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Background: Topical 5% 5-fluorouracil (5-FU) is known to cause toxicity, such as erythema, pain, and crusting/erosions. Objectives: We sought to develop a scale to measure this toxicity and test the scale for reliability. Methods: A scale was developed involving four parameters: erythema severity, percentage of face involved in erythema, crusting/erosions severity, and percentage of face involved in crusting/erosions. Thirteen raters graded 99 sets of photographs from the Veterans Affairs Keratinocyte Carcinoma Chemoprevention (VAKCC) Trial using these parameters. Results: Intraclass correlation overall for 13 raters was 0.82 (95% CI 0.77–0.86). There was no statistically significant trend in reliability by level of training in dermatology. Conclusions: This scale is a reliable method of evaluating the severity of toxicity from topical 5-fluorouracil and can be used by dermatologists and nondermatologists alike.

Chronic posttraumatic stress disorder (PTSD) can result in significant social and physical impairments. Despite the Department of Veterans Affairs' (VA) expansion of mental health services into primary care clinics to reach larger numbers of Veterans with PTSD, many do not receive sufficient treatment to clinically benefit. This study explored whether the odds of premature mental health treatment termination varies by patient race/ethnicity and, if so, whether such variation is associated with differential access to services or beliefs about mental health treatments.Prospective national cohort study of VA patients who were recently diagnosed with PTSD (n = 6,788). Self-administered surveys and electronic VA databases were utilized to examine mental health treatment retention across racial/ethnic groups in the 6 months following the PTSD diagnosis controlling for treatment need, access factors, age, gender, treatment beliefs, and facility factors.African American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and African American Veterans were less likely to receive a minimal trial of any treatment in the 6 months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino but not African American Veterans. Access factors did not contribute to treatment retention disparities.Even in safety-net healthcare systems like VA, racial and ethnic disparities in mental health treatment occur. To improve treatment equity, clinicians may need to more directly address patients' treatment beliefs. More understanding is needed to address the treatment disparity for African American Veterans.

Several retrospective studies have raised concerns regarding digoxin therapy in select subgroups of heart failure patients. To assess the impact of digoxin therapy on outcomes in the current era of heart failure therapy, the authors analyzed data representing 5010 patients enrolled in the Valsartan Heart Failure Trial (Val-HeFT) to examine the relationship of baseline digoxin use and all-cause mortality, first morbid event, and heart failure hospitalizations. At baseline, 3374 patients (67%) were receiving digoxin therapy and 1636 (33%) were not. Patients receiving digoxin had features of worse heart failure with higher New York Heart Association class and lower blood pressure, ejection fraction, and β-blocker use (32.1% vs 40.8%). Digoxin use was associated with worse mortality (21.1 vs 15.0%, P.001), first morbid event (34.6 vs 21.7, P.001), and HF hospitalization rate (19.1 vs 10.1%, P.001). After adjustment for baseline group differences including medical therapy and baseline rhythm, patients receiving digoxin remained at a higher risk for all-cause mortality (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.05-1.57), first morbid event (HR, 1.35; 95% CI, 1.15-1.59), and heart failure hospitalization (HR, 1.41; 95% CI, 1.12-1.78). These results remained materially unchanged with propensity matched analysis. No benefit with digoxin use was observed in this study, underscoring the need to reassess the role of digoxin in the contemporary management of heart failure.

32 Background: Little data exist on the incidence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease in managed care plans. Objective: To estimate the incidence of secondary stroke and myocardial infarction (MI) over 3 years. Methods: Patients were identified as having atherosclerotic vascular disease (either stroke, MI, or peripheral arterial disease {PAD}) using administrative data from 11 UnitedHealthcare plans (3 with Medicare) from 1995–98. The stroke cohort includes patients ≥ 40 years old hospitalized with a primary or secondary ICD-9-CM code of either 434 or 436, and length of stay ≥ 1 day. Patients with a carotid endarterectomy or claims consistent with cardioembolic strokes were excluded. Persons age ≥ 40 with a primary ICD-9-CM code of 410 and a length of stay ≥ 2 days were included in the MI cohort. The PAD cohort included patients ≥ 40 with a hospital admission or an office visit with an ICD-9-CM code of 440.2x or 440.3. Cumulative incidences of subsequent stroke or MI were estimated for each cohort using Kaplan-Meier survival analysis. Results: For stroke, MI, and PAD cohorts, 3527 (49% Medicare), 9039 (26% Medicare), and 10,925 (46% Medicare) members were identified, respectively. Nearly 96% of MI and 89% of stroke patients were discharged alive. During an average follow-up period of 12 months in the stroke cohort, the cumulative incidences of stroke or MI were 4%, 7%, 12% and 14% at 0.5, 1, 2, and 3 years, respectively. Incidences in the MI cohort were 4%, 6%, 8% and 11% at 0.5, 1, 2, and 3 years (mean follow-up=15 months). In the PAD cohort with a mean follow-up of 15 months, the cumulative percentages with subsequent AMI or stroke were 2%, 3%, 5% and 8% after 0.5, 1, 2, and 3 years. Stroke accounted for 79%, 16%, and 39% of the secondary events in the stroke, MI, and PAD cohorts, respectively. Conclusions: Among persons with atherosclerotic vascular disease enrolled in managed care plans around the US, the incidence of subsequent ischemic events is consistent with a significant burden of symptomatic disease. Among stroke patients who have a subsequent ischemic event, stroke is the secondary event in the vast majority of cases.