SUMMER 2015

RESEARCH CURRENTS Research News from the U.S. Department of Veterans A airs

VA Photo by Sciose Joe De WHAT’S INSIDE

Veterans as tour guides around the VA: New research method 8 gleans insights from patients

VA study with 160 Gulf War Veterans will test red, near-infrared 12 light to help brain function

In pursuit of precision medicine 20 for PTSD Fast Findings A drop in prescriptions 2 Link between PTSD, heart disease 3 Strong statin-diabetes link 4 CBT as effective as light therapy 5 Training the next generation of nurses: Studies Compound in may combat head and neck cancers 6 highlight success of VA’s partnership with nursing Pilot study yields promising results on 6 schools 14 Swedish massage for knee pain  FAST FINDINGS

| A study in VA’s Pacific Northwest region found 50 percent greater risk of developing heart failure that despite increases in testing, and in the actual over about a seven-year follow-up period, compared proportion of men with low testosterone levels, with their non-PTSD peers. the number of VA patients who received testoster- The study adds to a growing body of evidence one therapy has actually decreased. linking PTSD and heart disease. The research to date—including these latest findings—doesn’t show male VA patients within the target age group, from a clear cause-and-effect relationship. But most 129,247 in 2002 to 163,572 in 2011. Part of the Photo Moody by Michael experts believe PTSD, like other forms of chronic increase, they say, is due simply to the fact that men stress or anxiety, can damage the heart over time. The print edition of are living longer. VA Research Currents The proportion of men in the target group who is published quarterly by: were tested for low testosterone also increased during the same time frame, from slightly more than VA Research Communications 3 percent to nearly 6 percent. U.S. Department of Veterans Affairs A drop in testosterone prescriptions, Among those tested, the overall number of men 31 Hopkins Plaza, Ste. 102 with low testosterone levels increased as well, from Baltimore, MD 21201 despite upward trend in diagnoses 35 percent to more than 47 percent. 443-759-3456 Despite that increase, though, the number of Testosterone therapy rates are on the rise 410-962-0084 (fax) men who received testosterone therapy within worldwide, with some reports citing an “epidemic” [email protected] a given year decreased during the study period, of testosterone prescribing. VA may be bucking the from 31 to 28 percent. That contrasts with results Vecchio Richard Del Spc. by Photo trend, however, according to research by a team from studies outside VA looking at testosterone U.S. Army soldiers receive instruction while Read the expanded online edition of with the University of Washington and VA’s Pacific therapy trends. waiting for Iraqi detainees to unload from a bus VA Research Currents at www.research.va.gov Northwest region. The researchers explain that for one thing, Veter- in Baghdad in 2008. Veterans with PTSD are at The results suggest that despite increases in ans in VA care are more likely to have comorbidities higher risk of heart failure as they age, according testing, and in the actual proportion of men with low facebook.com/VAResearch that directly contribute to lowered testosterone. Also, to a new VA study. testosterone levels, the number of VA patients who twitter.com/VAResearch rather than prescribe testosterone therapy, clinicians received testosterone therapy has actually decreased. may choose to address what they believe is the root “There are many theories as to how exactly Testosterone therapy isn’t necessarily a bad Editor: Mitch Mirkin cause—being overweight, for example. In many cas- PTSD contributes to heart disease,” says Dr. Alyssa thing. Numerous studies have shown the negative Layout: Michael Escalante es, write the researchers, it’s more relevant to try and Mansfield, one of the study authors. “Overall, the effects of testosterone deficiency, from erectile remedy the underlying cause rather than simply try to evidence to date seems to point in the direction of a dysfunction and decreased libido to increased risk of raise testosterone levels. causal relationship.” osteoporosis, weight gain, and depression. But while (Andrology, March 2015) The study tracked 8,248 Veterans who had been the hazards of low testosterone are well-documented, outpatients in the VA Pacific Islands system. The so too are the risks of therapy. Recent studies have researchers followed them an average of just over suggested a link between testosterone therapy and Any health information in this newsletter is strictly seven years. Those with a PTSD diagnosis were heart disease, sleep apnea, and even cancer. for informational purposes and is not intended as Study adds evidence on link between PTSD, 47 percent more likely to develop heart failure during For the study, researchers with VA and the medical advice. It should not be used to diagnose or heart disease the follow-up period. The researchers controlled University of Washington identified male Veterans treat any condition. for differences between the groups in health and aged 40 - 89 years and examined what proportion In a study of more than 8,000 Veterans demographic factors. were tested, diagnosed, and subsequently treated for living in Hawaii and the Pacific Islands, those Out of the total study group, about 21 percent low testosterone between 2002 and 2011. with posttraumatic stress disorder had a nearly were diagnosed with PTSD. Of the total 371 cases of They saw an increase in the total number of

2 VA RESEARCH CURRENTS SUMMER 2015 3 heart failure during the study, 287 occurred among the connection in a relatively healthy group of statin use for primary prevention.” Photo by Senior Airman Hailey R. Staker/USAF those with PTSD, whereas only 84 cases occurred people. The study included only people who at He adds: “I myself am a firm believer that these among the group without PTSD. baseline were free of heart disease, diabetes, and medications are very valuable for patients when Combat service, whether or not it led to a full- other severe chronic disease. there are clear and strict indications for them. But blown PTSD diagnosis, was itself a strong predictor “In our study, statin use was associated with knowing the risks may motivate a patient to quit of heart failure. Those Veterans with combat expe- a significantly higher risk of new-onset diabetes, smoking, rather than swallow a tablet, or to lose rience were about five times more likely to develop even in a very healthy population,” says lead author weight and exercise. Ideally, it is better to make heart failure during the study period, compared with Dr. Ishak Mansi. “The risk of diabetes with statins those lifestyle changes and avoid taking statins if those who had not seen combat. Other predictors has been known, but up until now it was thought possible.” of heart failure were advanced age, diabetes, high that this might be due to the fact that people who (Journal of General Internal Medicine, online blood pressure, and overweight or obesity. were prescribed statins had greater medical risks to April 28, 2015) (American Journal of Public Health, April 2015) begin with.” An airman uses a "happy light" at Ellsworth Air Mansi is a physician-researcher with the VA Force Base in 2014. A clinical trial by VA researchers North Texas Health System and the University of and colleagues found that light therapy and Texas Southwestern in Dallas. Cognitive behavioral therapy as effective as ognitive behavioral therapy are equally effective Strong statin-diabetes link seen in large study In the study, statin use was also associated with light therapy for seasonal affective disorder for seasonal affective disorder. a “very high risk of diabetes complications,” says of Tricare patients Mansi. “This was never shown before.” Among 3,351 researchers suspect the light may replace lost sun People with winter seasonal affective disorder, pairs of similar patients—part of the overall study exposure due to shorter days and reset the body’s In a database study of nearly 26,000 beneficiaries or SAD, could benefit as much from cognitive group--those patients on statins were 250 percent internal clock, or circadian rhythms. For this reason, of Tricare, the military health system, those taking behavioral therapy as they do from light therapy, the more likely than their non-statin-using counterparts most clinicians who use light therapy advocate statin drugs to control their were 87 current gold-standard for treatment, according to to develop diabetes with complications. morning treatment. percent more likely to develop diabetes. new research. Statin users were also 14 percent more likely to The CBT used in the study was an adaptation of The study confirms past findings on the The findings could offer patients additional become overweight or obese after being on the drugs. traditional cognitive therapy. “We had to condense link between the widely prescribed drugs and treatment options, and perhaps a better long-term Mansi points out that other studies have arrived at a the treatment into a shorter time frame in order to diabetes risk. But it is among the first to show solution, says Dr. Kelly Rohan, a professor at the similar finding through different research methods. fit the winter season,” says Rohan. “It’s kind ofa University of Vermont who completed her residency The study also found that the higher the dose of CBT boot camp.” The participants underwent twelve and post-doctoral fellowship at the G.V. Montgomery any of the statins, the greater the risk of diabetes, 1.5-hour sessions, delivered twice per week over VA Medical Center in Jackson, Miss. diabetes complications, and obesity. six weeks, in groups with a community therapist. “People would like for us to split these treat- Mansi stresses that the study doesn’t definitively Participants focused on behaviors that would help ments out and say one is more effective than the show that statins cause diabetes, nor does it mean them cope with winter, such as changing negative other or that one works better for certain patients, people should stop using the drugs, which are thoughts related to the weather or season, and but in terms of the data it is neck and neck. The widely prescribed to help people lower their cardiac were encouraged to engage in pleasurable activities treatments were not distinguishable in terms of risk factors. during the winter to counteract avoidance. their performance,” says Rohan.

Photo by Airman 1st Class Lauren Pitts Airman 1st Class Lauren by Photo “No patient should stop taking their statins based Light therapy is effective, says Rohan, but it re- The study randomized 177 adults who were on our study, since statin therapy is a cornerstone quires a person to commit to daily therapy every win- experiencing a current bout of SAD. Eighty-eight in treatment of cardiovascular diseases and has ter. Not all patients may be willing or able to adhere. were given light therapy. The rest underwent been clearly shown to lower mortality and disease CBT, on the other hand, is based on the assumption A pharmacist scans a prescription at the Joint Base cognitive behavioral therapy. In the end, both groups progression,” he says. “Rather, this study should that people learn skills in treatment to fortify them- McGuire-Dix-Lakehurst pharmacy, serving Tricare experienced remission rates of 47 percent. alert researchers, [clinical] guideline writers, and selves against recurrence after treatment ends. customers. VA research based on the records of Previous studies support the effectiveness of policymakers that short-term clinical trials might (American Journal of Psychiatry, online April nearly 26,000 Tricare patients shows a link between light therapy in treating seasonal affective disorder, not fully describe the risks and benefits of long-term 10, 2015) statin drugs and increased diabetes risk. although the reasons are not entirely clear. Many

4 VA RESEARCH CURRENTS SUMMER 2015 5 Compound in magnolia may combat head and shown how it works against head and neck cancers: as part of their arthritis treatment neck cancers It blocks a protein called epidermal growth factor plan. Nearly 90 percent said they , or EGFR. Prior research has found that thought other Veterans would try

almost all head and neck cancer cells display an massage if it were offered in VA. are prized for their large, colorful, over-abundance of the protein, and it had been sug- Dr. Kelli Allen, a VA health fragrant flowers. Does the attractive, showy tree also Debenport ©iStock/Steve gested in the literature as a potential target. services researcher who worked harbor a potent cancer fighter? The VA-UAB team says, based on its lab studies, on the study, says recruiting Yes, according to a growing number of studies, that honokiol binds more strongly with EGFR than a diverse mix of VA arthritis including one from VA and the University of Alabama does the drug gefitinib (sold as Iressa), which is patients for the study posed no at Birmingham. commonly used to treat head and neck cancers. particular challenge. The study focused on squamous cell head and The researchers tested honokiol on cell lines “We had comparable rates neck cancers, a scourge among those who use derived from human cancers of the oral cavity, of recruitment, among eligible tobacco and . According to the National larynx, tongue, and pharynx. In all cases, the participants, as those we Cancer Institute, at least 3 in 4 head and neck cancers botanical shut down the aberrant cells. The team have seen in clinical trials of are caused by the use of tobacco and alcohol. The also tested it against tumors implanted into mice, other behavioral and lifestyle cancers have only a 50 percent survival rate, killing Veterans with osteoarthritis of the knee benefited from Swedish massage in with similar results. interventions among Veterans some 20,000 Americans each year. a VA-Duke University pilot study. Senior author Dr. Santosh K. Katiyar and his with osteoarthritis. That was an Enter honokiol— C18H18O2. colleagues wrote, “Conclusively, honokiol appears important aspect of feasibility As one of the major active compounds in magnolia to be an attractive bioactive small molecule phyto- Medicine Center, working with VA colleagues, led for us to assess in a pilot study. Our experience extract, the phytochemical has been used for chemical for the management of head and neck can- the trial, involving 25 Veterans. The group was suggests there is indeed interest in massage therapy centuries in traditional Chinese and Japanese cer which can be used either alone or in combination mostly men, whites and African Americans, with an among VA health care users.” medicine to treat anxiety and other conditions. with other available therapeutic drugs.” average age of 57, and an average BMI of around 32, (Journal of Alternative and Complementary More recently, scientists have been discovering that (Oncotarget, online May 19, 2015) which is above the obesity threshold. Medicine, June 2015) the compound, found in magnolia bark, is a wily Perlman led an earlier clinical trial that found the and versatile adversary of cancer. It seems to exploit therapy effective for knee osteoarthritis in a general many biochemical pathways to shrink tumors of Photo by Joe De Sciose population. But he wanted to put Swedish massage various types, or to keep them from to the test for VA patients. growing in the first place. Pilot study yields promising results on For one thing, most VA patients are men, who The Alabama scien- Swedish massage for knee pain as a group might be somewhat less receptive than tists have women to the idea of massage. Think about who now Put down the pill bottle—get a massage instead. typically goes to spas. Lots of people with arthritis pain would be happy Second, VA patients are more likely than to hear this advice from their doctor. But researchers the general population to have multiple health are still testing the benefits of this therapy with problems—physical or mental. This could complicate ancient roots—whom it helps, for what conditions. how massage is delivered, or its effects. Here’s the story Now, a team at Duke University and the Durham As it turns out, the idea of Swedish massage sat (N.C.) VA Medical Center has shown in a small pilot Journalists and marketers have long used people's well with the Veterans in the study. study that Swedish massage is an acceptable and personal stories to get their point across. Now, VA Almost all of those who started the study—23 out feasible treatment for VA health care users with health researchers are tapping into the same power. of 25—completed the eight weekly one-hour massage osteoarthritis of the knee. Moreover, the Veterans who sessions, given at Duke Integrative Medicine, about Read more at Honokiol, a compound derived from the bark of took part in the study reported, on average, about a 30 a mile from the Durham VA. More than 90 percent of www.research.va.gov/currents/ the magnolia tree, is proving to be a potent cancer percent improvement in pain, stiffness, and function. them said they wanted to continue to receive massage winter2015/winter2015-24.cfm. fighter in lab studies. ©iStock/Dole08 Dr. Adam Perlman of the Duke Integrative

6 VA RESEARCH CURRENTS SUMMER 2015 7 INNOVATIVE METHODS

Seeing VA medical centers through the eyes of Comments on everything from wall color to the Veterans who come there for care—that was the waiting time goal of recent research by a VA team. Locatelli says she came upon the guided-tour Veterans as tour guides around the VA: New research method The researchers used guided tours, given by method when her group was developing a proposal the patients themselves. Thirty Veterans took for VA’s Office of Patient-Centered Care and gleans insights from patients part. Each one individually gave a tour, taking a Cultural Transformation. The group, under LaVela’s Seeing VA medical centers through the eyes of the Veterans who come researcher around the medical center for about 30 direction, was eventually funded to study two VA to 45 minutes. pilot sites where a suite of changes were underway, there for care—that was the goal of recent studies by a VA team. The “We asked the Veterans to take us through what aimed at making VA care more patient-centric. researchers used guided tours, given by the patients themselves. would be a typical visit for them—what clinics they Those changes covered everything from the would go to, where they would go if they needed help color of patient on the walls—the goal being to use finding something, where they would go to wait for more soothing, calming hues—to the physical layout things,” says VA investigator Dr. Sara Locatelli. “The of clinics, to the routines that patients would go participants were in charge. We followed them.” through on their visits. Navy Veteran Pernell Baker is a patient at The approach is new in health care settings. The guided tours yielded frank comments from the Washington, DC, VA Medical Center. “I’ve seen this method used in community- Veterans on all of the above. VA patients like him took part in “guided based research, looking at things like how navigable “I feel good about going through most areas, tour” research at other VA sites to let a neighborhood is for residents, or whether there especially up and down the corridor and around the researchers know their thoughts and is enough green space. But I hadn’t seen it used [cafeteria],” said one participant. “[In] the Atrium, feelings about the care they receive. before in health care systems,” says Locatelli, with there’s plenty of light.” the Center of Innovation for Complex Chronic But said another: “Typically the lobby is full of a Healthcare, based at the Hines (Ill.) VA Hospital. bunch of people. … People on top of people. … It is Locatelli and colleagues Dr. Sherri LaVela and overwhelming when you come through here because Stephanie Turcios will present the work at a July 2015 you don’t know where you are going.” national meeting of VA health services researchers. The researchers audio-recorded the tours as The team previously published the study, and a they followed along, asking follow-up questions and related one based on guided tours by VA health posing the occasional open-ended query. They later care providers and other employees, in the Patient coded and analyzed the Veterans’ remarks, paying Experience Journal and Health Environment close attention to the emerging themes. Research and Design Journal. Many of the “tour guides” commented on the

“We asked the Veterans to take us     through what would be a typical visit for them. …” Photo by Robert Turtil Turtil Robert by Photo

8 VA RESEARCH CURRENTS SUMMER 2015 9 signage around the medical center. and see your primary care provider. If they write Non-researchers may be able to use method be careful to not ask the questions in a biased way “In terms of getting around, everyone—Veterans you a prescription, you first go wait in this line to She says qualitative research such as focus that is going to push people toward answering in a and employees alike—had comments on signs in the talk to a pharmacist, right in the primary care clin- groups or the guided-tour method typically involves certain way.” facility,” says Locatelli. “They often had problems ic. That’s to tell you about interactions, to see if you small samples—in this case, 30 Veterans and 25 with the signs, especially when they were too small have any questions—standard pharmacist counsel- employees—and may not be generalizable in the Tours elicit strong sense of Veteran identity or contained a lot of information, or weren’t up to ing. After that, you go to a completely different area same way that large surveys or database studies One especially noteworthy theme that came up date. As part of patient-centered care, there has of the hospital, where the pharmacy is, to pick up might be. However, the research can point to in the guided tours was Veteran identity. By and been a lot of reorganization of clinics, but the signs the prescription.” “relationships between variables that you can then large, says Locatelli, Veteran patients expressed a The problem was, further explore in a quantitative way,” says Locatelli. strong sense of identity with their fellow Veterans— says Locatelli, that For example, some findings from the guided tours and, by extension, with VA. “some people who might be useful items for medical centers to include “They identified themselves as Veterans—that’s didn’t realize that the in patient surveys. an important part of who they are—and they see pharmacist wasn’t in For that matter, health care managers may be their receiving care through VA as an extension of the pharmacy. So they able to harness the power of guided tours for their that identity. They said things like, ‘Even though immediately went own sites, even without the formal expertise of there are problems—the wait times can be long from the primary care trained researchers. sometimes—this is the best place for me for the clinic to the pharmacy “For the most part, it’s about listening, keeping issues I have.’ They talked a lot about camaraderie— and sat there for 20 or on your toes, and being able to ask timely follow-up just sitting in the clinic and knowing they could turn minutes before asking questions on the fly. There are lots of people who to anyone around them and talk to them, and relate someone ‘when is my have that skill set,” says Locatelli. to that person. prescription going to “If I am the director of a primary care clinic,” “Working in the VA, it wasn’t surprising, be ready?’ And it was she adds, “and I want to do these guided tours with because we see those interactions on a daily only at that point that some of my patients, I am probably going to be basis,” says Locatelli. “But it was neat to hear them they learned they had familiar enough with the particular environment articulate that.”  missed a step.” and processes to be able to come up with some pretty

Photo by Robert Turtil Robert by Photo Even some pro- good follow-up questions. Of course, I would have to Steve Borowsky receives care at the Washington, DC, VA Medical Center. Veterans like viders—those writ- him took part in “guided tour” research at other VA sites to share their experiences ing the prescrip- tions—weren’t aware as VA patients. Photo byBowen Jeff of the correct proce- dure, says Locatelli. New studies to use MVP data haven’t always been up to date. So people could get “They were erroneously telling Veterans, ‘OK, I confused and lost.” sent the prescription, you can go to the pharmacy VA is funding four new studies that will use to pick it up.’ They didn’t know the Veteran was genetic and other data from its Million Veteran Tours shed light on confusing pharmacy supposed to first talk to a pharmacist in the pri- Program to answer key questions on heart disease, process mary care clinic.” kidney disease, and substance use—high-priority Veterans’ confusion could also stem, in some Those types of insights, gleaned from the conditions affecting Veterans. cases, from changes to the process of care. Locatelli guided tours, could be valuable nuggets for clinic or shares an example: medical center directors, says Locatelli. They might Read more at “Veterans and employees alike talked about the want to rethink the process, or perhaps ensure that www.research.va.gov/ complicated processes around receiving prescrip- patients—and providers—are better informed. currents/0715-4.cfm. tions. At some facilities, what you do is you go in

10 VA RESEARCH CURRENTS SUMMER 2015 11 ONGOING RESEARCH

and pains, and joint problems. We’re starting to use rehabilitation therapy. These people still showed it on the brain.” additional progress after the LED treatments. It’s VA study with 160 Gulf War Veterans will test red, Naeser is a research linguist and speech pathol- likely a combination of both methods would produce near-infrared light to help brain function ogist for the Boston VA, and a research professor of the best results.” neurology at Boston University School of Medicine The LED approach has its skeptics, but Naeser’s An innovative therapy that applies red and near-infrared light to the brain (BUSM). She is also a licensed acupuncturist and group has already published some encouraging is now being tested at the Boston VA for Gulf War Illness, TBI, and PTSD. has conducted past research on laser acupuncture results in the peer-reviewed scientific literature. to treat paralysis in stroke, and pain in carpal tun- nel syndrome. Results published from 11 TBI patients Following up on promising Last June in the Journal of Neurotrauma, they results from pilot work, research- How do the diodes work? reported the outcomes of LED therapy in 11 patients ers at the VA Boston Healthcare The LED therapy increases blood flow in the with chronic TBI, ranging in age from System are testing the effects of brain, as shown on MRI scans. It also 26 to 62. Most of the injuries light therapy on brain function in appears to have an effect on dam- occurred in car accidents Veterans with Gulf War Illness. aged brain cells, specifically on or on the athletic field. Veterans in the study wear their mitochondria. These are One was a battlefield a helmet lined with light- bean-shaped subunits with- injury, from an im- emitting diodes that apply red and in the cell that put out ener- provised explosive near-infrared light to the scalp. gy in the form of a chemical device (IED). They also have diodes placed in known as ATP. The red and Neuropsycho- their nostrils, to deliver photons near-infrared light photons logical testing to the deeper parts of the brain. penetrate through the skull before the ther- The light is painless and gen- and into brain cells and spur the mi- apy and at sever- erates no heat. A treatment takes tochondria to produce more ATP. That al points thereafter about 30 minutes. can mean clearer, sharper thinking, says showed gains in areas The therapy, though still con- Naeser. such as executive func- sidered “investigational” and not Naeser says brain damage caused by explosions, tion, verbal learning, and covered by most health insurance or exposure to pesticides or other neurotoxins—such memory. The study volunteers plans, is already used by some as in the Gulf War—could impair the mitochondria also reported better sleep and fewer alternative medicine practi- in cells. She believes light therapy can be a valuable PTSD symptoms. tioners to treat wounds and pain. adjunct to standard cognitive rehabilitation, which The study authors concluded that the pilot results The light from the diodes has typically involves “exercising” the brain in various warranted a randomized, placebo-controlled trial— been shown to boost the output of ways to take advantage of brain plasticity and forge the gold standard in medical research. near where the LEDs new neural networks. That’s happening now, thanks to VA support. One are placed, which improves blood “The light-emitting diodes add something trial, already underway, aims to enroll 160 Gulf War flow in that location. beyond what’s currently available with cognitive Veterans. Half the Veterans will get the real LED ther- “We are applying a tech- rehabilitation therapy,” says Naeser. “That’s a very apy for 15 sessions, while the others will get a mock A staffer in Dr. Naeser’s lab demonstrates the equipment built for the nology that’s been around for a important therapy, but patients can go only so far version, using sham lights. research: an LED helmet (Photomedex), intranasal diodes (Vielight), and while,” says lead investigator Dr. with it. And in fact, most of the traumatic brain Then the groups will switch, so all the volunteers LED cluster heads placed on the ears (MedX Health). The real and sham Margaret Naeser, “but it’s always injury and PTSD cases that we’ve helped so far with will end up getting the real therapy, although they devices look identical. Goggles are worn to block out the red light. The been used on the body, for wound LEDs on the head have been through cognitive won’t know at which point they received it. After near-infrared light is beyond the visible spectrum and cannot be seen. healing and to treat muscle aches Continued on page 19 Illustration ©iStock/Firstsignal

12 VA RESEARCH CURRENTS SUMMER 2015 13 IMPACTS ON CARE

Instructor Dr. Randy Moore (left) and recent nursing graduate Nobody wants a urinary catheter intensive and well-coordinated Most felt no extra burden—a find- Chenoa Leopard tend to Birmingham VA patient Kenneth inserted. But if you need the clinical experience in VA, tightly ing that contrasts with past stud- Hollingshead. procedure, you want it done right. focused on Veterans’ care. ies on nurse training at large. Nursing instructor Dr. Randy In turn, as shown in studies, What’s more, the more in- Moore says his VA site and others VA reaps a range of benefits. They volved the VA staff nurses were are ahead of the curve in using a include enhanced recruitment with the training, the greater new type of swivel clamp that and retention of nurses, and their job satisfaction. helps secure the catheter. One an upsurge in evidence-based “Greater interaction with the benefit? Lower infection risk. He nursing practice. The staffing students, more information on is passing along the technique to piece is big: Amid a nationwide the program, and a preceptor his students. “This is something that many nursing students don’t get any “They’ve been hands-on practice with. Here, they do. So our students are acculturated into VA. learning the latest and greatest They understand the through their clinical experience culture and respect at the VA.” Moore, based in Birmingham, the mission.” Ala., is in the vanguard of

Photo by Sciose Joe De nursing education. He is part of a program called VANAP, for VA Nursing Academic Partnerships. shortage of nurses, VA has felt [teacher] role were all … associ- Now in its second year, following the pinch, with 4 in 10 VA nurses ated with greater program satis- a multiyear pilot phase, it builds eligible to retire within the next faction,” wrote the study authors, on existing partnerships between couple of years. from VA, RAND Corporation, and VA medical centers and nearby UCLA. Dr. Aram Dobalian led the nursing schools. Schools selected Spillover effects on VA staff evaluation. to take part—there are now 25 nurses Coauthor Dr. Tamar Wyte- active sites nationwide—get One recent evaluation, pub- Lake, a VA health services Training the next generation of nurses: Studies highlight success of support from VA to beef up their lished in May 2015 in the journal researcher in Los Angeles, says enrollment and develop their BMC Nursing, looked at the pi- some VANA sites had “dedicated VA’s partnership with nursing schools Veteran-centered curriculum. lot version of VANAP, called the education units” where almost VA’s Office of Academic Affil- VA Nursing Academy (VANA). every VA nurse became a teacher, Innovative partnerships between VA medical centers and their affiliated iations provides seed money the The study found positive “spill- in essence, at least part of the time. nursing schools are preparing a new generation of nurses who are well- first five years to aid in implemen- over” effects from the five-year “Basically everyone on the tation and growth. Afterward, the program on VA staff nurses who unit becomes part of the teaching attuned to Veterans’ health issues, whether they end up working in VA or partnerships support themselves worked on clinical units along- team,” says Wyte-Lake. “It be- other health systems. through internal funding from side students. For starters, only comes a very intense experience.” the local VA and its affiliated 20 percent of these nurses per- Chenoa Leopard just finished nursing school. ceived the presence of students as her four-year nursing degree and Either way, students get an making their work more difficult. passed her RN licensing exam.

14 VA RESEARCH CURRENTS SUMMER 2015 15 Daniel Wyers (left), a nurse Photo by Joe De Sciose is passionate about advancing Vet- practitioner student at VA erans’ care. She lists a string of ac- and UAB, shows instructor complishments, all in areas critical Chance Nicholson an infor- to VA health care, that she says can matics tool he is studying to be traced to VA’s special nursing ed- help incorporate patients' ucation programs. “We were able to family histories into their change the culture and produce con- electronic health records. crete results, such as reducing psy- chiatric inpatient recidivism, reduc- ing length of stay in ICUs, improving the therapy for diabetes.” Driving those results, she says, is the bond that programs like VA- NAP create between the academic side of nursing—what is taught in the classroom and practiced in labs—and real-world clinical practice. “This is what the standard should be,” argues Dougherty. “Having two She is now hoping to come on staff at the Birmingham of experience and one in which a faculty member is separate divisions—practice and VA, where her husband, a Navy Veteran, receives coming in whom you know, whom you’re able to en- academia—doesn’t work. Practice will Photo by Sciose Joe De care. She attests to the rigor and efficiency of the gage with, who’s telling you, these are the goals, this shrivel if you don’t have scholarship VANAP experience from a student perspective. is what we’re talking about this week in school. This and research. And scholarship and is what we’re trying to get at. Try to have the stu- research go off track if they are not Cohesive clinical experience dents get this type of experience.” grounded in practice.” “One benefit was that we got to have consistent clinical groups and site locations,” says Leopard. Impact similar to that of medical school Mutually beneficial relationship “Since we were already familiar with our clinical partnerships This ideal is playing out in Birmingham, as at practices and make sure they are disseminated at group and site each semester, we were able to be- Dr. Mary Dougherty, director of nursing educa- other VANAP sites. the hospital, both among the students and among gin patient care right away.” tion in VA’s Office of Academic Affiliations, says the Moore, a former Navy nurse who is now co- the RNs at the bedside.” According to the research, that type of cohesive- positive effects on VA nurses who work with VANAP director of the VANAP undergraduate program at Chance Nicholson, a psychiatric nurse practi- ness makes a difference not only for the students, students is just one part of a much larger picture. the Birmingham VA and the University of Alabama tioner at UAB who teaches graduate students in VA- but for the VA nurses who work with them. The ef- She says VANA and now VANAP have had an at Birmingham (UAB) School of Nursing, says he NAP, says: “It’s a mutually beneficial relationship. fect is further enhanced when the VANAP faculty are impact similar to that of VA’s storied partnership first goes over concepts in the classroom. Then, his The clinical aspect of VA gives us a place to dissem- themselves part of the VA nursing staff. That doesn’t with the nation’s medical schools, which began after students move to the lab, where they might practice on inate the research and evidence-based practice that always happen—VANAP faculty are sometimes re- World War II as a way to help care for the waves of a mannequin or each other. Then, it’s on to the clinic. we do as part of our job. The folks at the VA are the cruited from outside VA—but it often does. returning Veterans. “I take my students into VA for their clinical ones who are putting it into practice and seeing it Wyte-Lake: “In some situations in nursing “There is empirical evidence,” she says, “that rotations. If you think of a PhD doing bench research, work. By our keeping the VA people abreast of the education, students are just ‘dropped off’ at their unit. these nursing partnerships produce significant value and how they get that into practice—my degree as newest information, on top of what they’re already And the staff aren’t really told what the goals are. similar to the medical academic partnership.” a doctor of nursing practice is to take research and doing, we learn from each other.” They’re basically told, have these students shadow you. Dougherty, a former Army reservist whose apply that at the bedside. VANAP provides a good The academic spirit infuses VA nursing practice “You could see a big difference between that type husband served in the Air Force for 40 years, avenue to do that, to take the latest evidence-based in a variety of ways, says researcher Wyte-Lake. For

16 VA RESEARCH CURRENTS SUMMER 2015 17 example, units participating in VANAP have start- doctoral degrees, will help solve the nation’s over- ed “journal clubs” where nurses get together to talk all nursing crisis. VANA and VANAP have already about recent studies and how they can apply the made a dent in VA’s shortage. VA study with 160 Gulf War Veterans will test red, near-infrared light to findings in their work. help brain function Also, VA preceptors, who are not full-fledged fac- ‘Everything is Veterans’ Continued from page 13 ulty but who do hands-on teaching on the VA hospi- Dougherty says by the time VANAP students tal units, get exposure to the academic side of nursing. have completed their four-year degree—and their Nicholson says the preceptors are invited to share their post-bachelor’s residency in VA—they are well- each Veteran’s last real or sham treatment, he or she will lead a VA-funded trial looking at the impact of knowledge in the formal classroom or lab setting. attuned to the VA environment. will undergo tests of brain function. LED therapy on sleep and cognition in Veterans “We give them an opportunity to teach over here “They’ve been acculturated into VA. They under- Naeser points out that “because this is a blinded, with blast TBI. at the school,” he says. “They share some of their stand the culture and respect the mission.” controlled study, neither the participant nor the as- evidence-based practices with our students.” She presses the point that while VANAP students • Naeser is collaborating on an Army study testing sistant applying the LED helmet and the intranasal do get a strong nursing education, the raison d’etre LED therapy, delivered via the helmets and the diodes is aware whether the LEDs are real or sham. Programs spurs higher education for nurses of the program is to help VA meet its organizational nose diodes, for active-duty soldiers with blast So they both wear goggles that Some VA preceptors, inspired by their taste goals. It is designed mainly to help VA meet the chal- TBI. The study, funded by the block out the red LED light.” The of higher-level nursing education and perhaps lenges of caring for the nation’s Veterans. Army’s Advanced Medical Tech- near-infrared light is invisible to encouraged by personal contacts they make at “This is all done within a model that focuses “We are applying a nology Initiative, will also test begin with. the feasibility and effectiveness the university, decide to pursue more advanced on the major priorities within the organization,” technology that’s degrees, such as a doctor of nursing practice, or a says Dougherty. “For us, that is Veterans. Every- of using only the nasal LED de- Upcoming trials to focus on doctor of nursing science. thing is Veterans.” been around for a vices—and not the helmets—as TBI, PTSD That’s been one of the findings from the research As for those graduates of the program who an at-home, self-administered Besides the Gulf War study, while.” by Wyte-Lake and colleagues. In a 2014 study pub- end up working outside VA, they will contribute to treatment. The study leader is other trials of the LED therapy lished in the Journal of Professional Nursing, in Veterans’ care in other ways, leveraging what they Dr. Carole Palumbo, an investi- are getting underway: which they interviewed more than 200 nurses who learned in VANAP. gator with VA and the Army Re- took part in VANA at 15 sites, they found a strong Moore: “We know there are some 24 million Vet- • Later this year, a trial will launch for Veterans age search Institute of Environmental Medicine, and link between VANA participation and enrollment in erans in the U.S., and only about 8 million receive 18 to 55 who have both traumatic brain injury an associate professor of neurology at BUSM. an advanced nursing degree program. some portion of their care inside VA. We want our (TBI) and posttraumatic stress disorder—a com- Naeser hopes the work will validate LED therapy Having more young people graduate as RNs, graduates to be conscious of Veterans’ health issues, mon combination in recent war Veterans. The as a viable treatment for Veterans and others with and having more nurses go on for their master’s or wherever they encounter those Veterans.”  VA-funded study will be led by Naeser’s colleague brain difficulties. She foresees potential not only for Dr. Jeffrey Knight, a psychologist with VA’s Na- war injuries but for conditions such as depression,

Photo by Tony F. Barnett tional Center for PTSD and an assistant professor stroke, dementia, and even autism. of psychiatry at BUSM. “There are going to be many applications, I think. Can aspirin ward off cancer? • Dr. Yelena Bogdanova, a clinical psychologist with We’re just in the beginning stages right now.”  A VA lab study found that a daily dose of aspirin was VA and assistant professor of psychiatry at BUSM, effective at blocking breast tumor growth. Previous studies have already shown a similar effect on colon, gastrointestinal, prostate, and other cancers.

Read more at www.research.va.gov/currents/ spring2015/spring2015-25.cfm.

18 VA RESEARCH CURRENTS SUMMER 2015 19 KEY FINDINGS

researcher Dr. K. Luan Phan, chief of neuropsychiatric One nuance in the findings was that the brain area In pursuit of precision medicine for PTSD research at the Jesse Brown VA Medical Center and that appeared to predict response to SSRIs—the right professor of psychiatry at the University of Illinois ventrolateral prefrontal cortex—was not the exact Brain scans of war Veterans with posttraumatic stress disorder have at Chicago. “We hope in the future to be able to use area that appeared to be affected by SSRI treatment. scans to help distinguish PTSD from other illnesses, According to the fMRI scans, it was a related area— led researchers to an area of the prefrontal cortex that appears to be a and then to predict how well someone will do with the left dorsolateral prefrontal cortex, which has good predictor of response to treatment with SSRIs—the first-line drug a certain medication, or with talk therapy. What we similar functions—along with another region called treatment for PTSD. envision is being able to say to a patient, ‘Given your the supplementary motor area, that showed more scan value, you have an X percent chance of getting activation after treatment. better on this treatment.’” Phan explains: “It would be intuitive that Photo by Jerry Daliege Photo by Jerry The approach, says Phan, will benefit patients something you’re trying to correct would also be Dr. K. Luan Phan is chief of and providers alike: “We’ll be saving a lot of resources the very same thing that would predict how well neuropsychiatric research at on the clinical side, and more importantly, we’ll also you do. But data from our lab and others suggest the Jesse Brown VA Medical not be wasting patients’ time sending them for a this isn’t always true. A mechanism of change could Center and a professor of treatment that is not likely to help them.” be different than a predictor of change. One area psychiatry at the University of could change with treatment, but another area could Illinois at Chicago. Study involved 34 Veterans predict your treatment response.” His latest study included 34 Iraq and Afghanistan In any case, while the results need replication Veterans, half of them with PTSD. They all got in larger trials, they point to a potential method to functional MRI scans, which track blood flow in target drug therapy for PTSD patients. the brain to show which areas are using the most “Patients with the least recruitment of prefrontal oxygen—a sign of increased activity. emotion regulatory brain regions may benefit most The researchers saw that among the PTSD group, from treatment with SSRIs, which appear to augment who were all taking the drug paroxetine (sold as Paxil), activity in these regions,” the researchers wrote.

“We hope in the future to be able to use scans to help distinguish PTSD from other illnesses, and     then to predict how well someone will do with a certain medication, or with talk therapy.”

the patients who showed the most improvement The first author was Annmarie MacNamara, a post- from the SSRI were those who showed the least doctoral research fellow in Phan’s lab. Brain scans of war Veterans with posttraumatic “precision medicine,” in which doctors will tailor activation, prior to treatment, of a brain area called stress disorder have led researchers to an area of the drug regimens and other treatments based on the right ventrolateral prefrontal cortex, also known Other SSRIs similar, but may have subtle prefrontal cortex that appears to be a good predictor patients’ individual gene profiles or other factors. as the inferior frontal gyrus. The region is known to differences of response to treatment with SSRIs—the first-line President Obama announced the initiative earlier help with emotional regulation. It serves as a rational Paroxetine and sertraline (Zoloft) are both drug treatment for PTSD. this year. counterbalance to parts of the brain that generate part of the SSRI class of antidepressants. They are The findings, which came out online June 26, So far, though, little of this approach is in use in raw emotion. It helps with tasks like impulse control, currently the only drugs approved by the Food and 2015, in the journal Neuropsychopharmacology, everyday psychiatry. cognitive flexibility, and executive function. “These are Drug Administration to treat PTSD. Another SSRI, are hopeful news amid a new national push toward “This is the holy grail for brain imaging,” says lead all ingredients of emotional regulation,” says Phan. (Prozac), also has evidence of effectiveness

20 VA RESEARCH CURRENTS SUMMER 2015 21 comparing different PTSD treatments. The team is “Based on previous research on depression, we see Dr. K. Luan Phan prepares a looking at how each affects the brain and whether some changes that are similar between treatments, research participant for an EEG brain markers can predict response to a particular but we also see distinct patterns,” says Rauch. study. His lab is looking for brain treatment. She, like Phan, believes the scanning approach patterns that predict how well a The trial began in 2011 with VA and Army may eventually yield reliable biomarkers to guide patient will respond to particular funding and is still ongoing at three VA sites and PTSD treatment, but she says it will likely take treatments for PTSD. at Massachusetts General Hospital. It has involved several more years. more than 400 Iraq and Afghanistan Veterans with “Within PTSD, this research is in the early PTSD. Some are being treated with sertraline, and stages,” she says. “We need larger studies that will others with a type of psychotherapy called prolonged allow replication and application to a treatment exposure therapy, which is one of the two main talk population,” and those generally take at least five therapies used in VA for PTSD. Others in the study years to implement and yield results, she says. are receiving a combination of the two. “This is a marathon and not a sprint. Expecting an Lead investigator Dr. Sheila Rauch, with the overhaul in the next couple of years is unrealistic, Atlanta VA Medical Center and Emory University, but I do think 10 years from now, PTSD care will be says it’s too early in the study to compare how each even more advanced and effective than it is today. of the therapies affects the brain—that is, which We are moving in the right direction, but we are not

Photo by Jerry Daliege Photo by Jerry precise regions get activated or calmed—but some there yet.”  clues may come from past work on depression.

VA Research Fact Sheets New for 2015 Available as print-ready PDFs at www.research.va.gov/topics for PTSD, but it’s not yet approved for that purpose. and they are often not tolerated well by our Veterans,” Phan says the study was limited to patients using he says. “It can be a very claustrophobic experience. Depression Parkinson’s Disease paroxetine, because while all SSRIs work similarly, You can feel trapped in the tube, in this dark, tight Diabetes Posttraumatic Stress there may be subtle differences among them, and space. And there are loud random noises that many Gastrointestinal Health Disorder the researchers wanted to control for this. He noted Veterans have told me remind them of artillery fire.” Gulf War Veterans Prosthetics that some patients may respond well to one SSRI but Besides being distressing for the Veterans, says Respiratory Health not another. Phan, this can all detract from the research: “It’s Health Care Delivery Rural Health His lab is also involved in other efforts to problematic on two fronts. It makes them move Health Care Disparities tailor PTSD therapy based on brain patterns. during the scan, which is not great for our science. Afghanistan/Iraq Veterans Hearing Loss Spinal Cord Injury In one VA-funded study, he is using a type of Also, it may evoke different kinds of emotions that Alzheimer’s Disease Hepatitis C Substance Use Disorders electroencephalography (EEG)—in which Veterans we’re not explicitly looking to test in the scanner. It Arthritis Homelessness Suicide Prevention wear an electrode-studded cap on their head—to induces a different emotional state that is hard to Cancer Traumatic Brain Injury trace brain patterns that may eventually serve as control for.” Infectious Diseases Cardiovascular Disease Vietnam Veterans biomarkers. The research method is much less Kidney Disease expensive and more portable than brain imaging— Larger VA-Army study comparing PTSD Caregiving Mental Health Vision Loss and it carries an added advantage for combat treatments, looking for brain markers Complementary & Obesity Women’s Health Veterans, notes Phan. Phan is also collaborating on a multisite Alternative Medicine Pain Management “Functional MRIs typically cost around $500, randomized, controlled clinical trial that is

22 VA RESEARCH CURRENTS SUMMER 2015 23 RESEARCH CURRENTS VA Research News from the U.S. Department of Veterans A airs Did you know? Dr. Dudley Childress (1934 – 2014) had humble roots in small- town Missouri and went on to become one of the world’s leading prosthetics engineers. It was on his grandparents’ farm that he first took an interest in machinery. He studied electrical engineering at the University of Missouri, where he was also a star quarterback. After a stint in the Army Reserve, Childress joined VA and Northwestern University and helped pioneer myoelectric control, which applies electrical signals from muscles to prosthetic limbs. His lab later developed the “sip and puff” wheelchair and many other technologies. He received VA’s Magnuson Award in 2002 for his achievements on behalf of people with disabilities.

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