Veterans Administration Hospital Research Articles

An Innovative Approach to Adequate Oral Hydration in an Inpatient Geriatric Psychiatry Unit.

Suboptimal hydration status and dehydration are problems that often exacerbate comorbid conditions in geriatric patients. At a Veterans Administration Hospital, it was observed that suboptimal hydration status in Veterans hospitalized in the geriatric psychiatry unit was a contributing factor in the worsening of their psychiatric and medical conditions. A quality improvement project was chartered to improve hydration in this group of patients. Using a three-pronged intervention approach (i.e., providing flavored water, providing larger cups, and increasing the prompting by nurses for patients to drink more), the project was successful. The goal was to increase average daily fluid intake by 125 mL; the result was an increase of 700 mL. This project has been sustained and the interventions have also benefitted non-geriatric psychiatry in-patients. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 15-20.].

Association Between Noninvasive Fibrosis Markers and Postoperative Mortality After Hepatectomy for Hepatocellular Carcinoma

The selection criteria for hepatectomy for hepatocellular carcinoma (HCC) is not well established. The role of noninvasive fibrosis markers in this setting is unknown in the US population. To evaluate whether aspartate aminotransferase-platelet ratio index (APRI) and fibrosis 4 (Fib4) values are associated with perioperative mortality and overall survival after hepatectomy for HCC. In a multicenter cohort study, Veterans Administration Corporate Data Warehouse was used to evaluate a retrospective cohort of 475 veterans who underwent hepatectomy for HCC between January 1, 2000, and December 31, 2012, in Veterans Administration hospitals. Data analysis occurred between September 30, 2016, and December 30, 2017. Logistic regression, survival analysis, and change in concordance index analysis were performed to evaluate the association between APRI and Fib4 values and mortality. The cohort was stratified based on preoperative APRI and Fib4 values. Analysis was performed accounting for the validated and established predictors of outcome. Thirty-day mortality, 90-day mortality, and overall survival were the primary outcomes. An APRI value greater than 1.5 was considered high risk (cirrhosis), and an Fib4 value greater than 4.0 was considered high risk (advanced fibrosis). Portal hypertension (diagnosis of ascites or encephalopathy indicates presence of portal hypertension) and Child-Turcotte-Pugh (CTP) class (A indicates preserved liver function; B, mild to moderate liver dysfunction) served as 2 other measures of liver function. A total of 475 patients with HCC underwent hepatectomy. The mean (SD) age was 65.6 (9.4) years; Model for End-Stage Liver Disease score, 8.9 (3.1); and body mass index, 28.1 (4.9) (calculated as weight in kilograms divided by height in meters squared). A total of 361 patients (76.0%) were men, 294 (61.9%) were white; 308 (64.8%) were hepatitis C positive, and 346 (72.8%) were categorized as CTP class A. The most common surgical procedure was partial lobectomy, with 321 (67.6%) procedures. The APRI value greater than 1.5 vs 1.5 or lower was associated with increased 30-day mortality (odds ratio [OR], 6.45; 95% CI, 2.80-14.80) and 90-day mortality (OR, 2.65; 95% CI, 1.35-5.22), as was Fib4 greater than 4.0 vs Fib4 4.0 or lower for 30-day mortality (OR, 5.41; 95% CI, 2.35-12.50) and 90-day mortality (OR, 2.74; 95% CI, 1.41-5.35). Survival analysis showed that overall survival was significantly different for APRI greater than 1.5 vs 1.5 or lower (mean survival time, 3.6 vs 5.4 years; log-rank P < .001) and Fib4 greater than 4.0 vs 4.0 or lower (mean survival time, 4.1 vs 5.3 years; log rank P = .01). Adjusted Cox proportional hazards regression analysis revealed that elevated APRI was significantly associated with worse survival (hazard ratio [HR], 1.13; 95% CI, 1.03-1.23) but Fib4 values were not (HR, 1.04; 95% CI, 0.99-1.09). Change in concordance index showed that APRI and Fib4 improved the ability of CTP class and portal hypertension to predict postoperative mortality. Elevated APRI and Fib4 values, which are noninvasive markers of fibrosis, were associated with higher perioperative mortality. The APRI was also associated with worse overall survival. Use of APRI and Fib4 measures improved the ability of established markers to predict postoperative mortality. These findings suggest incorporating APRI and Fib4 to the selection process for hepatectomy for HCC as predictors associated with mortality may be warranted.

A tribute to the inventor of arteriovenous fistula for hemodialysis: James E Cimino

A tribute to the inventor of arteriovenous fistula for hemodialysis: James E Cimino

Veterans have greater variability in their perception of binocular alignment.

IntroductionA significant population of our wounded veterans suffer long-term functional consequences of visual deficit, disorientation, dizziness, and an impaired ability to read. These symptoms may be related to damage within the otolith pathways that contribute to ocular alignment. The purpose of this study was to compare perception of vertical and torsional ocular alignment between veterans and healthy controls in an upright and supine test position.Materials and methodsVeterans (n = 26) with reports of dizziness were recruited from the East Orange Veterans Administration Hospital. Healthy controls (n = 26) were recruited from both Johns Hopkins University and the East Orange VA. Each subject performed 20 trials each of a novel vertical and torsional binocular alignment perception test. Veterans underwent semicircular canal and otolith pathway function testing.Results88% of the Veterans had an absent otolith response. Only the veterans had an abnormally large variability in perception of both vertical and torsional ocular alignment, and in both upright and supine position. Neither post-traumatic stress disorder, nor depression contributed to the misperception in binocular alignment.ConclusionsOur novel method of measuring vertical and torsional misalignment distinguishes veterans with dizziness from healthy controls. The high prevalence of absent otolith function seems to explain this result. Further studies are needed to better understand the fundamental mechanism responsible for the increased variability of perception of binocular alignment.

The Meaning of Care for Veterans

Experiences of care shape the meaning of experience with health-care providers and are important to understand as they are related to quality of care. This hermeneutic phenomenological study describes the meaning of veterans’ experiences in a Veterans Administration (VA) hospital from analyses of interviews with 20 veterans. Caring is at the heart of what veterans valued. Veterans linked communicating, following up, and using specialized knowledge with caring. Veterans’ military and medical histores are complex and require specialized knowledge, care, and skills. Education and interventions that promote caring as perceived by veterans will improve the quality of care.

Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain and Photophobia

"Dry eye" or "keratoconjunctivitis sicca" is a multifactorial disease estimated to have a worldwide prevalence of 5-33%. Conventional therapies targeting the ocular surface with artificial tears, anti-inflammatories, punctal closure, eyelid hygiene, and antibiotics do not provide relief in all patients, especially those with neuropathic-like ocular complaints (wind hyperalgesia and photophobia). We anticipated that ocular transcutaneous electrical nerve stimulation (TENS) would alleviate symptoms of ocular pain, photophobia, and dryness in these latter individuals. All individuals who received electrical stimulation between May 10, 2016 and April 6, 2017 for the treatment of chronic ocular pain at the oculofacial pain clinic of the Miami Veterans Administration Hospital were included in this retrospective review. All patients had symptoms of dryness along with other neuropathic-like symptoms (e.g., photophobia) and minimal signs of tear dysfunction. Ocular pain intensity, symptoms of dryness, and light sensitivity were compared pre-treatment and five min post-treatment via a two-tailed paired Student's t-test. The use of TENS significantly reduced the mean pain intensity in both the right and left eyes five min after treatment compared to prior to treatment (p < 0.05, paired t-test). The use of TENS significantly decreased light sensitivity in both eyes (p < 0.05). The findings for symptoms of dryness, however, were equivocal with a significant decrease in the left eye but not the right (p < 0.05, paired t-test). Our data indicate that TENS may similarly provide analgesia in patients with dry eye symptoms as it does for many other chronic pain conditions. Furthermore, the noted effect on symptoms of photophobia and dryness suggest that all may be linked by similar trigeminal-thalamic-cortical pathways. Prospective studies with electrical stimulation of dry eye are needed to further elucidate its benefit and mechanism of action.

Bowel Control Strategies Used by Veterans With Long-Standing Spinal Cord Injuries

The aim of the study was to describe strategies used by veterans with spinal cord injury to achieve control over bowel function and fit their bowel programs into their lifestyles in the years following the initial injury. Using a qualitative descriptive design, 18 outpatient veterans with spinal cord injuries were interviewed at a Veteran's Administration hospital. Recorded interviews were transcribed verbatim and analyzed to determine major themes. Fourteen of 18 participants had gained control over bowel function and led active lives. They emphasized the importance of positive attitudes, listening to their bodies, being physically active, taking charge, and using trial and error to find the best bowel control strategies. Findings also highlighted the value of peer support and the problem of military service connected back injury leading to spinal cord injury. Participants provided practical advice for adapting strategies learned during rehabilitation for long-term bowel control after discharge home.

Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound.

We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital system's performance. A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veteran's Administration Hospital. Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.

Foot Osteomyelitis in Patients Without Diabetes—Editorial Comment

Relatively few articles have been written on the subject of foot osteomyelitis in patients without diabetes. Even a PubMed search using the terms “osteomyelitis, foot” yields a majority of articles on diabetic foot osteomyelitis. But is there a difference between the two? In this article, Mitbander et al1 conclude that foot osteomyelitis is not clinically distinct in patients with diabetes versus those without, and the approach to management need not differ. We commend the authors for their important and interesting article. It is the first study to our knowledge that seeks to directly compare the two. There are pitfalls for any investigator trying to study osteomyelitis, whether in patients with or without diabetes. The answers to the most basic questions such as definition of the condition, appropriate diagnosis, length and course of treatment, surgical versus medical therapies, and even the definition of a “cure” remain elusive. Various clinical practice guidelines have attempted to answer some of these questions, but most recommendations are based on relatively low levels of evidence and tend to comprise mostly consensus opinion. For the case definitions used to include patients into this study, the authors reference the International Working Group on the Diabetic Foot 2008 consensus statement. That this work was specifically looking at diabetic foot osteomyelitis is, in and of itself, demonstrative of the central premise of this work. Are criteria used to define osteomyelitis in the diabetic foot different from those in patients without diabetes? Should clear diagnostic criteria (was osteomyelitis diagnosed via positive bone culture, histopathology, changes on plain x-ray or magnetic resonance imaging, elevated erythrocyte sedimentation rate?) be required to define a case? The authors state that the frequency of peripheral arterial disease (PAD) was similar in both groups, yet the nondiabetes cohort was more frequently found to be smokers. The authors reference the relatively recent Society for Vascular Surgery “WIFI” consensus document to define PAD. These guidelines utilize not only ankle-brachial index but also ankle systolic pressure, toe pressures, and transcutaneous oximetry to stratify patients into 1 of 4 risk grades. Were any, or all, of these techniques used to diagnose PAD in this population? Is it possible that the cigarette smoking in the nondiabetic group led to microvascular disease of the toes that may not have been appreciated if only ankle-brachial index or ankle pressures were utilized? How is a cure defined other than “no further surgery being necessary”? This singular point is one of the reasons there are so few outcome studies on the treatment of osteomyelitis. No one can agree upon an end point! Is there a better definition of treatment failure, which the authors define as “unanticipated resection of additional bone from the initial area of infection or an above-ankle amputation because of ongoing infection”? It's not at all uncommon for patients with osteomyelitis, either with or without diabetes, to have to undergo serial bone debridements. This does not mean that the treatment is a “failure” but rather is part of the standard treatment. Likewise, it would be important to mention the length of treatment for each group. Do patients without diabetes require a longer or shorter course of therapy? The question of “how long to treat” is an important one and is usually based on radiographic studies, biomarkers, and clinical signs. Finally, given that the patient population was skewed toward older males because the study took place on the vascular service at a Veterans Administration Hospital (all but 2 patients were male, and only 20 subjects did not have diabetes), are these results generalizable across a broader population? It would be interesting to see if there were similar outcomes in future studies that included a more diverse demographics and a larger patient base. It was heartening to see the authors use oral antibiotics as their primary treatment regimen. Over the years, intravenous antibiotics have remained for many the perceived criterion standard for treating osteomyelitis. Many clinicians still doggedly cling to the notion that intravenous is superior to oral despite mounting evidence to the contrary. It is nice to see this timeworn dogma give way to an evidence-based approach. We look forward to more studies of this type and applaud the authors for taking the first step in answering the question: Are diabetic and nondiabetic foot osteomyelitis clinically distinct entities?

Evaluation of quality of life after implementation of a clinical decision support tool for guiding chronic opioid therapy in a veteran population

The VA system is the largest single provider of healthcare in the United States and to individuals infected with HIV specifically. High quality medication management is particularly important since HIV is a chronic infectious condition which requires taking multiple medications with strict requirements for adherence to medication regimens. Veterans Administration (VA) patients are required to obtain all chronic medications using the VA mail-order pharmacy system.Drawing on Donabedian's Quality Improvement framework, this study sought to examine experiences that Veterans with HIV have with the Veterans Administration medication mail-order system, and to explore opportunities for quality improvement.A sequential, explanatory mixed-methods design was used to interview Veterans receiving care at a Midwestern Veterans Administration Hospital using a mail-order experience survey followed by in-depth interviews. All 57 Veterans, out of 72, who were successfully contacted consented to participate.Overall, Veterans evaluated the mail-order service positively and valued the accuracy (correct medication delivery). However, a notable problem emerged with respect to assuring access to HIV medications with about half (47%) indicating running out of HIV medication. Respondents identified structural issues with respect to days covered by mailed medications (90 versus current 30 days) and process issues with scheduling new refills. Veterans also indicated the information sheets were too long, complex and not helpful for their queries. Patients were open to pharmacists playing an active role during clinic visits and felt this would help manage their conditions better.Veterans generally reported that the VA Mail-order service was of high quality. However, some findings indicate there are opportunities to improve this service to be more patient-centered particularly for vulnerable HIV patients.

Impact of a retrospective drug utilization review program on changing opioid prescribing behavior

The VA system is the largest single provider of healthcare in the United States and to individuals infected with HIV specifically. High quality medication management is particularly important since HIV is a chronic infectious condition which requires taking multiple medications with strict requirements for adherence to medication regimens. Veterans Administration (VA) patients are required to obtain all chronic medications using the VA mail-order pharmacy system.Drawing on Donabedian's Quality Improvement framework, this study sought to examine experiences that Veterans with HIV have with the Veterans Administration medication mail-order system, and to explore opportunities for quality improvement.A sequential, explanatory mixed-methods design was used to interview Veterans receiving care at a Midwestern Veterans Administration Hospital using a mail-order experience survey followed by in-depth interviews. All 57 Veterans, out of 72, who were successfully contacted consented to participate.Overall, Veterans evaluated the mail-order service positively and valued the accuracy (correct medication delivery). However, a notable problem emerged with respect to assuring access to HIV medications with about half (47%) indicating running out of HIV medication. Respondents identified structural issues with respect to days covered by mailed medications (90 versus current 30 days) and process issues with scheduling new refills. Veterans also indicated the information sheets were too long, complex and not helpful for their queries. Patients were open to pharmacists playing an active role during clinic visits and felt this would help manage their conditions better.Veterans generally reported that the VA Mail-order service was of high quality. However, some findings indicate there are opportunities to improve this service to be more patient-centered particularly for vulnerable HIV patients.

The secret sorrows of men: impact of Dynamic Interpersonal Therapy on ‘masculine depression’

Men are underrepresented among depression diagnoses, yet are more likely to engage in self-harm. Masculinities research has sought to better understand the mechanisms through which men may conceal or suppress depression, and has suggested that traditional diagnostic criteria may fail to recognize the many ways that gender may influence the presentation of negative affect. Ideals of hegemonic masculinity dominate military culture, making mental health treatment in a veterans’ hospital an ideal setting to work through the influence of rigid gender norms on interpersonal relationships. Relational therapy can be particularly useful to help some men reconstruct their sense of self in relation to their own rigid gender norms. Dynamic interpersonal therapy is a powerful therapeutic modality that can help men recognize and connect with parts of themselves that have been previously disowned. By giving voice to these more vulnerable affects, men may be freed up to connect to and communicate their own longing for care in relationships. We will present three case vignettes to illustrate this approach among American male veterans seeking psychotherapy at a Veterans Administration (VA) Hospital in New York City.

National Trends of Hospital Performance in Acute Myocardial Infarction Care: Department of Veterans Affairs, 2011-2014.

Rates of mortality and readmission, both within 30 days of an admission with an acute myocardial infarction (AMI), are key measures of hospital performance. A recent report demonstrated that Veterans Administration (VA) hospitals had lower AMI mortality but higher readmission rates at 30 days compared with Medicare fee for service hospitals from 2010 to 2013.1 Although this information provides an overall assessment of the quality of care provided, it is also important to understand facility-level and temporal variations of these performance metrics to inform ongoing quality improvement efforts. Accordingly, we sought to characterize contemporary facility-level variations (ie, variation across hospitals not explained by variation in patient risk) in 30-day risk-standardized mortality rates (RSMRs) and 30-day risk-standardized readmission rates (RSRRs) across the VA, to identify underperforming or overperforming sites, and to assess temporal variations in these metrics. Data from the VA External Peer Review Program, in which trained staff abstracted clinical data from comprehensive chart reviews, were linked with the VA Corporate Data Warehouse—a source of inpatient and outpatient administrative data inclusive of vital status. Patients who were admitted to a VA hospital from January 1, 2011, to February 28, 2014, and assigned an International Classification of Diseases, Ninth Revision: Clinical Modification diagnosis code of 410.xx irrespective of age were included. Those transferred into the VA system were excluded. If a patient had multiple AMIs in the study time period, 1 AMI was randomly chosen for inclusion in the study. Outcome measures of interest were 30-day all-cause mortality and 30-day unplanned, all-cause readmission. The latter included VA and non-VA hospital readmissions for which the VA was billed. Hospitals with <20 AMI admissions during the study period were excluded. To assess outcome variation across hospitals, hospital-specific RSMRs and RSRRs were estimated using hierarchical log-binomial regression models to account for the clustering …

Granular Cell Tumor: Report of 13 Cases in a Veterans Administration Hospital.

Granular cell tumors (GCTs) are of neuroectodermal origin and account for 0.5% of soft tissue tumors. They are most prevalent in African-Americans in the fourth to sixth decades, with a predilection for the head and neck regions. GCTs usually resemble more common lesions and hence are difficult to diagnose preoperatively. The tumor is readily identified on needle biopsy. Although usually benign with a malignancy rate of only 2-3%, the malignant form has a reported 3-yr mortality of 60%. Clinical records of the Gulf Coast Veterans Healthcare System were surveyed for the period 1996-2016. Thirteen cases of GCT were found and reviewed for demographics, clinical course, method of diagnosis, management, and outcome. All patients had a solitary GCT. Eleven lesions were benign and two were atypical. Sites involved were skin (8), colon (2), larynx (1), bronchus (1), and esophagus (1) (see Table I). The two atypical lesions occurred in the skin and larynx. Skin tumors were slow-growing, painful nodules, and, except for the two with preoperative needle biopsies, were misdiagnosed as epidermal inclusion cysts, lipoma, and papillary condyloma. Two colon lesions resembling a sessile polyp and submucosal lipoma, respectively, were found on colonoscopy performed for occult blood in the stool. The bleeding was attributed to adenomatous polyps also present. An atypical laryngeal GCT, found on laryngoscopy for hoarseness, was removed by submucosal resection. A bronchial GCT, excised during bronchoscopy for atelectasis, required re-excision 3 mo later. The esophageal GCT was an incidental finding on EGD for a dilated esophagus and gastric outlet obstruction. The patient declined surgical excision and elected MRI follow-up. Granular cell tumors are infrequent and usually resemble more common lesions. Although almost always benign, the malignant form has a very poor prognosis. It is important to identify GCT preoperatively by fine-needle aspiration or core needle biopsy to improve outcome.

The PRESERVE trial: does it guide prevention strategies for post angiography acute kidney injury?

The PRESERVE trial, recently published in the New England Journal of Medicine, is a prospective randomized trial conducted in 53 sites including United States Veterans Administration hospitals, and sites in Malaysia, Australia and New Zealand (1).

Improving Patient Safety Culture: A Report of a Multifaceted Intervention.

The aim of the study was to improve the safety culture at a Veterans Administration hospital using evidence-based approaches. We implemented a patient safety summit with follow-up actions. We measured safety climate before and after the summit using the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture with modifications and the Safety Attitudes Questionnaire (SAQ). The summit brought hospital leaders together to discuss patient safety topics and relate them to our hospital. At the summit's end, hospital workgroups collectively submitted Safety Culture Action forms, indicating their intended actions to improve safety culture. We analyzed all survey results using the χ2 test. We shared lessons learned. The hospital leadership started safety walk rounds. There were 107 hospital employees at the summit. Attendees submitted 53 Safety Culture Action forms. We received 232 AHRQ survey responses in 2014 and 116 in 2016, for response rates of approximately 11% and 8.9%, respectively. We received 140 SAQ responses (11%) from 1244 employees in 2016 and 242 responses (18%) from 1342 employees in 2017. The AHRQ survey results indicated that perception of teamwork within hospital units improved. The SAQ results indicated that employees' comfort with reporting errors and expressing disagreement with physicians improved, and employees' perceptions of leadership's safety efforts and the levels of staffing worsened. Although some aspects of safety culture improved after the summit and follow-up interventions, others did not. Future interventions should be targeted toward individual microsystems or units and measure safety climate perceptions for intervention recipients exclusively.

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

Pediatric Ophthalmology Fellowship Survey: Fellows Selection Criteria for Training Programs

Purpose This article investigates the characteristics that trainees look for in a pediatric ophthalmology fellowship program. Methods A 14-question anonymous survey was created and sent out via the United States Postal Service to all physicians of American Association of Pediatric Ophthalmology and Strabismus. The survey addressed demographics, the interview process, and the qualities of fellowship training programs that were important factors in ranking fellowship training programs. A Likert scale was used to rate different qualities (1: not important, 9: very important) and summary statistics were reported as overall means and standard deviations. Results In total, 1,061 were mailed out with 413 returned amounting to a 38.9% response rate. The qualities with the highest mean were diversity of surgical procedures, volume of procedures/surgeries, reputation of the fellowship director, advice from mentor, emphasis on type of surgery performed, program association with an academic institution, and national reputation of program. The characteristics that ranked the lowest were presence of a Veteran's Administration hospital and presence of a county hospital. Females rated proximity to family significantly higher than males. Among responders who ranked volume of procedures/surgeries as very important, strabismus surgery was the most important. Conclusion Pediatric ophthalmologists chose fellowship training programs based on the diversity and surgical volume of procedures and the reputation of the program director.

Extended models for nosocomial infection: parameter estimation and model selection.

We consider extensions to previous models for patient level nosocomial infection in several ways, provide a specification of the likelihoods for these new models, specify new update steps required for stochastic integration, and provide programs that implement these methods to obtain parameter estimates and model choice statistics. Previous susceptible-infected models are extended to allow for a latent period between initial exposure to the pathogen and the patient becoming themselves infectious, and the possibility of decolonization. We allow for multiple facilities, such as acute care hospitals or long-term care facilities and nursing homes, and for multiple units or wards within a facility. Patient transfers between units and facilities are tracked and accounted for in the models so that direct importation of a colonized individual from one facility or unit to another might be inferred. We allow for constant transmission rates, rates that depend on the number of colonized individuals in a unit or facility, or rates that depend on the proportion of colonized individuals. Statistical analysis is done in a Bayesian framework using Markov chain Monte Carlo methods to obtain a sample of parameter values from their joint posterior distribution. Cross validation, deviance information criterion and widely applicable information criterion approaches to model choice fit very naturally into this framework and we have implemented all three. We illustrate our methods by considering model selection issues and parameter estimation for data on methicilin-resistant Staphylococcus aureus surveillance tests over 1 year at a Veterans Administration hospital comprising seven wards.

The Effect of Mindfulness and Acupuncture on Psychological Health in Veterans: an Exploratory Study

iRest Yoga Nidra® is a guided mindfulness approach that encourages relaxation, focused attention, experience of joy, observation of opposite feelings and emotions, non-judgment, and integration of these principles into daily life. iRest was developed for the military population, but the research on its effectiveness is in its infancy. This exploratory study examined the effectiveness of iRest in combination with acupuncture compared to acupuncture alone in improving psychological health in Veterans. The combined treatment yielded significant psychological benefit in depression, psychological symptom severity, depression or tension due to pain, and emotional interference with life activities, while the acupuncture-only treatment did not. Although both conditions showed significant decreases in perceived stress, the effect size for the treatment group was medium to large compared to a small effect size for those receiving acupuncture only. The combined treatment condition, iRest plus acupuncture, also demonstrated clinically meaningful change, with significant decreases in the number of Veterans meeting criteria for mild, moderate, and severe depression. Finally, the combined treatment was equally beneficial independent of factors such as age, gender, or race. Given the pervasiveness of psychological distress and depression in the Veteran population and the efficiency with which these group treatments can be provided, these findings lend preliminary support for the extension of complementary and integrative health offerings including iRest and acupuncture into more Veterans Administration hospitals across the country to improve military mental health. Indeed, the encouraging results of this exploratory study underscore the importance of expanded research on iRest and acupuncture for the treatment of psychological health.