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VA researchers are doing amazing things to improve the lives of Veterans. Here’s just one example: the Smart Home. This unique project uses advanced technology to help patients with traumatic brain injury (TBI) independently plan, organize and complete everyday activities.Some Veterans with TBI have lost the ability to manage basic tasks like doing the laundry or taking out the trash. Smart Home has been described as a “cognitive prosthetic.” VA’s Smart Home helps them relearn those skills by tracking their movements around their house and then sending them text or video prompts when they get off track. The remarkable indoor tracking technology can pinpoint the Veterans’ location to within six inches.  Ben “Ty” Edwards and wife Anna Edwards The Tampa VA Medical Center has installed the high tech equipment in five apartments housing 10 Veterans. It has a system that not only tracks their locations but has sensors that monitor the use of appliances. For example, the washing machine sensors determine when the Veteran puts soap in the machine and also shows when he or she empties the machine after the load is completed. If the user forgets to do either, a nearby screen prompts them to complete those steps. The Smart Home can also notify a caregiver if an activity is not completed. Other sensors in the bathroom determine how long a patient has been shaving and if they are taking too long, they are prompted to finish that task and move on.The technology promotes Veterans’ independence by providing reminders for the management of other daily activities such as medication, meal planning, and other necessary tasks. Smart Home has been described as a “cognitive prosthetic” with the goal of rehabilitating Veterans with TBI so they can function normally in society.A powerful feature of the Tampa Smart Home is the precision of the customized therapeutic information that can be provided to the recovering Veteran. Data for every interaction with clinical and medical staff are recorded continuously and analyzed, helping the staff visualize subtle but therapeutically significant behavioral changes. Reports are sent back to the clinical team on a weekly basisThis helps to better inform treatment plans and potentially prevent problematic medication effects on Veterans' memory, as well as gait and balance.  Joseph “Pepper” Coulter and wife Jill Coulter A little more technical information? The Veteran patients and VA staff wear wrist tags linked to a real-time location system that tracks the tags using wall sensors. It’s ultra-wideband technology. The wrist tags broadcast their ID on a 6-to-8 gigahertz channel and uses time-delay-of-arrival and angle-of-arrival methods to determine position in three dimensions.The Smart Home innovation recently received third place in VA’s Brain Trust summit. The national summit brought together the public and private sector, Veterans, caregivers, clinicians and innovators to tackle the issues of brain health.       One of the leaders of the project is Dr. Steven Scott, co-director of VA's Center of Innovation on Disability and Rehabilitation Research and chief of physical medicine and rehabilitation at the James A. Haley Veterans Hospital in Tampa. Scott is a nationally known expert in the fields of physical medicine and rehabilitation with research expertise in polytrauma and traumatic brain injury. Much of his work focuses on the rehabilitation and reintegration of Veterans who have experienced blast-related injuries.Advances like this are being celebrated this week, Research Week, at VA medical centers around the country.Join us as we celebrate 91 years of research excellence and attend one of the many activities being conducted nationwide.For more than 90 years, the VA’s Research and Development program has been improving the lives of Veterans and all Americans through health care discovery and innovation.VA research is unique because of its focus on health issues that affect Veterans. The groundbreaking achievements of VA investigators—more than 60 percent of whom also provide direct patient care—have resulted in three Nobel prizes, seven Lasker awards, and numerous other national and international honors.  
The VA is opening its first primary care clinic at the Orlando VA Medical Center campus. While the new hospital is not yet ready to open, the Department of Veterans Affairs is moving the clinic— which serves about 1,200 clients — from a nearby annex to the Lake Nona hospital complex to begin serving veterans there. The move Tuesday marks the first time that Central Florida veterans will receive primary care at the yet to be completed campus. "We're trying to open up the clinic as timely as we can," Orlando VA spokesman Mike Strickler said. "At least the clinic is open for business. We're raising the flag to say we have a portion of the clinic open." In addition to the clinic opening, the $665 million VA medical complex in Orlando's Lake Nona area — just west of the Brevard County line — is to include a 134-bed hospital, 118-bed nursing home and a veterans benefit service center. Strickler said other departments likely will open while the final phase of the medical complex construction is completed and turned over from the builder to the VA, which is expected later this year. "It's demonstration of progress," said Bill Vagianos, president of the Brevard Veterans Memorial Center. "It's a gesture of good faith, certainly." Vagianos added that while it is good to see the opening of the clinic, the veterans' community has been frustrated by the delays in getting the medical center opened. The medical center will serve veterans from a 10-county area, including Brevard. Groundbreaking for the medical center was in October 2008 and was supposed to open four years later. "That hospital was supposed to open three years ago," Vagianos said. "I guess the veteran community has taken a cautious wait-and-see, given the track record the VA has demonstrated." Strickler said that more and more services will be available at Lake Nona until the medical center's grand opening, expected in June or or July. He said veterans will be pleased with the facility and the services that will be available to them. It marks the first time primary care services will be offered at the new Lake Nona campus. "It's a quantum leap in how we serve veterans," he said.   by R. Norman Moody  
BOSTON (AP) -- A 64-year-old cancer patient has received the nation's first penis transplant, a groundbreaking operation that may also help accident victims and some of the many U.S. veterans maimed by roadside bombs. In a case that represents the latest frontier in the growing field of reconstructive transplants, Thomas Manning of Halifax, Massachusetts, is faring well after the 15-hour operation last week, Massachusetts General Hospital said Monday. His doctors said they are cautiously optimistic that Manning eventually will be able to urinate normally and function sexually again for the first time since aggressive penile cancer led to the amputation of the former bank courier's genitals in 2012. They said his psychological state will play a big role in his recovery. "Emotionally he's doing amazing. I'm really impressed with how he's handling things. He's just a positive person," Dr. Curtis Cetrulo, who was among the lead surgeons on a team of more than 50, said at a news conference. "He wants to be whole again. He does not want to be in the shadows." Manning, who is single and has no children, did not appear at the news conference but said in a statement: "Today I begin a new chapter filled with personal hope and hope for others who have suffered genital injuries. In sharing this success with all of you, it is my hope we can usher in a bright future for this type of transplantation." The identity of the deceased donor was not released. The operation is highly experimental - only one other patient, in South Africa, has a transplanted penis. But four additional hospitals around the country have permission from the United Network for Organ Sharing, which oversees the nation's transplant system, to attempt the delicate surgery. The loss of a penis, whether from cancer, accident or war injury, is emotionally traumatic, affecting urination, sexual intimacy and the ability to conceive a child. Many patients suffer in silence because of the stigma their injuries sometimes carry; Cetrulo said many become isolated and despondent. Unlike traditional life-saving transplants of hearts, kidneys or livers, reconstructive transplants are done to improve quality of life. And while a penis transplant may sound radical, it follows transplants of faces, hands and even the uterus. "This is a logical next step," said Dr. W. P. Andrew Lee, chairman of plastic and reconstructive surgery at Johns Hopkins University School of Medicine. His hospital is preparing for a penis transplant in a wounded veteran soon, and Lee said this new field is important for "people who want to feel whole again after the loss of important body parts." Still, candidates face some serious risks: rejection of the tissue, and side effects from the anti-rejection drugs that must be taken for life. Doctors are working to reduce the medication needed. Penis transplants have generated intense interest among veterans from Iraq and Afghanistan, but they will require more extensive surgery since their injuries, often from roadside bombs, tend to be more extensive, with damage to blood vessels, nerves and pelvic tissue that also will need repair, Lee noted. The Department of Defense Trauma Registry has recorded 1,367 male service members who survived with genitourinary injuries between 2001 and 2013. It's not clear how many victims lost all or part of the penis. A man in China received a penis transplant in 2005. But doctors said he asked them to remove his new organ two weeks later because he and his wife were having psychological problems. In December 2014, a 21-year-old man in South Africa whose penis had been amputated following complications from circumcision in his late teens received a transplant. Dr. Andre van der Merwe of the University of Stellenbosch told The Associated Press that the man is healthy, has normal sexual function and was able to conceive, although the baby was stillborn. But his recovery was difficult, with blood clots and infections, the doctor said. For congenital abnormalities or transgender surgery, doctors can fashion the form of a penis from a patient's own skin, using implants to achieve erection. But transplanting a functional penis requires connecting tiny blood vessels and nerves. A bigger challenge than the surgery itself is finding donor organs. "People are still reluctant to donate," van der Merwe said. "There are huge psychological issues about donating your relative's penis." In the U.S., people or their families who agree to donate organs such as the heart or lung must be asked separately about also donating a penis, hand or other body part, said Dr. Scott Levin, a hand transplant surgeon at the University of Pennsylvania and vice chairman of UNOS' committee on reconstructive transplants. In Boston, Cetrulo said the transplanted penis has good blood flow and so far shows no signs of rejection. He said that Manning should be released from the hospital soon, and that the surgery had three aims: ensuring the transplanted penis looks natural, is capable of normal urination - which he hopes will resume in a few weeks - and eventually normal sexual function. Reproduction won't be possible, he said, since Manning did not receive new testes. Dr. Dicken Ko, who directs the hospital's urology program, said Manning has been shown post-operation photos but hasn't actually seen his new penis, since it is still bandaged. A big test, Ko said, will be when reconnected nerves start to take hold, bringing feeling back to the organ. "We don't know how he would feel until that times comes," he said. --- Associated Press writers Patrick Mairs in Philadelphia and Maria Cheng in London contributed to this report. Neergaard reported from Washington.
CHICAGO (AP) -- Rep. Tammy Duckworth lost both legs when her helicopter was shot down in Iraq, then went on to hold leadership roles in the Illinois and U.S. Veterans Affairs departments. Yet, the Democratic Senate hopeful now finds her record on helping military veterans under attack by her opponent, Republican Sen. Mark Kirk, as he tries to hold on to a seat Democrats believe is key to their efforts to regain the Senate majority. Kirk, one of the GOP's most endangered incumbents, has accused Duckworth of failing to protect veterans in her care and putting her political ambitions ahead of her duties. He's also touted the more than two decades he served in the Navy Reserve and his own high-profile efforts to highlight problems at the VA. This week his campaign launched an online ad featuring a hearing on a lawsuit two Illinois VA employees filed against Duckworth, accusing her of retaliating against them when she led the agency- complaints that have twice been dismissed. Kirk also has repeated claims by two whistleblowers who say Duckworth ignored their reports of misconduct at a federal VA hospital west of Chicago. Trying to take down Duckworth on veterans' issues is a bold move for Kirk, with even some Republicans saying they don't think voters will buy it. The strategy also could backfire. Kirk acknowledged during his 2010 Senate bid that he had exaggerated some of his own military record. And he risks alienating voters who see Duckworth as a hero. Garrett Anderson, who lost part of one arm and suffered traumatic brain injury in a roadside-bomb attack in Iraq, said Duckworth was the first service member the U.S. Army sniper spoke to when he woke up from a coma at Walter Reed National Military Medical Center in 2005. The 39-year-old University of Illinois graduate student plans to vote for Kirk this fall for a simple reason: Anderson is a Republican. But he said the ads targeting her are out of bounds and called Duckworth "a nice person" who has a strong track record of looking out for veterans. "I've seen a few of (the ads) and I don't like them because she served her country very well, and she's a decorated war veteran," Anderson said. Kirk's campaign says Duckworth's record is a legitimate area for criticism, and that there's no shortage of people who agree. They point to two employees at Edward Hines, Jr. VA Hospital near Chicago who say they took their concerns to Duckworth and other Democrats but heard nothing, and to an Illinois Auditor General report of the state Department of Veterans' Affairs that found inadequate financial controls and programs that were supposed to be implemented but weren't during the time Duckworth was leading the office. The two other employees, whose lawsuit is in court Thursday, say she tried to fire one employee and gave another a bad review that cost her raises after the women complained about facility leadership at an Illinois VA home, where they still work. Duckworth was appointed to lead the Illinois VA in 2006 by now-imprisoned ex-Gov. Rod Blagojevich. "Of course Duckworth is a war hero, and that's what makes this entire court case even more tragic," said Kirk campaign manager Kevin Artl. "These VA employees only wanted to prevent veterans from being abused, but instead were ignored and punished by Duckworth while American heroes suffered," Deputy campaign manager Matt McGrath called it "a cynical and desperate ploy." He said Duckworth gets most of her own health care at Hines and is "deeply familiar" with issues at VA medical centers. Duckworth was born in Thailand to a Chinese mother and an American father, who fought with the Marines in Vietnam. She joined ROTC during graduate school and later signed up with the Illinois National Guard. She was co-piloting a Black Hawk in 2004 when Iraqi insurgents hit it with a rocket-propelled grenade. Among her accomplishments, her campaign says, is launching the first 24-hour hotline for suicidal veterans and introducing legislation to improve mental health treatment that was signed by President Obama. Jon Soltz, who leads the liberal political action committee VoteVets, which is backing Duckworth, said the group is prepared to spend significant money to attack Kirk. "It's just a very dangerous strategy for them to continue to try to define Tammy Duckworth in this way, when if you just look at a picture of her you can see she's a war hero," Soltz said. Anderson, who works at the University of Illinois' Center for Wounded Veterans in Higher Education, doesn't believe either candidate has clear offered a plan for veterans. "They haven't given us a blueprint of what their objectives are," he said.   by SARA BURNETT
VIRGINIA BEACH, Va. (AP) -- A retired Navy veteran must pay for two flags after stealing one from his Virginia Beach neighbor because it wasn't being illuminated at night. News outlets report a judge on Monday found John Parmele Jr. guilty of three misdemeanors after Parmele's neighbor Mike Anderson presented footage of the crime being committed. Parmele said he took the American flag to the Veterans of Foreign Wars to give it a proper retirement. Parmele says he had tried in vain to get Michael to illuminate the flag on his mailbox at night so it would be in accordance with federal code. Parmele was found guilty of stealing the flag, trespassing and destruction of property. He was ordered to pay a $300 fine and reimburse Anderson about $100. His 90-day jail sentence was suspended.
WASHINGTON (AP) — The House has voted to ban the display of the Confederate flag on flagpoles at Veterans Administration cemeteries. The 265-159 vote would block descendants and others seeking to commemorate veterans of the Confederate States of America from flying the Confederate Battle Flag over mass graves, even on days that flag displays are permitted. California Democrat Jared Huffman authored the prohibition, saying the flag represents "racism, slavery and division."   After a mass shooting at a South Carolina black church last year, the state legislature ordered the flag removed from the capitol in Columbia.   The House approved amendments last year to block the display and sale of the Confederate flag at national parks but a backlash from Southern Republicans caused GOP leaders to scrap the underlying spending bill.
A Must Read from NPR— together with member stations from across the country — NPR has been reporting on troubles with the Veterans Choice program, a $10 billion plan created by Congress two years ago to squash long wait times veterans were encountering when going to see a doctor. But as we reported in March, this fix needs a fix. Around the nation, our joint reporting project — called Back at Base — has found examples of these problems. Emily Siner of Nashville Public Radio reported on troubles with overcrowding in Tennessee. And Monday, we reported on hospitals and doctors not getting paid in Montana and veterans getting snarled in the phone systems trying to make appointments in North Carolina. Congress and Department of Veterans Affairs officials are in the middle of overhauling the program. Here are some reasons: • The VA's most recent data show compared to last year, there are now 70,000 more appointments that kept a veteran waiting at least a month to get care. • A March General Accounting Office report shows the Choice program had little impact on getting veterans to see a primary care physician in 30 days. • Thousands of veterans referred to the program are returning to the VA for care — sometimes because the program couldn't find a doctor for them, and for 28,287 vets, because the private doctor they were told to see was too far away, according to data NPR obtained from the VA. • The VA's own inspector general found that Colorado Springs, Colo., veterans were waiting longer than 30 days for care because staff at the local VA hospital was not adding them to the list of patients eligible for the Choice program. The VA recently set up a hotline to help veterans who have issues with their credit because the programs hadn't paid doctors on time. Click Below http://www.npr.org/2016/05/17/478215589/how-congress-and-the-va-left-many-veterans-without-a-choice
It may very well have been the largest American Legion Walk for Veterans yet. An estimated 220 Legion family members and veterans walked alongside a series of memorials adjacent to the National Infantry Museum and Soldier Center in Fort Benning, Ga., on May 14. Part of the success can be attributed to the home field advantage of National Commander Dale Barnett. And in the spirit of a hometown hero, Barnett began the event with a pre-game pep talk to the large group of walkers. “This really is a welcome home,” Barnett said, pointing out that his daughter Michelle was born at the local hospital. “I deployed for Desert Shield/Desert Storm from Columbus, Georgia, with the 2nd Battalion, 18th Infantry. I chose (to visit) Columbus, Georgia, Fort Benning and Callaway Gardens because this truly is a homecoming.” He explained the rationale for the gold T-shirts given to registered walkers. “We are wearing these funky shirts because they stand out," he said. "When people look at us and ask why are we here with our families and why are we here as veterans and why do we do what we do, I want you to tell your story about why you are an American Legion member. I’m proud that my family is part of this journey with The American Legion. I hope you can be visible in your community to raise awareness of veterans. God bless you for being with us." The morning festivities began with a reading of a proclamation issued by Columbus mayor and city council, declaring May 14 as “Commander Dale Barnett Day.” U.S. Rep. Sanford Bishop, D-Ga., also attended the walk. “I want you to know that The American Legion is very, very special. It is the number one veterans service organization,” Bishop said. “As your member of Congress for the Second Congressional District, I can tell you firsthand that because of The American Legion, the issues that matter to veterans and their families are first and foremost on the table in Congress. And whenever (legislation) gets screwed up, The American Legion shows up, just like the cavalry, and gets it straight.” The walk raised $14,811 for Barnett's primary fundraiser, the National Emergency Fund (NEF). The NEF provides financial grants to qualified posts and Legion family members affected by declared natural disasters to help with out-of-pocket expenses, such as temporary housing, food and clothing. “Everything we’ve done for the past few years has been for Dale, our commander, our favorite son," said Department of Georgia Commander Thom Mash. "Our membership reflected that last year, and you’ll see it reflected again this year. We do it for Dale. We’re proud of him.” While Barnett frequently reminds the public of the estimated 22 veterans a day that commit suicide, Mash added a few additional reasons why The American Legion needs to "walk for those who marched for us." “A lot of thought went into that message,” Mash said. “It’s simple and right to the point. People from around the country tell me that they are in anti-veteran or anti-military states. Georgia is lucky in that sense. I think that the VA claims list and VA wait times need to be shortened, although it is going in the right direction.” During an evening homecoming banquet, Barnett reflected on highlights of the more than 30 awareness walks that he has participated in from Florida to California. “I will tell you, my Georgia American Legion family, it would have never happened if you hadn't stood behind me and allowed me to have these wonderful adventures and raise awareness about our great organization.” By John Raughter for American Legion News
Newswise — A University of Iowa researcher is working with the Veterans Administration on a pilot program to help female veterans suffering from postpartum depression. MomMoodBooster is an online intervention tool that helps mothers who live in rural areas cope with their depression. “Women in rural areas often don’t seek out or have access to mental health care,” saysMichael O’Hara, professor and Starch Faculty Fellow in the UI Department of Psychological and Brain Sciences. “Reaching out in particular to rural veteran women seemed to me like it was just something important to do.” Each year, about 300,000 new mothers in the United States suffer from postpartum depression, experiencing low moods, loss of interest in normally enjoyable activities, insomnia, appetite disturbances, difficulty concentrating, and suicidal thoughts—and O’Hara says this estimate is low. So far, about 40 women from across the country have taken part in MomMoodBooster with positive results. Over a six-week period, women participate in six sessions that target managing mood, increasing pleasant activities, managing negative thoughts, increasing positive thoughts, and planning for the future. Phone coaches also call to check in with the women, tracking progress, answering questions, and providing encouragement. O’Hara says it seems possible, given the combat experience of many female veterans, that they may be more at risk for depression, though that has not been quantified. “I was in the Navy for four-and-a-half years, and it’s not an easy life,” O’Hara says. “These are women who have served our country, and we have a way of contacting them. You put that together, and it’s sort of a winning combination.” Treating postpartum depression is important not only for mothers, but also for the well-being of their children. A depressed parent often pays less attention to the baby’s cues, either interacting less and neglecting the child or working so hard to interact that the baby becomes overwhelmed, leading to developmental problems. The self-focus caused by depression can be harmful to children in other ways as well. For example, when parents choose whether to make a meal or drive to a fast food restaurant, depression can influence them to make the easier choice. “Any time a parent is distracted by mental health concerns, this can lead to problems with the children,” O’Hara says. “We know that inconsistent parenting often makes it harder for children to internalize societal rules, a situation that often sets the stage for behavior problems. Having parents who are emotionally stable is quite a benefit to the child.” For some women, postpartum depression represents a recurrence of depression at a stressful time in their lives. For others, it stems from issues surrounding the marriage, finances, or simply the challenge of caring for an infant. Biologically, there is increasing evidence that pregnancy hormones may the set the stage for low mood, which, when combined with environmental factors, may cause postpartum depression. “The most dominant things I see are poor social support systems and conflict with the partner,” O’Hara says. The program will continue at least through the end of September, when the VA will determine whether to continue funding, and O’Hara expects to write a research study based on the results of the pilot. The MomMoodBooster project is funded by the VA Office of Rural Health and the VA Office of Women’s Health Services.
Newswise — Over the last decade, repair of the mitral valve (MV) has become widely favored over its replacement. Data available from such sources as the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) have documented this trend at non-governmental hospitals, but there is little known about mitral surgery practice in the largest federal health system in the US - the Veterans Affairs (VA) Health System. In a presentation at the 96th AATS Annual Meeting, Faisal G. Bakaeen, MD, presents data from more than 4,100 mitral valve surgeries showing that mitral valve operations are performed with low mortality in the VA and that the percentage of repair vs. replacement surgeries has increased significantly since 2001. However, despite the survival advantage for mitral repair in primary mitral regurgitation, the rate of valve repair was quite variable among the VA centers and offers an opportunity for system-wide quality improvement. Baltimore, MD, May 17, 2016 – Little is known about mitral valve (MV) surgical outcomes within the largest US federal health system – the Veterans Administration (VA) Health System. At the 96th AATS Annual Meeting, data presented from 40 VA cardiac surgery centers reveal that although MV repair rates increased from 48% in 2001 to 63% in 2013, a wide variability exists in repair rates among medical centers. This is especially important because MV repair mortality rates were significantly lower in patients with primary degenerative disease. “This large multi-center study adds further evidence to support the use of MV repair over replacement in patients with degenerative MV disease. Despite the benefits associated with MV repair, the rate of valve repair utilization varied widely among centers and presents an opportunity for education and quality improvement”, explained lead author Faisal G. Bakaeen, MD, Department of Surgery, Baylor College of Medicine, The Michael E. DeBakey VA Medical Center (Houston, TX), and the Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic (Cleveland OH). The investigators found that between 2001 and 2013, 4,165 mitral valve surgeries were performed, including 2,408 MV repairs and 1,757 MV replacements at 40 VA centers. The overall MV repair rate increased from 48% of the total number of MV surgeries to 63% in 2013. “The increased rate of MV repairs in VA hospitals mirrors the trend revealed by analyses of the STS ACSD,” commented Dr. Bakaeen. “These findings indicate that the introduction and adoption of novel surgical procedures occur in tandem at VA and non-VA facilities. This is expected because all VA cardiac programs are affiliated with academic centers and some share faculty and educational programs with their university affiliates.” The study highlighted other advantages of MV repair compared to MV replacement, including fewer complications around the time of surgery and shorter hospital stays. MV repair also showed some survival advantage. While some differences between surgical groups were sometimes not statistically significant (e.g. unadjusted and adjusted 30-day operative mortality rates), mortality rates for MV repair were significantly lower at both 180 days (2.5% vs. 5.0%) and 365 days (3.0% vs. 5.7%) in patients with primary degenerative disease. After 10 years, mortality was marginally lower for MV repair. When the investigators examined annual MV procedural volume per medical center, they found it varied widely: from 0 to 29, with a median of 7. The median number of annual MV repairs ranged from 0 to 21, with a median of 4 per center. Other studies have suggested that MV surgery volume is a significant predictor of greater MV repair use and better mitral surgery outcomes. In fact, some reports have specified that 40 MV repairs per year should be the minimum number performed annually to maintain a high level of care. This report, however, found that none of the VA centers met this 40 case per year threshold and, in fact, center volume accounted for only 19% of the total variation in facility-level MV repair. Dr. Bakaeen noted that the 40 case per year threshold may not be applicable to the VA system. “VA hospitals are not typical low-volume community hospitals. The shared-faculty model and educational collaboration that exists between some VAs and their academic affiliates may help mitigate these hospitals’ low-volume status, which would explain their good MV outcomes.” Nevertheless, he suggests that determining why MV repair rates are very low in some VA hospitals presents an opportunity for quality improvement.