Veterans Affairs New Research Articles

Implementation of relative phase analysis to evaluate continuous interlimb coordination and stability in individuals with lower limb loss: Design and protocol for a retrospective analysis

IntroductionThe number of people with lower limb loss continues to grow, though most research to date has been non-committal and lacks the appropriate clinical guidance required for proper prosthetic prescription....

Atypical jobs in psychology: Interview of Dr. Donna Rasin-Waters.

This article provides an overview of Dr. Donna Rasin-Waters' career path and experiences providing telehealth at the Brooklyn Campus of the Veterans Affairs New York Harbor Healthcare Systems. Dr. Rasin-Waters, a psychologist and neuropsychologist with a specialty in geropsychology, began working toward the provision of evidence-based therapy via telehealth for Veterans in 2010. She believed that, in addition to rural communities, telehealth held utility for Veterans in densely populated areas, particularly for elderly adults with limited means for transportation. Since the COVID-19 pandemic, Dr. Rasin-Waters has seen a rapid boom in the use of telehealth for a variety of clinical activities with Veterans. This has further brought to light promising implications for the provision of remote mental health services, as well as important telehealth training and cultural considerations for clinicians. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Perceptions and Use of Telehealth Among Mental Health, Primary, and Specialty Care Clinicians During the COVID-19 Pandemic

Clinician attitudes toward telehealth may impact utilization rates, and findings may differ based on specialty. To determine whether clinician beliefs regarding telehealth quality and ease of use were associated with the proportion of care delivered via video, phone, and in-person across specialties. This survey study used a voluntary, anonymous survey conducted from August to September 2021 in the Department of Veterans Affairs New England Healthcare System (VANEHS). Mental health (MH), primary care (PC), and specialty care (SC) clinicians were invited to participate. Data were analyzed from October 2021 to January 2022. Participation in a 32-item survey. The main outcomes were clinicians' views on relative quality of video, phone, and in-person care; factors contributing to clinicians' modality choice; telehealth challenges; and clinician modality preferences and utilization when treating new and established patients. There were 866 survey respondents (estimated 64% response rate); 52 respondents reported no video or phone telehealth use in the 3 months prior to survey completion and were excluded, resulting in a final sample of 814 respondents. Respondents were divided among MH (403 respondents [49.5%]), PC (153 respondents [18.8%]), and SC (258 respondents [31.7%]). Compared with PC and SC clinicians, MH clinicians rated the quality of video care the highest (eg, compared with in-person care with masks when treating new patients: χ2 = 147.8; P < .001) and were more likely to prefer video over phone when treating both new (χ2 = 26.6; P < .001) and established (χ2 = 100.4; P < .001) patients remotely. PC and SC clinicians were more likely to rate phone care as being at least equivalent in quality to video for both new (χ2 = 26.3; P < .001) and established (χ2 = 33.5; P < .001) patients. PC and SC clinicians were also more likely to endorse challenges of video care, including patient barriers and the inability to conduct a physical examination (χ2 = 292.0; P < .001). Most PC and SC clinicians either had no preference (46 PC respondents [36.2%]; 59 SC respondents [28.4%]) or preferred phone (36 PC respondents [28.3%]; 67 SC respondents [32.2%]) for remote care of established patients. Findings aligned with utilization rates within VANEHS, with MH clinicians conducting significantly more of their encounters via video (36 734 encounters [40.3%]) than PC (3201 encounters [3.9%]) and SC (1157 encounters [4.9%]) clinicians. These findings suggest that clinician attitudes regarding telehealth quality and ease of use were associated with utilization rates. Moving forward, clinician use of telehealth may be impacted by additional data regarding the relative effectiveness of modalities as well as improvements in video telehealth workflows.

Metformin Use Is Inversely Associated with Prevalent, but Not Incident Colorectal Adenomas.

Chemoprevention for colorectal neoplasia has attracted growing interest, with multiple medications investigated. Metformin may decrease the overall incidence of cancer in patients with diabetes and may decrease the incidence of colorectal cancer. We aimed to determine the impact of metformin use on the behavior of colorectal adenomas in a US veteran population. All patients with at least two high-quality colonoscopies between January 1997 and December 2013 at Veterans Affairs New York Harbor Healthcare System were identified. Outpatient prescription records were used to determine metformin exposure, and colonoscopy findings were recorded. Multivariable logistic regression was used to determine factors associated with adenoma detection on baseline and interval colonoscopy. In total, 1869 patients with two successive colonoscopies (median 4.5years) were included. Four hundred and sixty patients had metformin exposure prior to baseline and/or interval colonoscopy. Overall adenoma detection rate was 59.7% at baseline and 45.9% at interval colonoscopy. On multivariable analysis, metformin use was associated with decreased adenoma prevalence at baseline (OR 0.68; 95% CI 0.51-0.92; p = 0.015). Metformin did not impact adenoma incidence at interval colonoscopy whether prescribed before baseline (OR 1.26; 95% CI 0.60-2.67), after baseline (OR 1.25; 95% CI 0.91-1.72), or before and after baseline (OR 1.14; 95% CI 0.82-1.58). In this retrospective analysis of an average-risk cohort, metformin use was associated with a decreased prevalence of colorectal adenomas at baseline colonoscopy. This inverse association did not persist on interval colonoscopy. Prospective studies are needed to evaluate potential chemoprotective effects of metformin over time.

Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology.

Voiding Function and Dysfunction, Bladder Physiology and Pharmacology, and Female Urology.

Impact of Fellow Participation During Colonoscopy on Adenoma Detection Rates.

An endoscopist's adenoma detection rate (ADR) is inversely related to interval colorectal cancer risk and cancer mortality. Previous studies evaluating the impact of gastroenterology fellow participation in colonoscopy on ADR have generated conflicting results. We aimed to determine the impact of fellow participation, duration of fellowship training, and physician sex on ADR and advanced ADR (AADR). We retrospectively analyzed average-risk patients undergoing screening colonoscopy at Veterans Affairs New York Harbor Healthcare System Brooklyn Campus and Kings County Hospital Center. Review of colonoscopy and pathology reports were performed to obtain adenoma-specific details, including the presence of advanced adenoma and adenoma location (right vs. left colon). There were 893 colonoscopies performed by attending only and 502 performed with fellow participation. Fellow participation improved overall ADR (44.6% vs. 35.4%, p < 0.001), right-sided ADR (34.1% vs. 25.2%, p < 0.001), and AADR (15.3% vs. 8.3%, p < 0.001); however, these findings were institution-specific. Year of fellowship training did not impact overall ADR or overall AADR, but did significantly improve right-sided AADR (p-value for trend 0.03). Female attending physicians were associated with increased ADR (47.1% vs. 37.0%, p = 0.0037). Fellow sex did not impact ADR. Fellow participation in colonoscopy improved overall ADR and AADR, and female attending physicians were associated with improved ADR. Year of fellowship training did not impact overall ADR or AADR.

Simulation-Based Up-Training in Response to the COVID-19 Pandemic

The dramatic outbreak of COVID-19 placed unprecedented strain on the critical care workforce of New York City. The enhanced precautions required to safely care for COVID-19 patients impacted the performance of even routine critical care procedures. Meanwhile, staff were stretched to care for exponentially rising case volume as COVID intensive care units (ICUs) expanded. Simulation was used to bridge these gaps-first to familiarize personnel within the Division of Pulmonary and Critical Care with revised COVID-19 care procedures, then to orient noncritical care clinicians volunteering from other specialties for COVID ICU deployment to general critical care and COVID-19 care principles. Using mannequin-based simulation scenarios followed by comprehensive debriefing sessions, simulation participants received high-intensity, high-fidelity training in respiratory failure, circulatory failure, bedside ultrasound, bedside ICU procedures, and elements of COVID-19-specific care. More than 200 physicians and advanced practice practitioners completed simulation training in preparation for deployment, supplementing and enhancing the ICU workforce at a decisive time during the outbreak.

Type 2 Diabetes Predicts Increased Risk of Neurodegenerative Complications in Veterans Suffering Traumatic Brain Injury.

Obese type 2 diabetes and traumatic brain injury are associated with persistent peripheral and neuro-inflammation, respectively. We tested whether adult type 2 diabetes increased the hazard rate for neurodegeneration complications following traumatic brain injury. Retrospective chart review of patients treated at the Veterans Affairs New Jersey Healthcare System between 2016-2019 and having a diagnosis of prior traumatic brain injury was performed in adult veterans, age 50 years or older. Cox proportional hazards regression analysis was used to identify risk factors predictive of an increased risk of neurodegeneration, i.e. worsening major depression, dementia or Parkinson's disease following traumatic brain injury. Type 2 diabetes predicted a nearly three-fold increased hazard ratio (HR = 2.95, 95% CI 1.15-7.56, P =0.02) for the occurrence of worsening major depression, dementia or Parkinson's disease in eighty adults age 50 years or older who had experienced prior traumatic brain injury. After adjusting for other covariates, hypertension (HR= 4.15, 95% CI 1.21-14.29, P =0.02) was significant and body mass index (HR=1.14, 95% CI 0.99-1.30; P=0.06) modestly significant predictors of the risk for the time to first occurrence of the composite neurodegenerative outcome. Type 2 diabetes, hypertension and higher body mass index increase the hazard for the occurrence of worsening depression, Parkinson's disease and dementia following traumatic brain injury in middle-aged and older adults.

Peer to Peer observation: real-world faculty development.

Medical EducationVolume 53, Issue 5 p. 513-514 Really Good Stuff: Lessons learned through innovation in medical education Peer to Peer observation: real-world faculty development Neil Shapiro, Corresponding Author Neil Shapiro Neil.shapiro@va.gov Correspondence: Neil Shapiro, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Room 11103 South, New York, New York 10010, USA. Tel: 00 1 212 686 7500; E-mail: Neil.shapiro@va.govSearch for more papers by this authorMichael Janjigian, Michael JanjigianSearch for more papers by this authorVerity Schaye, Verity Schaye orcid.org/0000-0003-0816-4037 Search for more papers by this authorKevin Hauck, Kevin HauckSearch for more papers by this authorDaniel Becker, Daniel BeckerSearch for more papers by this authorPenelope Lusk, Penelope Lusk orcid.org/0000-0001-6202-9376 Search for more papers by this authorAnne Dembitzer, Anne DembitzerSearch for more papers by this author Neil Shapiro, Corresponding Author Neil Shapiro Neil.shapiro@va.gov Correspondence: Neil Shapiro, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Room 11103 South, New York, New York 10010, USA. Tel: 00 1 212 686 7500; E-mail: Neil.shapiro@va.govSearch for more papers by this authorMichael Janjigian, Michael JanjigianSearch for more papers by this authorVerity Schaye, Verity Schaye orcid.org/0000-0003-0816-4037 Search for more papers by this authorKevin Hauck, Kevin HauckSearch for more papers by this authorDaniel Becker, Daniel BeckerSearch for more papers by this authorPenelope Lusk, Penelope Lusk orcid.org/0000-0001-6202-9376 Search for more papers by this authorAnne Dembitzer, Anne DembitzerSearch for more papers by this author First published: 15 April 2019 https://doi.org/10.1111/medu.13865Citations: 4Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume53, Issue5May 2019Pages 513-514 RelatedInformation

Financial IncEntives for Smoking TreAtment: protocol of the FIESTA trial and FIESTA Oral Microbiome Substudy

BackgroundSmoking is the leading preventable cause of death in the United States, but evidence-based smoking cessation therapy is underutilized. Financial incentive strategies represent an innovative approach for increasing the use of counseling and pharmacotherapy. If effective, they could supplement or supplant resource-intensive policy options, particularly in populations for whom smoking has substantial societal costs. FIESTA (Financial IncEntives for Smoking TreAtment) will randomize hospitalized smokers to receive usual smoking cessation care alone or usual smoking care augmented with financial incentives. We aim to compare the impact of these two strategies on 1) smoking abstinence, 2) use of counseling and nicotine replacement therapy, and 3) quality of life of participants. We also will evaluate the short-term and long-term return on the investment of incentives. The FIESTA Oral Microbiome Substudy will compare the oral microbiome of smokers and nonsmokers to longitudinally assess whether smoking cessation changes oral microbiome composition.MethodsWe will enroll 182 inpatient participants from the Manhattan campus of the Veterans Affairs New York Harbor Healthcare System. All participants receive enhanced usual care, including screening for tobacco use, counseling while hospitalized, access to nicotine replacement therapy, and referral to a state Quitline. Patients in the financial incentive arm receive enhanced usual care and up to $550 for participating in the New York Smoker’s Quitline, using nicotine replacement therapy (NRT), and achieving biochemically confirmed smoking cessation at 2 months and 6 months. In the microbiome substudy, we enroll nonsmoking control participants matched to each recruited smoker’s hospital ward, sex, age, diabetes status, and antibiotic use. After discharge, participants are asked to complete periodic phone interviews at 2 weeks, 2 months, 6 months, and 12 months and provide expired carbon monoxide and saliva samples at 2 months, 6 months, and 12 months for cotinine testing and oral microbiome analysis.DiscussionThe incentive interventions of FIESTA may benefit hospitalized smokers, an objective made all the more critical because smoking rates among hospitalized patients are higher than those in the general population. Moreover, the focus of FIESTA on evidence-based therapy and bioconfirmed smoking cessation can help guide policy efforts to reduce smoking-related healthcare costs in populations with high rates of tobacco use and costly illnesses.Trial registrationClinicalTrials.gov, NCT02506829. Registered on 1 July 2014.

Assessing the Impact of Metformin Use on Colonic Polyp Behavior

Introduction: Colorectal cancer (CRC) is the third most common cancer worldwide. Age-appropriate CRC screening with colonoscopy provides two benefits: (1) early cancer detection; and (2) resection of premalignant colonic polyps. The principle of cancer chemoprophylaxis has been proposed as a possible synergistic approach to endoscopic colon cancer prevention. Patients with diabetes mellitus (DM) are at increased risk of CRC, compared to non-diabetics. Metformin, one of the most commonly used therapeutic agents used to treat type 2 DM has previously been studied as a potential chemoprophylactic agent against CRC, however, the results have been mixed. We investigate the impact of metformin use on the behavior of colonic polyp generation in a veteran population. Methods: We performed a retrospective observational study. Included were average-risk patients with at least two documented screening colonoscopies between 1997 and 2013 at the Veterans Affairs New York Harbor Healthcare System. Exclusion criteria were: family history of CRC; personal history of IBD; personal or family history of polyposis syndromes. Patient demographics (age, sex, race, ethnicity, body mass index) and colon polyp-specific data (number, histology, largest size) were collected via chart review. Comparative statistics were performed. Results: 1,344 patients were included in our analyses (190 had prescription for metformin prior to their index colonoscopy, 1,154 were non-users). Mean follow-up was 6.9 vs. 7.2 years, respectively. Baseline demographic characteristics are summarized in Table 1. At index colonoscopy, metformin users had fewer adenomatous polyps compared to non-users 1.16 vs. 1.68 (p = 0.0046). In follow-up, however, metformin users had a statistically significant a higher per-annum rate of adenoma generation 0.36 vs. 0.25 as well as higher per-annum rates of high-risk adenoma generation (defined as villous histology, high-grade dysplasia, and/or size > 1 cm). Conclusion: While metformin appeared to be protective against adenomatous polyps at time of index colonoscopy, metformin users demonstrated higher rates of per-annum adenoma generation, including high-risk adenomas. There were no differences in sessile serrated polyp generation at baseline or in follow-up. The effect of metformin use on colon polyp behavior should be further investigated with specific aim of assessing impact of timing of drug exposure on colon cancer chemoprophylaxis.248_A Figure 1 No Caption available.248_B Figure 2 No Caption available.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England.

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Improving Family Meetings in Intensive Care Units: A Quality Improvement Curriculum.

Family meetings in the intensive care unit are associated with beneficial outcomes for patients, their families, and health care systems, yet these meetings often do not occur in a timely, effective, reliable way. The Department of Veterans Affairs Comprehensive End-of-Life Care Implementation Center sponsored a national initiative to improve family meetings in Veterans Affairs intensive care units across the United States. Process measures of success for the initiative were identified, including development of a curriculum to support facility-based quality improvement projects to implement high-quality family meetings. Identified curriculum requirements included suitability for distance learning and applicability to many clinical intensive care units. Curriculum modules were cross-mapped to the "Plan-Do-Study-Act" model to aid in planning quality improvement projects. A questionnaire was e-mailed to users to evaluate the curriculum's effectiveness. Users rated the curriculum's effectiveness in supporting and achieving aims of the initiative as 3.6 on a scale of 0 (not effective) to 4 (very effective). Users adapted the curriculum to meet local needs. The number of users increased from 6 to 17 quality improvement teams in 2 years. All but 3 teams progressed to implementation of an action plan. Users were satisfied with the effectiveness and adaptability of a family-meeting quality improvement curriculum to support implementation of a quality improvement project in Veterans Affairs intensive care units. This tool may be useful in facilitating projects to improve the quality of family meetings in other intensive care units.

Personal and professional challenges confronted by hospital staff following hurricane sandy: a qualitative assessment of management perspectives.

BackgroundAdequate hospital staffing during and after a disaster is critical to meet increased health care demands and to ensure continuity of care and patient safety. However, when a disaster occurs, staff may become both victim and responder, decreasing their ability and willingness to report for work. This qualitative study assessed the personal and professional challenges that affected staff decisions to report to work following a natural disaster and examined the role of management in addressing staff needs and concerns.MethodsSemi-structured interviews were conducted with individuals who filled key management roles in the United States Department of Veterans Affairs New York Harbor Healthcare System’s response to Superstorm Sandy and during the facility’s initial recovery phase. All interviews were audio recorded and transcribed. Three major themes were identified: 1) Barriers to reporting (“Barriers”), 2) Facilitators to reporting (“Facilitators”), and 3) Responses to staff needs and concerns (“Responses”). Atlas.ti 7.1.6 software program was used for the management and analysis of the transcripts.ResultsResults indicated that staff encountered several barriers that impeded their ability to report to work at mobile vans at the temporarily nonoperational Manhattan campus or at two other VA facilities in Brooklyn and the Bronx in the initial post-Sandy period including transportation problems, personal property damage, and communication issues. In addition, we found evidence of facilitators to reporting as expressed through descriptions of professional duty. Our findings also revealed that management was aware of the challenges that staff was facing and made efforts to reduce barriers and accommodate staff affected by the storm.ConclusionsDuring and after a disaster event, hospital staff is often confronted with challenges that affect decisions to report for work and perform effectively under potentially harsh conditions. This study examined barriers and facilitators that hospital staff encountered following a major natural disaster from the management perspective. Insights gained from this study can be used to inform future disaster planning and preparedness efforts, and help ensure that there is adequate staffing to mount an effective response when a disaster occurs, and to recover from its aftermath.

Off to a good start.

Medical EducationVolume 49, Issue 5 p. 514-514 Really Good Stuff Off to a good start Ann Danoff, Corresponding Author Ann DanoffCorrespondence: Ann Danoff, Endocrinology Unit, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, New York, New York 10010, USA. Tel: 00 1 212 263 8060; E-mail: ann.danoff@nyumc.orgSearch for more papers by this authorMichael Garabedian, Michael GarabedianSearch for more papers by this authorVictoria Harnik, Victoria HarnikSearch for more papers by this authorMelvin Rosenthal, Melvin RosenthalSearch for more papers by this author Ann Danoff, Corresponding Author Ann DanoffCorrespondence: Ann Danoff, Endocrinology Unit, Department of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, New York, New York 10010, USA. Tel: 00 1 212 263 8060; E-mail: ann.danoff@nyumc.orgSearch for more papers by this authorMichael Garabedian, Michael GarabedianSearch for more papers by this authorVictoria Harnik, Victoria HarnikSearch for more papers by this authorMelvin Rosenthal, Melvin RosenthalSearch for more papers by this author First published: 28 April 2015 https://doi.org/10.1111/medu.12700Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume49, Issue5May 2015Pages 514-514 RelatedInformation

Panel Management to Improve Smoking and Hypertension Outcomes by VA Primary Care Teams: A Cluster-Randomized Controlled Trial.

Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice. We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education. We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans. Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans. Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone. Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services. Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95% CI 1.2-1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95% CI 1.1-1.6) and Telehealth (OR = 1.7, 95% CI 1.4-2.1) than patients on control teams. Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

VA Facility Upgrades Continuity of Mental Health Care

The beneficial effects of postdischarge follow-up after inpatient hospitalizations have been documented, as has increased recidivism from lack of such care after discharge. Using this literature for evidence-based research, this article discusses a system-wide postdischarge initiative at the Veterans Affairs New York Harbor Healthcare System to improve con-tinuity of care.

Defining, assessing, and certifying procedural competency in endocrinology, diabetes, and metabolism.

Division of Endocrinology, Diabetes, and Metabolism (P.W.L.), Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; Division of Diabetes, Endocrinology, and Metabolism (A.B.), Baylor College of Medicine, Houston, Texas 77030; Division of Endocrinology (A.D.), Veterans Affairs New York Harbor Health Care System and New York University Langone Medical Center, New York, New York 10016; and Research Program in Men’s Health: Aging and Metabolism (S.B.), Brigham and Women’s Hospital, Boston, Massachusetts 02115

Characteristics, Treatment, and Outcomes Associated with &amp;lt;i&amp;gt;Clostridium difficile&amp;lt;/i&amp;gt; Associated Diarrhea in a Veterans Affairs Medical Center

We conducted a study to assess the characteristics, treatment and outcomes associated with Clostridium difficile associated diarrhea in a Veterans Affairs Medical Center. Fifty-eight consecutive individual cases of C. difficile infection in 2013 were observed within the Veterans Affairs New Jersey Health Care System (VA NJHCS). We molecularly typed all 58 individual strains and identified the associated characteristics, treatment and outcomes. Forty-four out of 58 specimens (76%) which were probed had characteristics of the epidemic strain BI/NAP1/027 making this virulent strain to be the predominate strain at the VA NJHCS. All C. difficile BI/NAP1/027 strains were resistant to fluoroquinolones and sensitive to fidaxomicin, metronidazole and vancomycin. Fidaxomicin had the most potent in vitro activity (MIC90 = 0.5 μg/ml) against the BI/NAP1/027 strain. Twenty-six of 44 patients (59%) with the virulent strain were from a long-term care facility (LTCF). Patients possessing the virulent strain from the LTCF had a mean APACHE II score of 14.1 and a predicted death rate of 21.9%. Two-third of patients were treated with metronidazole alone (mean APACHE II scores 9.6), and one-third required oral vancomycin and metronidazole (mean APACHE II scores 14.1). There were no C. difficile infection related deaths. C. difficile BI/NAP1/027, an epidemic strain, is the endemic strain at the VA NJHCS, but no increased mortality was seen with infection with this strain.

Research on Homeless Vets Suggests Ways to Target Services Based on Risk Factors

FEAR THAT US VETERANS RETURNING from Iraq and Afghanistan would be disproportionately affected by homelessness because of posttraumatic stress disorder (PTSD) and blast-related injuriesmaybemisplaced,suggestedStephen Metraux, PhD, associate professor of health policy and public health at the UniversityoftheSciencesinPhiladelphia. Metraux spoke in an April webcast on homelessnessamongveteranssponsored bytheSubstanceAbuseandMentalHealth Administration (SAMHSA). Rather, evidence suggests that poverty, substance abuse, and mental illness—the same factors that drive homelessness in the general population— may pose greater risks to veterans than the so-called signature injuries of the wars in Iraq and Afghanistan. Metrauxisamongagroupofresearchers tryingtobetterunderstandthecauses ofhomelessnessamongveterans inorder to prevent the problem and to better tailorservicestoveteransfacingit.Theirfindings so far offer some surprises. For example,womenveteransarenotathigher riskofhomelessness than theirmalecolleagues,butwhentheydofacehomelessness, they have unique needs stemming fromahighlikelihoodofhavingchildren or having experienced sexual trauma. Metrauxandcolleaguesanalyzeddata from the Department of Defense and the DepartmentofVeteransAffairs(VA)and foundthatofveteransdischargedbetween July 1, 2005, and September 30, 2006, 1.8%(5694of310 685)hadrecordsofreceivinghomelessservices.“It’saboutwhat you’d expect in the general population,” he said. “It’s not consistent with some of thealarmist languagepeoplehaveused.” Veterans who had been deployed to Iraq or Afghanistan did have a somewhat higher risk of homelessness (odds ratio [OR]=1.3), and PTSD was associated with a higher risk of homelessness only among veterans who were deployed (OR=1.2 among male veterans and OR=1.6 among female veterans), according to research presented by Metraux. Still, a veteran’s pay grade prior to discharge appears to be a better predictor of the risk of homelessness, with individuals in the lowest pay grade making up 44% of this cohort of veterans but 72% of the homeless group. Individuals with behavioral health problems made up 17.8% of the discharge cohort but made up 44% of the homeless group. “We hope this represents the beginning steps of developing a system to identify persons at risk,” said Metraux. Although female veterans are not at greater risk of homelessness than their male colleagues, they are at greater risk of homelessness than nonveteran women. Additionally, women veterans appear to have their own set of risk factors for homelessness. For example, sexual trauma is a greater risk factor for homelessness among women than men, said Jack Tsai, PhD, an investigator for the Veterans Affairs New England Mental Illness Research, Education, and Clinical Center and an assistant professor of psychiatry at Yale University.