Department Of Veterans Affairs Medical Centers Research Articles

Patients with schizophrenia and breast cancer: Adjuvant radiation treatment.

e17506 Background: Schizophrenia affects about 1% of subjects in all populations studied so far. It impairs medical care delivery. We sought to evaluate how patients with schizophrenia who are later diagnosed with breast carcinoma fare when adjuvant radiation therapy (ART) is indicated. Methods: We searched the Patient Treatment File (PTF) of the Department of Veterans Affairs (DVA) to identify subjects with schizophrenia who later developed breast carcinoma and were treated in DVA Medical Centers (DVAMCs) from 1999 - 2005. Chart-based clinical data from the DVAMCs where the subjects had been treated supplemented PTF data. Results: 42 patients had preexisting schizophrenia, later developed breast carcinoma, and were candidates for ART. There were 31 women (74%) and 11 men (26%). 27 of the 42 study subjects had records specifying TNM stage; 18 of the 27 (67%) had TNM stages III-IV. 31 subjects had records about compliance with indicated medical therapies; 24 (77%) had previously been non-compliant. 39 subjects had records regarding therapy delay; 20 (51%) had previously delayed medically indicated therapy. Of the 42 subjects who were candidates for ART based on TNM stage, we found data about the decision to recommend ART in 37; only 23 (26%) were offered ART and 3 of those 23 (26%) refused it. Of the 6 subjects who refused ART, 4 had been non-compliant with previous medically indicated care, 3 had delayed initial cancer treatment, 4 had documented suicidal ideation, and 2 had documented homicidal ideation before being offered ART. Conclusions: Subjects with schizophrenia and breast carcinoma often do not understand their illnesses well. They often do not comply with recommended standard therapies such as ART. Treatments that rely on ART are likely to be met with non-compliance. A history of non-compliance appears to be a predictor of non-compliance with ART. Our results should be of interest to caregivers because we describe ways to avoid suboptimal ART in patients with breast carcinoma. Breast-conserving multi-modality treatment with ART is frequently not appropriate; radical surgery is often preferable.

Surgery for constipation in patients with prior spinal cord injury: The Department of Veterans Affairs experience

ObjectivePatients with spinal cord injury (SCI) typically have difficulty with constipation. Some undergo surgery for bowel management. We predicted that SCI patients would have higher mortality and/or morbidity rates following such surgery than neurally intact patients receiving the same procedures. We sought to evaluate this using a large population-based data set.MethodsPatients receiving care at Department of Veterans Affairs Medical Centers (DVAMCs) with computer codes for SCI and constipation who later underwent colectomy, colostomy, or ileostomy during fiscal years 1993–2002 were identified. Charts were requested from the VAMCs where the surgery had been performed and a retrospective chart review of these charts was done. We collected data on patient demographics, six specific pre-operative co-morbidities, surgical complications, and post-operative mortality. Comparisons were made to current literature evaluating a population receiving total abdominal colectomy and ileorectal anastomosis for constipation but not selected for SCI.ResultsOf 299 patients identified by computer search, 43 (14%) had codes for SCI and 10 of 43 (24%) met our inclusion criteria. All were symptomatic and had received appropriate medical management. Co-morbid conditions were present in 9 of 10 patients (90%). There were no deaths within 30 days. The complication rate was zero. The mean post-operative length of stay was 17 days.ConclusionsPatients with SCI comprise about 14% of the population who receive surgery for severe constipation in the Department of Veterans Affairs system. The mortality and morbidity rates in these patients are similar to those reported in other constipated patients who have surgery for intractable constipation. Our data suggest that stoma formation ± bowel resection in patients with SCI is a safe and effective treatment for chronic constipation.

Adjuvant chemotherapy for breast cancer in patients with schizophrenia.

The outcomes of treatment of physical illnesses are strongly affected by the presence of schizophrenia. We aimed to quantify the clinical course of schizophrenic breast cancer patients who were eligible for adjuvant chemotherapy to determine whether patients with this mental illness receive appropriate treatment for this physical illness. We searched the national Department of Veterans Affairs (DVA) computer database using computer codes for schizophrenia to identify patients who later developed breast cancer and were treated in DVA medical centers. Computer-based data were supplemented with chart-based clinical indicators. There were 55 subjects who appeared to be appropriate candidates for adjuvant systemic therapy. A number of these candidates were not offered postoperative endocrine or cytotoxic chemotherapy, while others refused treatment or were non-compliant. Behaviors typical of schizophrenic subjects, including hostility to caregivers, often disrupt their care. Schizophrenic patients often have advanced-stage cancer at diagnosis, often delay diagnosis and are frequently hostile towards healthcare workers. Many of these patients refuse therapy and/or are non-compliant.

Use of Court‐ordered Supervised Disulfiram Therapy at DVA Medical Centers in the United States

Having reported high adherence to court-mandated disulfiram treatment, we hypothesized that other Department of Veterans Affairs (DVA) medical centers would report frequent use of this modality. Telephone interviews with DVA substance abuse clinics in 48 of the 50 states matched the national DVA frequencies. Phone survey responders reported disulfiram prescription as never/rarely 63%, sometimes 32%, and often 5%, while court-ordered disulfiram was used never/rarely 95%, sometimes 3%, and often 2%. Nationally, disulfiram prescriptions covered only 0.07% of all veterans seen. These data suggest a need for a re-evaluation of disulfiram as an underused treatment for alcohol dependence.

Attentional Modulation of Language Performance

Harold Goodglass Aphasia Research Center, Department of Neurology, Boston UniversitySchool of Medicine and Research Service of the Department of Veterans Affairs MedicalCenter, Boston; Language in the Aging Brain Laboratory, Boston University School ofMedicine; and CUNY Graduate Center, Program in Speech and Hearing Sciences

Diazepam Usage in Veterans With Spinal Cord Injury

Diazepam is widely prescribed for persons with spinal cord injury (SCI) to treat muscular spasticity. To assess the current usage of diazepam in those persons with SCI being followed by the Department of Veterans Affairs Medical Centers (DVAMCs), a survey was mailed to all 23 DVAMCs that have specialized SCI Services. We discovered that no policy regarding the prescription of benzodiazepines existed at 65 percent of the SCI Services. At 70 percent of the SCI Services, diazepam or another benzodiazepine was routinely precribed. One-third of patients were estimated to have taken diazepam for greater than 10 years and an additional 37 percent for six to 10 years. Despite the potential for addiction, only 10 of the 23 SCI Services reported having a program to encourage discontinuation of diazepam use; a 20 percent success rate was reported in withdrawing this medication. A need for greater understanding with regard to the prescription of diazepam exists and strategies for its withdrawal should be considered. Appropriate guidelines for its use in patients with SCI and spasticity should be developed. (J Spinal Cord Med 1997;20:406-409)

Collaboration Between a Referring Hospital and a Tertiary Care Center in Improving the Transfer Process for Cardiac Patients

Transfer of cardiac patients between hospitals is a complex process with many implications for quality of care. In the case of heart disease, specialized procedures such as coronary angioplasty, coronary bypass surgery, and valve replacement or repair require the performance of cardiac catheterization and coronary arteriography in a catheterization laboratory, as well as the availability of cardiac surgical services. The Department of Veterans Affairs Medical Center (DVAMC) at Muskogee, Oklahoma, transfers most cardiac patients requiring specialized diagnostic procedures and advanced cardiac care to DVAMC at Oklahoma City, Oklahoma. Concerns about the inefficiency of the transfer process led to the launch of a quality improvement project in late 1992. CHANGES IN THE TRANSFER PROCESS: Greater emphasis was placed on medical aspects compared to administrative aspects of transfer, and ready access to the physicians at DVAMC at Oklahoma City was provided. The time from request for transfer to the actual transfer decreased. Before the quality improvement project, only 33% of transfers of cardiac patients were completed within 24 hours-versus 78% in 1993 and 1994, 89% in 1995, and 84% in the first half of 1996. In addition, DVAMC-Muskogee physician satisfaction regarding services at DVAMC-Oklahoma City improved. Ongoing discussion between the cardiology team at the accepting hospital and physicians at the referring hospital expanded the continuum of care to both hospitals. Priority of transfers could be upgraded at any time without unduly jeopardizing patient safety or increasing resource utilization at the receiving center.

An investigation of the relationship between general belief patterns and well-being

One hundred and thirty-three employees (58 males, 75 females) of the Department of Veterans Affairs Medical Center (DVAMC), Coatesville, PA anonymously volunteered data on a Demographic Survey, The Brief Symptom Inventory (BSI, Derogatis), and The Irrational Beliefs Test (IBT, Jones). A canonical correlation analysis was used to investigate associations between general patterns of beliefs and symptomatology. Two significant pairs of variates were revealed. The first pair provided associations between Demand for Approval, High Self-Expectations, Frustration Reactive, Anxious Overconcern, and Perfectionism and psychological symptomatology. The second pair provided associations between Demand for Approval, Blame Proneness, Frustration Reactive, and Emotional Irresponsibility and somatic symptoms. A MANOVA was used to assess for gender differences. There was no significant general gender effect. However, univariate analyses revealed significant effects for seven BSI variables. This study supported the belief that one's pattern of thinking is related to one's pattern of symptomatology. This has implications for use in health psychology and behavioral medicine.

The ABCs of DME: a home care durable medical equipment/home oxygen program.

With the evolution of high-tech healthcare in the home setting, patients and families now need to learn the skills to perform the tasks that previously were done in hospital settings by health professionals. Numerous private and federally funded home health organizations are offering services to this patient population. The mission of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is to improve the quality of care provided to the public (JCAHO, 1991b). In 1988, the commission implemented standards for the accreditation of home care and began to survey home care providers (JCAHO, 1988). Standards governing the provision of durable medical equipment are included in the JCAHO Accreditation Manual for Home Care (1991a). The article describes an effective collaborative approach used to develop a comprehensive durable medical equipment/home oxygen (DME/home O2) program at the Department of Veterans Affairs Medical Center (DVAMC), now called the Veterans Health Administration Medical Center, in East Orange, NJ. Project management principles were used by the quality management (QM) staff to develop and implement the DME/home O2 program successfully.

Evaluation as an Imperative for Social Services Preservation: A Challenge to the Department of Veterans Affairs

Abstract Throughout the Department of Veterans Affairs (DVA), the largest single employer of professional social workers, there is increasing demand for clinicians to be accountable for the outcomes of client intervention. This article discusses how issues of accountability threaten the leadership role of the social work profession in the DVA extended care services continuum. Many innovations are needed to prepare direct services staff with the research skills they need to complete practice assessments and program evaluations. One project—the development of a research partnership between the doctoral social work program at the University of Kansas, Lawrence, and the Colmery-O'Neil DVA Medical Center—is analyzed to highlight system obstacles and administrative approaches that can reduce barriers between the academic and practice sectors. Examples of fiscal and personnel resources use are included as research partnership strategies of relevance to other schools and to DVA medical centers.