As counseling within Patient-Centered Medical Homes without overburdening providers/healthcare teams. METHODS:Thematic analyses of prior formative work (focus groups with patients [n = 54] and key informant interviews with staff [n = 25]) helped to create a technology-assisted, health coaching intervention called Goals for Eating and Moving (GEM). To further develop the intervention, we then conducted two rounds of testing with previous formative study participants (n = 5 for Round 1, n = 5 for Round 2). Each session included usability testing of prototypes of the online GEM tool, pilot testing of 5As counseling by a Health Coach, and a post-session open-ended interview. RESULTS:Three main themes emerged from usability data analyses: participants' emotional responses, tool language, and health literacy. Findings from both rounds of usability testing, pilot testing, as well as the open-ended interview data, were used to finalize protocols for the full intervention in the clinic setting to be conducted with Version 3 of the GEM tool. CONCLUSIONS:The use of qualitative research methods and user-centered design approaches enabled timely detection of salient issues to make iterative improvements to the intervention. Future studies will determine whether this intervention can increase enrollment in intensive weight management programs and promote clinically meaningful weight loss in both Veterans and in other patient populations and health systems.

Background By 2050 the worldwide incidence of hip fractures in men is projected to increase by 310%. It has been proposed that this increase will be due, in part, to the number of undiagnosed and untreated cases of osteoporosis in this population. Existing literature suggest that men may be under-screened, and screening recommendations for men lag behind those for women. The aim of this study was to identify the need for screening and appropriate follow up in this population by identifying the number of fractures that preceded screening, and assess whether these patients had appropriate treatment and follow up. Methods A retrospective chart review using the Computerized Patient Record System was performed on 1848 males aged 20-80, who had undergone DEXA scanning at the VA NY Harbor Healthcare System between 2011 and 2016. The primary endpoint for assessment was whether the DEXA scan was ordered in response to a fracture event. Among patients who suffered a fracture, a further assessment was performed to evaluate whether these patients were treated for osteoporosis and whether they suffered subsequent fractures. Time to follow up DEXA was also measured. Data was collected by three investigators using a standardized extraction algorithm. Results 1848 DEXA scans were performed on males from 2011 and 2016, including 485 individuals with a history of fracture. Average age at time of first fracture was 75. The 485 patients were assessed in two groups-those who had DEXA scans ordered in response to a fragility fracture (Group A: N=170) and those who had fractures following their first DEXA (Group B: N=315). In Group A, 30% received treatment for osteoporosis following their fracture and 40% of patients sustained another fracture (46% of the untreated patients and 23% of the treated patients). In Group B, 63% received treatment following the fracture. A further 25% sustained another fracture (13% of the treated patients, and 24% of the untreated patients). 47% of all patients had a follow up DEXA. Conclusion Given the high prevalence of fractures among males without a known history of osteoporosis, there is need for routine screening of this demographic of patients in order to prevent fractures. Fewer than half the patients had a follow up DEXA. Further, our data suggest that appropriate treatment can reduce the risk of subsequent fractures by 50%. We conclude that physicians should be educated on appropriate management of osteoporosis following fractures

LEARNING OBJECTIVE #1: Describe a rare presentation of Pasteurella multocida pneumonia without history of cat bite CASE: An 84 year oldmale with a history of HTN, HLD, BPH, PVD, extensive smoking presented to the ER with small volume hemoptysis of 1 day duration. He reported having a cough productive of scant amounts of clear/yellow phlegm for a few weeks prior to developing hemoptysis. Review of systems was only notable for fatigue. He emigrated from Puerto Rico in the 1950s and lives in an apartment with one cat that often sleeps in his bed with him. Exam showed a well-appearing man, afebrile with a HR of 103, RR of 20, BP of 165/92, saturating 94% on ambient room air. Pulmonary exam was notable for dry crackles throughout both lung fields. Hemoglobin was stable without leukocytosis. In the ER, patient underwent CT chest angiography revealing diffuse mediastinal lymphadenopathy, diffuse interstitial lung disease, and a pleuralbased infiltrate in the left upper lobe. The diffuse lung disease had been stable since 2006. The patient was admitted and placed on airborne isolation for further workup. Overnight on hospital day 1, the patient spiked a fever and was started on Unasyn to cover for community acquired pneumonia. Sputum acid-fast bacilli smear returned positive x2 and PCR later revealed Mycobacterium avium complex (MAC), thought to be a colonizer. Bacterial sputum cultures grew Pasteurella multocida. The patient improved on IV Unasyn for Pasteurella and hemoptysis resolved. The patient was discharged from the hospital on hospital day 9 with a plan to complete a 14-day course of antibiotics. IMPACT: This case broadened our differential when an immunocompetent patient presents with fevers and hemoptysis and also shed light on a rare presentation of Pasteurella multocida infection. DISCUSSION: Pasteurella multocida, is a gram negative bacilli most abundantly found in the oral cavity of cats. Pasteurella has been transmitted to humans most commonly through animal bites or scratches. Severe infection in previously healthy individuals without occupational exposure or bite/scratch history is thought to be extremely rare. Pasteurella pneumonia usually presents with non-specific symptoms, including fever, malaise, dyspnea, pleuritic chest pain, and sometimes hemoptysis. Though our patient's sputum was also positive for MAC, adding an extra layer of challenge in treating him, the acuity of the his illness, sputum findings, improvement on Unaysn all argued for Pasteurella Pneumonia as themain culprit of this patient's presentation. Our patient appeared to contract Pasteurella pneumonia without direct mucous secretion exposure, presumably only from sharing a bed with his cat. This is an exceedingly rare cause of Pasteurella pneumonia, but not completely unheard of. Given the presence of other case reports available of rare, but similar presentations of Pasteurella pneumonia in the elderly or those with underlying lung disease, we propose that this disease entity be called "Cat Fancier's Pneumonia"

BACKGROUND: Obesity is under-treated and primary care teams find it difficult to provide effective lifestyle-based weight management counseling. Further, only 10% of eligible patients attendMOVE!, theVAweight management and health promotion program. We developed an intervention called Goals for Eating and Moving (GEM) to improve counseling within primary care (PC) and increase attendance in intensive weight management programs such as MOVE!. METHODS: Veterans with a Body Mass Index of greater than or equal to 30 or between 25 and 29.99 with at least one comorbidity were recruited by phone and randomized toGEMor "Enhanced Usual Care" (EUC). GEMutilizes the Patient Aligned Care Teams (PACTs) within the VA to deliver 5As counseling (Assess, Advise, Agree, Assist and Arrange) to promote modest weight loss and behavior change. Participants use a goal-setting tool to generate tailored materials, which facilitates in-person and phone counseling with health coaches. Coaches support PACTcounseling during regular PC visits and encourage participants to join VA weight management services. Veterans in GEM received the intervention and Veterans in EUC met with a coach to receive the VA "healthy living messages" pamphlet. At baseline and 3 months, participants had weight measurements and completed surveys. We used the Paffenbarger Physical Activity Questionnaire and a 17-item screener to derive fruit and vegetable intake, energy from fat, and dietary fiber. Vegetable intake (leafy greens/salad) and sugar-sweetened beverage were measured as individual items. We performed per-protocol analyses (Wilcoxon Rank sums test and Spearman Correlation) to assess the relationship between GEM and different variables. RESULTS: Thirty-one Veterans (mean age = 53.48, 63% male, mean BMI = 31.72) enrolled and 25 returned at 3-months (1 dropped out and 5 were lost-tofollow up). Those in GEM lost significantly more weight at 3-months (-1.59 kg, SD = 1.76) than those in EUC (-0.63 kg, SD = 3.42, p = 0.03). There were no statistically significant differences in diet and physical activity. For Veterans that received GEM, higher number of phone coaching sessions was correlated with weight loss (Spearman Correlation -0.58, p = 0.09). CONCLUSIONS: This early analysis indicates that GEM promotes small but significant (p = 0.03) weight loss at 3-months and identified the need for high patient retention and engagement, since the number of health coaching calls may correlate with weight loss. Based on this we have refined protocols for phone coaching to ensure that scheduling and reminder calls are patientcentered. This pilot study informed the development of a multi-site cluster- RCT of GEM to begin in June 2017 (NIH # 1R01 DK111928-01)

BACKGROUND: An independent association between gout and coronary artery disease is well established. The relationship between gout and valvular heart disease, however, is unclear. The aim of this study was to assess the association between gout and aortic stenosis. METHODS: We performed a retrospective case-control study. Aortic stenosis cases were identified through a review of outpatient transthoracic echocardiography (TTE) reports. Age-matched controls were randomly selected from patients who had undergone TTE and did not have aortic stenosis. Charts were reviewed to identify diagnoses of gout and the earliest dates of gout and aortic stenosis diagnosis. RESULTS: Among 1085 patients who underwent TTE, 112 aortic stenosis cases were identified. Cases and non-aortic stenosis controls (n=224) were similar in age and cardiovascular comorbidities. A history of gout was present in 21.4% (n=24) of aortic stenosis subjects compared with 12.5% (n=28) of controls (unadjusted OR 1.90, 95% CI 1.05-3.48, p=0.038). Multivariate analysis retained significance only for gout (adjusted OR 2.08, 95% CI 1.00-4.32, p=0.049). Among subjects with aortic stenosis and gout, gout diagnosis preceded aortic stenosis diagnosis by 5.8 +/- 1.6 years. The age at onset of aortic stenosis was similar among patients with and without gout (78.7 +/- 1.8 vs. 75.8 +/- 1.0 years old, p=0.16). CONCLUSIONS: Aortic stenosis patients had a markedly higher prevalence of precedent gout than age-matched controls. Whether gout is a marker of, or a risk factor for the development of aortic stenosis remains uncertain. Studies investigating the potential role of gout in the pathophysiology of aortic stenosis are warranted and could have therapeutic implications.

OBJECTIVE: Osteoarthritis (OA) and gout have each been associated with increased cardiovascular disease (CVD), but their relative impact is unknown. We compared CVD rates among patients with gout versus patients with OA and no gout (OA-only). METHODS: We identified male patients at the VA New York Harbor Healthcare System with gout (with or without concur - rent OA) and with OA-only between August 2007 and August 2008. For each group, we collected baseline demographic data and CVD risk factors. The primary outcome was a composite index (CV4) of any diagnosis of coronary artery disease (CAD), angina, myocardial infarction (MI), or coro- nary bypass surgery (CABG). Secondary outcomes included individual diagnoses within the CV4, CHF, and death. We subsequently divided the gout patients into those who did versus did not have concurrent diagnoses of OA (gout-only; gout+OA). Logistic regression was used to compare the associations of OA-only, gout-only, and gout+OA with CV outcomes. RESULTS: 1,280 gout subjects met inclusion criteria (983 gout- only and 297 gout+OA), along with 1,231 OA-only subjects. Gout subjects overall had more CVD risk factors at baseline, including hypertension, hyperlipidemia, and chronic kidney disease, versus OA-only. Compared with OA-only, gout subjects overall had increased rates of all outcomes except MI. Both the gout-only and gout+OA subgroups also had increased risk for all outcomes except MI, and CABG in the case of gout+OA subjects. After adjusting for traditional CVD risk factors, both gout-only and gout+OA subjects continued to have increased risk for multiple CVD outcomes. Gout+OA did not impart ad- ditional risk over gout-only for any outcome studied. CONCLUSION: Our data suggest that gout is associated with higher risk of CVD compared with OA, and that OA does not impart any additive CVD risk to patients who also have gout. Significance and Innovations: * In our dataset, gout subjects both with and without con- comitant OA had more cardiovascular disease (CVD) risk factors at baseline, and higher prevalence of CVD outcomes, than patients with OA only. * After adjusting for traditional CVD risk factors, gout-only and gout+OA subjects continued to have increased rates of multiple CVD outcomes, suggesting an intrinsic CVD risk to the diagnosis of gout, compared with OA. * These observations underline that gout patients represent a group at increased CVD risk, for whom both rheumatic disease management and CVD prevention need to be addressed.