Water Infusion vs Air Insufflation During Colonoscopy in a Veteran Population

Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. 06/06/09. BACKGROUND: Intermittent warm-water infusion in lieu of air insufflation permitted 52% of patients who accepted sedation on demand to complete colonoscopy without sedation. OBJECTIVE: To test the hypothesis that the water method enhances cecal intubation and increases the proportion of patients who report willingness to repeat a scheduled unsedated colonoscopy. DESIGN: Observational study. PATIENTS: Two consecutive groups of veterans. INTERVENTIONS: From June 2005 to May 2006, the usual air insufflation method was used to aid colonoscope insertion. From June 2006 to October 2007, the water method was used. MAIN OUTCOME MEASUREMENTS: Cecal intubation; report of willingness to repeat unsedated colonoscopy. RESULTS: Sixty-two and 63 veterans were examined by the air method and the water method, respectively. Intention-to-treat analysis revealed that the cecal intubation rate with the water method (97% [61/63]) was significantly higher than that with the air method (76% [47/62]). The proportion of patients who reported willingness to repeat unsedated colonoscopy was significantly higher with the water method (90% [57/63]) compared with the air method (69% [43/62]). LIMITATIONS: Single site, nonrandomized, unblinded, small number of elderly male veterans. CONCLUSION: The effects of the water method in the group for scheduled unsedated colonoscopy were sufficiently provocative to warrant calling for their confirmation by a randomized controlled trial. Gastrointestinal Endoscopy via PubMed

Hearing Loss in Veterans

Hearing loss in veterans and the need for hearing loss prevention programs. 06/06/09. Currently, there are more than 445,000 veterans receiving compensation for hearing loss associated with military service, and 395,000 receiving compensation for service-related tinnitus. In addition to compensation payments, service-related hearing disorders cost the US Department of Veterans Affairs in terms of provision of hearing aids, hearing aid-related services, and clinical services at its 220 facilities nationwide. It is imperative that hearing conservation among military personnel and veterans be addressed. In this paper, we describe the rationale for and the development of a multimedia Hearing Loss Prevention Program aimed at preventing the progression of hearing loss among veterans associated with social, recreational, and nonmilitary occupational noise exposure. The program was developed based on the principles outlined in the Health Belief Model of Rosenstock (1966) and the Health Promotion Model of Pender et al. (2002). Noise & Health via PubMed

VA-DARPA Arm: A New Robotic Prosthesis

VA-DARPA Arm Clinical Trial Covered in The Washington Post 06/06/09. Last week, VA announced the start of a three-year clinical trial that represents the first large-scale testing of the "DARPA" arm, developed by Deka Research and Development, which undertook the project 30 months ago as part of a $100 million program to revolutionize prosthetics sponsored by the Pentagon's Defense Advanced Research Projects Agency (DARPA). The clinical trial is a critical step before the device can be made widely available. The first patient was fitted with an arm in April.

The robotic prosthesis provides a groundbreaking new range of movement and mobility, and is designed for those who have lost a limb up to their shoulder joint. Dr. Joel Kupersmith, VA's chief research and development officer, was recently quoted in The Washington Post as describing the prosthesis as being "light years closer to a real arm", and also noted that work developing effective devices for arm replacement is more difficult due to the refined movement associated with the hand, elbow, and shoulder.More about the DARPA arm and the VA's clinical trial is described in the May issue of Research Currents, as well as in the June 3 issue of The Washington Post. VA Office of Research & Development

Suicides Amongst Incarcerated Veterans

Suicide among incarcerated veterans. 06/03/09. Both veterans and jail/prison inmates face an increased risk of suicide. The incarcerated veteran sits at the intersection of these two groups, yet little is known about this subpopulation, particularly its risk of suicide. A Pubmed/Medline/PsycINFO search anchored to incarcerated veteran suicide, veteran suicide, suicide in jails/prisons, and veterans incarcerated from 2000 to the present was performed. The currently available literature does not reveal the suicide risk of incarcerated veterans, nor does it enable meaningful estimates. However, striking similarities and overlapping characteristics link the data on veteran suicide, inmate suicide, and incarcerated veterans, suggesting that the veteran in jail or prison faces a level of suicide risk beyond that conferred by either veteran status or incarceration alone. There is a clear need for a better characterization of the incarcerated veteran population and the suicide rate faced by this group. Implications for clinical practice and future research are offered. The Journal of the American Academy of Psychiatry and the Law via PubMed

Suicide and incarcerated veterans--don't wait for the numbers. 06/03/09. Using indirect evidence, Wortzel and his colleagues raise the likelihood that the rates of suicide will increase among incarcerated veterans, given past trends and current information about veterans returning from Iraq and Afghanistan. Although it might be argued that the data are inadequate for the formulation of public policy, there is sufficient information to begin creating programs for veterans now. Wortzel and colleagues suggest screening in jails to identify veterans at risk, with increased monitoring in the first weeks of incarceration, and use of the Critical Time Intervention during important transitions. While these recommendations are worthy, a better understanding of the factors associated with suicidality may help policy-makers to support programs for returning veterans before they develop the serious problems that can lead to suicide. Also promising is the Substance Abuse and Mental Health Administration's recent funding of six jail diversion programs with a focus on veterans. The Journal of the American Academy of Psychiatry and the Law via PubMed

Quality of Life in Post-TBI Veterans

A review of health-related quality of life in adult traumatic brain injury survivors in the context of combat veterans. 06/03/09. Health-related quality of life (HRQOL) research in traumatic brain injury (TBI) populations is beginning to emerge in the literature. Because rehabilitation and reintegration issues are complex with TBI, especially with new combat veterans, it is critical that future HRQOL research be designed to consider these issues. Utilizing explicit definitions and a conceptual model of HRQOL can provide researchers with a holistic base on which to build interventions for successful patient outcomes. The conceptual model of HRQOL of C.E. Ferrans, J.J. Zerwic, J.E. Wilbur, and J.L. Larson (2005) is an exemplar model that presents clear definitions and encompasses domains of HRQOL relevant to TBI survivors and their families. This review was organized utilizing the model of HRQOL of Ferrans et al. The objective of this review was to identify gaps in current knowledge of HRQOL and TBI. These findings were then used to develop recommendations for future research with combat veterans who have sustained a TBI. Journal of Neuroscience Nursing via PubMed

Sleep Experience of Caregivers for Veterans Post-stroke

Subjective sleep, burden, depression, and general health among caregivers of veterans poststroke. 06/03/09. The purposes of this article are to explore and describe subjective sleep experiences of informal caregivers of stroke survivors and to explore the relationships between subjective sleep experiences, caregiver burden, depression, and health to provide a broader portrait of the role that sleep plays in the stroke caregiving experience. A total of 276 caregivers and veterans participated in the study. Results indicate a greater risk of depression (Center for Epidemiologic Studies-Depression Scale) among caregivers who sleep less, have difficulty achieving daytime enthusiasm, use sleep medications, and have poor sleep quality. Caregivers who sleep less have difficulty achieving daytime enthusiasm and are at greater risk of poor health. Greater caregiver burden was associated with less sleep and use of sleep medications. This descriptive analysis demonstrates the important relationship between sleep, depression, health, and burden and can lead to interventions to diagnose and treat sleep difficulties in caregivers. Journal of Neuroscience Nursing

ORD Guidance on Pregnancy in Human Subject Research 06/03/09. The VHA Office of Research and Development (ORD) has received questions from drug companies and investigators about collecting information on pregnant females when they are study subjects, study subjects who have withdrawn from the study, or pregnant partners of male research subjects. The issue of pregnancy and the use of Pregnancy Category C drugs is important. Many prescription and over-the-counter drugs marketed drug for use in clinical care are labeled as Pregnancy Category C by the FDA.* When Category C drugs are administered to women enrolled in research studies, the information collection must be part of the study and the women must remain in the study while the information is collected. VA Office of Research & Development

5 New VAOIG Reviews

Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center Albany, New York 06/03/09. The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 199 employees. The review covered eight operational activities. The medical center complied with selected standards in the following two activities (1) contracted/agency registered nurses and (2) survey of healthcare experiences of patients. We identified early suicide risk detection, a new employee orientation initiative, and Schwartz Center rounds as organizational strengths. We made recommendations for improvement in the following six activities: QM program. Emergency/urgent care operations. Coordination of care. Environment of care. Suicide prevention program. Medication management. VAOIG

Combined Assessment Program Review of the VA Illiana Health Care System Danville, Illinois 06/03/09. The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 403 employees. The review covered seven operational activities. The system complied with selected standards in the following two activities (1) medication management, and (2) survey of healthcare experiences of patients. We identified the system’s recognition by the National Center for Patient Safety as an organizational strength. We made recommendations for improvement in the following five activities: QM program. Environment of care. Coordination of care. Emergency/urgent care operations. Suicide prevention program. VAOIG

Healthcare Inspection Alleged Mismanagement of the Fee Basis Program VA Connecticut Healthcare System, West Haven, Connecticut 06/03/09. The purpose of this inspection was to determine the validity of allegations regarding the mismanagement of the Fee Basis Program at the VA Connecticut Healthcare System (the system). We substantiated that the pre-authorization process for fee-based care was flawed. However, managers initiated new procedures to improve the process prior to the inspection. We did not substantiate that VA physicians self-referred VA patients through the affiliate hospital or benefited financially from fee basis claims paid to the affiliate hospital. We did not substantiate that the system inappropriately utilized the affiliate hospital as a sole source referral center. However, we concluded there was a lack of oversight of the Fee Basis Program and the absence of formal agreements contributed to the appearance of conflict of interest and may have resulted in the overpayments for care to the affiliate hospital. We recommended improved oversight of the program, an assessment of services paid through the program to determine if formal agreements should be considered, regular audits of fee basis claims, and enhanced physician training on VA regulations governing conflict of interest. VAOIG

Combined Assessment Program Review of the Charles George VA Medical Center Asheville, North Carolina 06/02/09. The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness briefings to 319 employees. This review focused on eight operational activities. The medical center complied with selected standards in the following four activities: (1) contracted/agency registered nurses, (2) coordination of care, (3) suicide prevention program, and (4) survey of healthcare experiences of patients. We made recommendations for improvements in the following four activities: QM. Environment of care. Emergency/urgent care operations. Medication management. VAOIG

Combined Assessment Program Review of the G. V. (Sonny) Montgomery VA Medical Center Jackson, Mississippi 06/02/09. The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 252 medical center employees. The review covered eight operational activities. The medical center complied with selected standards in the following four activities: (1) contract/agency registered nurses, (2) coordination of care, (3) emergency/urgent care operations, and (4) patient satisfaction. We identified the patient safety program as an organizational strength. We made recommendations for improvement in the following four activities: Suicide prevention program. Environment of care. QM. Medication management. VAOIG

VAOIG Semiannual Report to Congress

Office of Inspector General Department of Veterans Affairs Semiannual Report to Congress October 1, 2008 -March 31, 2009. 06/01/09. The SAR details the accomplishments of OIG, provides statistical information, and lists all reports issued between October 1, 2008-March 31, 2009. During this reporting period, OIG audits, investigations, and other reviews identified over $614 million in monetary benefits for a return of $16 for every dollar invested in OIG oversight. OIG issued a total of 102 reports on VA programs and operations and OIG investigations led to 253 arrests and 298 administrative sanctions. This document can be viewed using Adobe Reader 5.0 or greater and includes: Bookmarks that allow you to easily move from one part of the SAR to another. Hyperlinks that take you from the mention of a reference to the actual reference itself (including reports that are posted on the OIG Web page). VAOIG

Give Doctors Pay-For-Performance?

Pay-for-performance may benefit doctors who care for very sick 06/01/09. Physicians who treat patients with multiple health problems will fare well under pay-for-performance, which bases physician reimbursement on the quality of care provided, said researchers at Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical Center in Houston in a report in the current issue of the journal Circulation.

"Pay-for-performance raises a lot of fears and assumptions that the reimbursement will not be fair toward doctors who care for the sickest patients," said Dr. Laura A. Petersen (http://www.hsrd.houston.med.va.gov/health-policy/petersenl.htm), the study's lead author and director of the Houston VA Health Services Research and Development Center of Excellence and an associate professor of medicine at BCM. "What we found was that doctors do a good job of taking care of a lot of complex conditions, even better than they think they do."

In their study, the researchers identified 141,609 patients with high blood pressure in a VA database. Of these 22,595 had no other serious health conditions; 70,098 had conditions that could be related to the high blood pressure (concordant), 12,283 other health conditions not related to high blood pressure (discordant) and 36,633 had both. Baylor College of Medicine via Eurekalert!

Stress Response in Female Veterans

Stress response in female veterans: an allostatic perspective. 05/31/09. Women serving in the military face many sources of stress, such as separation from home and family, sexual harassment and assault, and deployment to traumatic war zones. Some women are vulnerable to the effects of these stressors, resulting in deleterious mental and physical health outcomes. Understanding these risks through the theoretical model of allostasis can help identify those who will be most vulnerable and help healthcare providers prevent some negative outcomes and improve rehabilitation for some women when they return stateside. Women may be more likely than men to present with mental health problems such as posttraumatic stress disorder and depression after military service. They also may be at increased risk, based on their war-zone stress response, for disparate illness such as medically unexplained illness, cancer, and heart disease. The need for care for these women is expected to increase as more women are deployed to conflicts. Rehabilitation Nursing via PubMed

Delayed PTSD

Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics. 05/31/09. Retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure. The British journal of Psychiatry via PubMed