Veterans Administration Research News Brief
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The Veterans Admininistration system undertakes a remarkable amount of research that helps improve lives.  Here's a rundown of some of the latest findings.

Nursing home quality of care linked to cost

Nursing home quality of care linked to cost - Photo: ©iStock/LPETTET

(10/10/2018) 
Higher quality of nursing home care was linked to higher cost, in a study of 132 VA community living centers. Researchers looked at data from two years for all community living centers in the VA system. They measured quality of care by looking at rates of adverse health events (such as falls). Fewer adverse events were linked to higher predicted cost, suggesting that greater resources allocated to quality lead to better care. However, higher costs were not driven by higher nurse staffing levels. According to the researchers, more studies are needed to determine what precisely drives the relationship between quality and cost. (PLoS One, Sept. 19, 2018)

Evidence lacking on outcomes of genetic testing for statin resistance

Evidence lacking on outcomes of genetic testing for statin resistance - Photo: ©iStock/jxfzsy

(10/10/2018) 
Information is lacking on patient outcomes for statin-associated muscle symptoms (SAMS) after testing for the SLCO1B1 gene, according to a VA Boston Healthcare System literature review. SAMS refers to muscle pain and weakness sometimes caused by statin medication used to treat cardiovascular disease. Previous studies have shown that people with the SLCO1B1 gene are more likely to get SAMS. The researchers looked at 37 studies for evidence that testing for SLCO1B1 could lead to treatment changes and improved cholesterol levels in statin-intolerant patients. They found very few reports of patient outcomes after SLCO1B1 testing. More studies are needed to explore whether this type of genomic testing can lead to improvements in care, say the researchers. (Clinical Pharmacology and Therapeutics, Aug. 23, 2018)

Study suggests adverse health impact on sexual minorities from religious freedom law

Study suggests adverse health impact on sexual minorities from religious freedom law  - Photo: ©iStock/JacobStudio

(10/10/2018) 
A team including a VA researcher found that “unhealthy days” increased for Indiana residents identifying as sexual minorities after that state passed a religious freedom restoration act (RFRA). Statewide religious freedom restoration laws aim to protect the free exercise of religion by ensuring that any government interference must be for “compelling” interests, and must employ the “least restrictive means” possible. Some legal scholars have argued that RFRAs could potentially expose sexual minorities to more discrimination. And past research has shown that stigma and discrimination could worsen physical and mental health for sexual minority individuals. The researchers surveyed sexual-minority individuals in 21 states with RFRAs in 2015. They found the number of people reporting more than 14 “unhealthy days” per month increased quarterly in Indiana following the passing of an RFRA there. Unhealthy days did not increase for heterosexual people. This trend did not occur in other states. Indiana was the only state to pass and enact an RFRA in the time frame of the study. Other states already had RFRAs in place or had passed an RFRA but not put it into practice. Indiana also differed from other states in that its law applies to cases between private parties, not just those involving government. (American Journal of Orthopsychiatry, Sept. 24, 2018)

Telehealth a viable way to improve antimicrobial stewardship

Telehealth a viable way to improve antimicrobial stewardship - Photo: ©iStock/vm

(10/04/2018) 
A pilot telehealth program shows promise in improving infectious disease control at rural medical centers, according to a Louis Stokes Cleveland VA Medical Center study. Staff at two rural VA medical centers used videoconferencing to work with infectious disease physicians at other facilities. These videoconference antimicrobial stewardship teams (VASTs) held weekly meetings to discuss ways to combat antimicrobial resistance on a patient-by-patient basis. After a year of the program, one site accepted VAST recommendations in 73 percent of cases presented, and the other accepted 65 percent of the recommendations. Participants felt that the sessions improved their antimicrobial stewardship efforts and patient care. (Infection Control and Hospital Epidemiology, Sept. 6, 2018)

Mental health disorders linked with more unintended pregnancy

Mental health disorders linked with more unintended pregnancy - Photo: ©iStock/Vasyl Dolmatov

(10/04/2018) 
Women Veterans with mental health disorders are more likely to have experienced unintended pregnancy than those without, found a study by VA Pittsburgh Health Care System researchers and colleagues. They surveyed almost 3,000 women Veterans by phone. Sixty percent of women with at least one mental health disorder reported having an unintended pregnancy, while 51 percent of women without a mental health disorder said they had had an unintended pregnancy. Mental health disorders were linked to a greater number of unintended pregnancies. Multiple mental health disorders were also connected to a greater number of unintended pregnancies. More research is needed on how to improve reproductive health outcomes for women with mental health disorders, say the researchers. (Journal of General Internal Medicine, Sept. 5, 2018)

Opioids not linked to better sleep for chronic pain patients

Opioids not linked to better sleep for chronic pain patients - Photo for illustrative purposes only. ©iStock fergusowen

(10/04/2018) 
Opioid use did not improve insomnia or fatigue for patients with chronic pain, in a Minneapolis VA Health Care System study. Insomnia is a common problem related to chronic pain. Researchers studied data on medication dosage and sleep disturbance for patients taking opioids or non-opioid medication for chronic pain. Over a year of treatment, neither group showed improvements in insomnia or fatigue despite improvements in pain severity. Medication dosage increased over the course of the trial. Patients with chronic pain commonly take extra opioid medication to sleep, but this increase did not lead to improved sleep. The results suggest that patients should be encouraged to used evidence-based behavioral sleep interventions to manage their insomnia, according to the researchers. (International Association for the Study of Pain, Sept. 13, 2018)

Early nonadherence to diabetes drugs leads to more heart attacks and strokes

Early nonadherence to diabetes drugs leads to more heart attacks and strokes - Photo: ©iStock/Wavebreakmedia

(09/27/2018) 
Patients who did not adhere early on to their medication treatment for type 2 diabetes were more likely to have poor health outcomes, found a study by VA Mid South Health Care Network researchers and their colleagues. Researchers looked at data for more than 159,000 Veterans with type 2 diabetes over an 11-year period. They measured patients’ adherence to oral diabetes medication by how often patients filled prescriptions in the first year of treatment. Patients who did not take their medication as prescribed were 14 percent more likely to have a heart attack in the five years after starting treatment, compared with those who took their medication. Those not regularly taking their medication were 22 percent more likely to have a stroke. The less compliant patients were to their medication regimen, the higher their chances were of having a heart attack or stroke. Those not adhering to treatment were also more likely to have died. The results underscore the need to help patients understand the importance of taking their oral antidiabetes medication regularly, say the researchers. (Diabetes Medicine, July 6, 2018)

Blood test could predict effectiveness of NSAID treatment in Alzheimer’s patients

Blood test could predict  effectiveness of NSAID treatment in Alzheimer’s patients - Photo by Derrick Morin

(09/27/2018) 
Blood tests could identify which Alzheimer’s disease patients will respond to non-steroid anti-inflammatory drug (NSAID) therapy, according to a study including a VA San Diego Healthcare System study. Previous research has shown the potential of NSAIDs to improve outcomes in Alzheimer’s patients because the disease has been linked to inflammation. An earlier study treated Alzheimer’s patients with two NSAIDs, rofecoxib and naproxen. In it, some patients improved and some declined in both groups as well as in controls. For the new study, researchers tested blood samples from these patients for four specific proteins that have been identified as inflammation biomarkers. They found that they could identify which patients in the rofecoxib group had cognitive improvements with 98 percent accuracy. They also predicted improvements in the naproxen group with 97 percent accuracy. The results show that a precision-medicine approach could identify which treatments will be most effective for specific patients with Alzheimer’s, according to the researchers. (Journal of Alzheimer’s Disease, Sept. 4, 2018)

Benzodiazepine prescribing higher than evidence warrants in older adults

Benzodiazepine prescribing higher than evidence warrants in older adults - Photo for illustrative purposes only. ©iStock/BraunS

(09/27/2018) 
Prescribing of benzodiazepines may be higher than appropriate in older adults, according to a study that included several VA researchers. The team looked at use of the drugs across various health systems, not just in VA. Benzodiazepines are sedative drugs commonly prescribed for conditions such as insomnia, anxiety disorders, and behavioral and psychological symptoms of dementia. However, evidence suggest that these drugs could be dangerous for elderly patients. The researchers looked at 31 studies on the effects of benzodiazepines in patients over age 50 with the above three conditions. They found 21 studies that demonstrated improved insomnia outcomes. Only one study showed a benefit of the drugs for patients with anxiety disorder. They also found only a single study that showed improvements in behavioral disturbances in patients with dementia. The results suggest that benzodiazepine prescribing in older adults is higher than what is supported by evidence, according to the researchers. Studies are needed on how to reduce use of this type of drug in older patients, they say. (Harvard Review of Psychiatry, Sept/Oct 2018)

Brain peptide implicated in migraine pain

Brain peptide implicated in migraine pain - Photo for illustrative purposes only. ©iStock/laflor

VA and University of Iowa researchers may have identified one of the sources of migraine pain. Researchers injected mice with calcitonin gene-relate peptide (CGRP), a substance naturally found in the brain that is believed to be related to nerve hypersensitivity and photosensitivity in migraine. They found that CGRP caused spontaneous pain in the mice, regardless of whether they were in light or darkness. When the researchers gave the mice an antibody that blocks CGRP receptors, the pain went away. They also found that the nonsteroidal anti-inflammatory drug meloxicam did not block the effects of CGRP. The antimigraine drug sumatriptan partially blocked CGRP response in male mice, but not females. (Pain, Sept. 1, 2018)

Suicide risk common in patients with anxiety

Suicide risk common in patients with anxiety - Photo for illustrative purposes only. ©iStock/PeopleImages

(09/20/2018) 
A high number of patients with anxiety could be at risk for suicide, found a Syracuse VA Medical Center study. Researchers surveyed 182 primary care patients who had anxiety symptoms but were not in psychotherapy specialty care. Forty percent had elevated suicide risk, based on a standard assessment. Suicide risk was more common in patients who also had depression (51 percent) than in those who had anxiety alone (27 percent). The severity of anxiety symptoms did not affect patients’ suicide risk. The results suggest that primary care providers should assess suicide risk in patients with anxiety, even when patients are not seeking mental health treatment or when their anxiety symptoms do not rise to the level of an anxiety disorder, say the researchers. (Family Practice, Sept. 14, 2018)

Oxytocin fails to boost social cognition in schizophrenia trial

Oxytocin fails to boost social cognition in schizophrenia trial - Illustration: ©iStock/goa_novi

(09/20/2018) 
Oxytocin did not improve social cognition in patients with schizophrenia, in a study by VA San Diego Healthcare System researchers and their colleagues. Social cognition refers to how a person deals with other people, including aspects like social knowledge and emotional processing. People with schizophrenia often have impaired social cognition. The researchers prescribed schizophrenic patients oxytocin—a drug that has been shown to improve social cognition in the general population—over 24 weeks, along with cognitive-behavioral training. Patients taking oxytocin showed no improvements in social cognition over the course of the study, compared with patients taking placebo. The results add to growing literature suggesting that oxytocin may not be effective in this population. (Psychological Medicine, Sept. 6, 2018)

Herbicide-related COPD rates differ between self-report and lung tests

Herbicide-related COPD rates differ between self-report and lung tests - U.S. Army, via Wikimedia Commons
Herbicide exposure during the Vietnam War was linked to self-reported chronic obstructive pulmonary disease (COPD), but the link was not supported by lung tests, in a study by VA's Office of Patient Care Services. Researchers surveyed more than 3,000 Veterans of the U.S. Army Chemical Corps who served in Vietnam. Those who had actively sprayed herbicides during their service were nearly twice as likely to say they had been told by a doctor that they had COPD, compared with non-sprayers. However, when the survey respondents were examined with spirometry—a common test of lung function—people in the spraying group were not more likely to have COPD than the non-spraying group. The difference may be due to physicians diagnosing COPD based on symptoms rather than spirometry, according to the researchers. Spirometry is underutilized by physicians, they say. (American Journal of Industrial Medicine, Aug. 29, 2018)

PTSD may disrupt parasympathetic nervous system during sleep

PTSD may disrupt parasympathetic nervous system during sleep - ©iStock/domoyega

(09/14/2018) 
Patients with PTSD had blunted parasympathetic nervous system modulation during sleep, found a Durham VA Health Care System study. The parasympathetic nervous system is the part of the nervous system that regulates rest and digestion. Heart-rate variability can be used to assess how well the parasympathetic system is working. Researchers studied the sleep of 62 post-9/11 Veterans and service members. They found that, for those with PTSD, high-frequency heart rate variability was lower during the non-rapid eye movement sleep phase, compared with those without PTSD. Impaired parasympathetic nervous system function increases the risk of cardiovascular events. This parasympathetic modulation could be one reason for the increased rates of cardiovascular disease among Veterans with PTSD, suggest the researchers. Patients with PTSD had blunted parasympathetic nervous system modulation during sleep, found a Durham VA Health Care System study. The parasympathetic nervous system is the part of the nervous system that regulates rest and digestion. Heart-rate variability can be used to assess how well the parasympathetic system is working. Researchers studied the sleep of 62 post-9/11 Veterans and service members. They found that, for those with PTSD, high-frequency heart rate variability was lower during the non-rapid eye movement sleep phase, compared with those without PTSD. Impaired parasympathetic nervous system function increases the risk of cardiovascular events. This parasympathetic modulation could be one reason for the increased rates of cardiovascular disease among Veterans with PTSD, suggest the researchers. (Sleep, Aug. 29, 2018)

Development of a new non-addictive pain drug

Development of a new non-addictive pain drug - ©iStock/SeventyFour

(09/14/2018) 
A team including a researcher from the W.G. Hefner VA Medical Center in Salisbury, North Carolina, is working on a pain medication that could potentially work as well as opioids without being addictive. They developed a new compound, AT-121, that works on the mu opioid receptor, a type of neuron that opioids interact with to block pain. AT-121 also activates the nociceptin receptor, which blocks the addictive side effects of opioids. Using non-human primates, the researchers showed that AT-121 gave the same level of pain relief as opioids without the risk of addiction that comes with opioids. The results suggest that this new drug could have potential to both safely and effectively relieve pain, and also treat prescription opioid abuse. More studies will be needed before AT-121 can be tested in humans. (Science Translational Medicine, Aug. 29, 2018)

Circadian rhythm disruption linked to cognitive decline in older men

Circadian rhythm disruption linked to cognitive decline in older men - ©iStock/MladenZivkovic

(09/14/2018) 
Disruptions in circadian rhythm are linked to greater cognitive decline in older men, according to a study including a Minneapolis VA Health Care System researcher. Circadian rhythm refers to the body's natural sleeping and waking patterns. Over multiple follow-up visits during an average period of three years, the researchers found that men with disrupted rest-activity circadian rhythm had greater cognitive decline, as measured by a standard cognition test, compared with those without disrupted circadian rhythms. Rest-activity circadian rhythm was measured using an accelerometer that recorded any time a patient's wrist moved. Aging is often associated with altered rest-activity circadian rhythm. The results add to growing evidence that age-related disruptions to sleep pattern are connected to cognitive decline, say the researchers. (Journal of the American Geriatric Society, Aug. 23, 2018)

Complex relationship between alcohol consumption and psychiatric distress

Complex relationship between alcohol consumption and psychiatric distress - Photo for illustrative purposes only. ©iStock/South_agency

(09/06/2018) 
Hazardous drinking was linked to higher likelihood of psychiatric symptoms, while results of moderate drinking were mixed, in a study by Durham VA Health Care System researchers and colleagues. Previous studies have linked heavy drinking with increased depression and anxiety, but the it is not clear what cause-and-effect relationships, if any, may exist. The researchers collected data on alcohol use and psychiatric conditions for 3,003 Veterans. They found that hazardous drinkers were more likely to have PTSD, depression, and suicidality, compared with moderate drinkers. For men, moderate drinkers were less likely than nondrinkers to have depression and suicidality. However, this relationship disappeared when nondrinkers with past alcohol use disorder were removed from the calculations. Women moderate drinkers had lower rates of PTSD than nondrinkers and light drinkers, even when those with past AUD were removed. More research is needed on the possible protective effects of moderate drinking, say the researchers. Also, patients with a history of AUD may benefit from mental health screening and treatment, they say. (Journal of Studies on Alcohol and Drugs, July 2018)

Written exposure therapy effective as PTSD treatment

Written exposure therapy effective as PTSD treatment - Photo: ©iStock/PeopleImages
Written exposure therapy (WET) could be as effective as cognitive processing therapy in treating PTSD, according to a VA Boston Healthcare System study. WET involves five weekly sessions in which patients write for 30 minutes in detail about a single traumatic event associated with their PTSD. Cognitive processing therapy (CPT), a common PTSD treatment, involves learning how to evaluate and change upsetting thoughts. WET is shorter than CPT, which usually lasts for 12 sessions and includes homework between each session. Patients in both a WET and CPT group showed similar improvement of PTSD symptoms when assessed 60 weeks later. Both treatments significantly reduced depressive symptoms, although the CPT group did have a more rapid decrease in symptoms. WET takes a similar approach to prolonged exposure therapy, another common psychological PTSD treatment, in that both focus on directly confronting memories of trauma. Prolonged exposure is usually based on talking with a therapist, and generally involves more sessions than WET. The results show that WET could be a short and long-lasting treatment for PTSD. (Depression and Anxiety, Aug. 24, 2018)

Study shows two genes may be linked to suicide attempts

Study shows two genes may be linked to suicide attempts - Photo: ©iStock/vchal

(09/06/2018) 
Durham VA Medical Center researchers have identified two genes that may be related to suicidal behavior. They conducted a genome-wide association study, in which they compared the genomes of a large number of Veterans to look for variations common among those with history of suicidal behavior. The researchers found an association between a gene called KCNMB2 and suicide attempts. This gene plays a key role in neuronal excitability. They also found evidence that may link another gene, ABI3BP, to both suicide attempts and suicidal thoughts. While the results are interesting, the researchers caution that they are preliminary and need replication in further studies. (Psychiatry Research, July 17, 2018)

Group treatment program curbs intimate partner violence

Group treatment program curbs intimate partner violence - Photo: ©iStock/RomoloTavani

(08/29/2018) 
The Strength at Home program can successfully reduce intimate partner violence use, found a study by Central Texas and Boston VA health care system researchers. SAH is a 12-week cognitive-behavioral and trauma-informed group treatment designed to reduce and end IPV use among military and Veteran populations. The pilot program is part of a national program within VA to help Veterans who use or experience IPV. It was implemented at 10 VA medical centers over a year. Seventy percent of sites successfully launched the program in the first year. Results from 51 Veterans who participated in the program showed a significant reduction in the number who exhibited violence toward a partner. The participants also showed reduced PTSD symptoms. While the pilot program showed overall successful implementation, more work is needed to reduce the time between initial training and the start of group treatment, according to the researchers. (BMC Health Services Research, July 24, 2018)

Repeated ketamine infusions may ease PTSD and depression

Repeated ketamine infusions may ease PTSD and depression - Photo: ©iStock/stevecoleimages

(08/29/2018) 
Repeated ketamine infusions may improve PTSD and depression symptoms, according to a Minneapolis VA Health Care System study. Researchers gave 15 people with both PTSD and major depressive disorder six intravenous infusions of ketamine—a medication used mainly for anesthesia—over two weeks. Eighty percent had remission of PTSD symptoms immediately after treatment. The remission lasted a median of 41 days. For major depressive disorder, 93 percent experienced remission of symptoms, which lasted a median of 20 days. The results suggest that repeated ketamine treatments are safe and may be an effective treatment for people with both PTSD and major depressive disorder, say the researchers. (Journal of Clinical Psychiatry, May/June 2018)