VA Gulf Coast Veterans Health Care System

Biloxi, Mississippi Financial Disclosure: None reported. Correspondence: C. Neal Ellis, M.D., Department of Surgery, VA Gulf Coast Veterans Health Care System, 400 Veterans Ave, Biloxi, MS 39531. E-mail: [email protected]

Virtual reality simulation for laparoscopic colectomy has been used for training of surgical residents and has been considered as a model for technical skills assessment of board-eligible colorectal surgeons. However, construct validity (the ability to distinguish between skill levels) must be confirmed before widespread implementation.This study was designed to specifically determine which metrics for laparoscopic sigmoid colectomy have evidence of construct validity.General surgeons that had performed fewer than 30 laparoscopic colon resections and laparoscopic colorectal experts (>200 laparoscopic colon resections) performed laparoscopic sigmoid colectomy on the LAP Mentor model. All participants received a 15-minute instructional warm-up and had never used the simulator before the study. Performance was then compared between each group for 21 metrics (procedural, 14; intraoperative errors, 7) to determine specifically which measurements demonstrate construct validity. Performance was compared with the Mann-Whitney U-test (p < 0.05 was significant).Fifty-three surgeons; 29 general surgeons, and 24 colorectal surgeons enrolled in the study. The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 of 14 procedural metrics by distinguishing levels of surgical experience (p < 0.05). The most discriminatory procedural metrics (p < 0.01) favoring experts were reduced instrument path length, accuracy of the peritoneal/medial mobilization, and dissection of the inferior mesenteric artery. Intraoperative errors were not discriminatory for most metrics and favored general surgeons for colonic wall injury (general surgeons, 0.7; colorectal surgeons, 3.5; p = 0.045).Individual variability within the general surgeon and colorectal surgeon groups was not accounted for.The virtual reality simulators for laparoscopic sigmoid colectomy demonstrated construct validity for 8 procedure-specific metrics. However, using virtual reality simulator metrics to detect intraoperative errors did not discriminate between groups. If the virtual reality simulator continues to be used for the technical assessment of trainees and board-eligible surgeons, the evaluation of performance should be limited to procedural metrics.

OBJECTIVES: Examined the severity of depressive symptoms and the rates of probable depression assessed by different instruments that were included in two separate surveys of residents in a predominately rural region of the United States. METHOD: Surveys of the Brazos Valley region in south central Texas were conducted and responses to the short form of the Center for Epidemiological Studies-Depression scale (in the 2006 survey) and the Patient Health Questionnaire-9 (in the 2010 survey) were analyzed. RESULTS: Regardless of instrument used, results indicate that women and African Americans are at greater risk for depression in this underserved region, but no unique effects were found for rural residency. IMPLICATIONS: Implications for research, assessment, program planning, and policy are discussed.

OBJECTIVE: The purpose of this study was to determine if veterans with posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) are treated differently pharmacologically than patients with PTSD alone. METHODS: A retrospective evaluation of PTSD pharmacotherapy of Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD (N=707) was conducted between April 1, 2007, and March 31, 2009. A total of 45 veterans had suffered a mild TBI. RESULTS: Compared with the patients with PTSD alone, the patients with PTSD and TBI were more likely to be prescribed an antidepressant (p<.001), a sedative-hypnotic (p<.001), or an antipsychotic (p=.024). The patients with TBI were also significantly more likely to receive psychotropic polypharmacy (p=.001) and to receive higher doses of psychiatric medications (p=.03). CONCLUSIONS: The differences in drug therapy found in this study may indicate that patients with TBI and PTSD respond differently to treatment than patients with PTSD alone.

INTRODUCTION: Granular cell tumors (GCTs) are of neuroectodermal origin and account for 0.5% of soft tissue tumors. They are most prevalent in African-Americans in the fourth to sixth decades, with a predilection for the head and neck regions. GCTs usually resemble more common lesions and hence are difficult to diagnose preoperatively. The tumor is readily identified on needle biopsy. Although usually benign with a malignancy rate of only 2-3%, the malignant form has a reported 3-yr mortality of 60%. MATERIALS AND METHODS: Clinical records of the Gulf Coast Veterans Healthcare System were surveyed for the period 1996-2016. Thirteen cases of GCT were found and reviewed for demographics, clinical course, method of diagnosis, management, and outcome. RESULTS: All patients had a solitary GCT. Eleven lesions were benign and two were atypical. Sites involved were skin (8), colon (2), larynx (1), bronchus (1), and esophagus (1) (see Table I). The two atypical lesions occurred in the skin and larynx. Skin tumors were slow-growing, painful nodules, and, except for the two with preoperative needle biopsies, were misdiagnosed as epidermal inclusion cysts, lipoma, and papillary condyloma. Two colon lesions resembling a sessile polyp and submucosal lipoma, respectively, were found on colonoscopy performed for occult blood in the stool. The bleeding was attributed to adenomatous polyps also present. An atypical laryngeal GCT, found on laryngoscopy for hoarseness, was removed by submucosal resection. A bronchial GCT, excised during bronchoscopy for atelectasis, required re-excision 3 mo later. The esophageal GCT was an incidental finding on EGD for a dilated esophagus and gastric outlet obstruction. The patient declined surgical excision and elected MRI follow-up. CONCLUSION: Granular cell tumors are infrequent and usually resemble more common lesions. Although almost always benign, the malignant form has a very poor prognosis. It is important to identify GCT preoperatively by fine-needle aspiration or core needle biopsy to improve outcome.

OBJECTIVE: Although intrusive cognition (IC) is remarkably common in soldiers postdeployment and successful coping with ICs may predict better long-term psychological health, few elements of current programmatic postdeployment trainings have directly addressed adaptive strategies for managing intrusive deployment-related cognitions. The current study explored the efficacy of a brief acceptance-based skills training for coping with ICs relative to a change-based skills training, a psychoeducation-only training, or training as usual. METHOD: Participants were 1,524 (1,372 men) active-duty U.S. Army soldiers between 3 and 12 months' postdeployment. RESULTS: Soldiers who received acceptance-based training demonstrated larger reductions in distress and impairment related to ICs about deployment at 1 month follow-up and larger reductions in symptoms of PTSD and general psychopathology relative to other training conditions. In contrast, participants in the change-oriented skills training showed relatively fewer benefits than did those in the acceptance-based training. In addition, soldiers who received the psychoeducation-only training showed no benefits relative to training as usual. CONCLUSIONS: Results suggest that brief trainings focused on postdeployment ICs may have benefits for soldiers up to 1 month later and may be a useful addition to a broader postdeployment transition program. Findings also indicate that an acceptance-based training approach may be more beneficial than a change-oriented approach for helping soldiers manage ICs and that psychoeducation alone may be insufficient for helping soldiers manage these cognitions. (PsycINFO Database Record

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Although it is an uncommon cause of knee pain and swelling, synovial chondromatosis should be included in the differential diagnosis when evaluating adults aged 30 years to 50 years with knee pain of insidious onset.

Few protocols have been published for the dental management of patients with head and neck cancer to prevent complications from head and neck radiation therapy. Radiation therapy not only affects the tumor cells targeted, but also the dentition, bone, salivary gland, and oral soft tissue structures. A comprehensive dental evaluation prior to head and neck radiation therapy can help prevent many complications. The following clinical guidelines were established by a workgroup of oral health providers within the Department of Veterans Affairs. This workgroup focused on developing a set of recommendations regarding dental care prior to the initiation of head and neck radiation therapy based on the best clinical evidence and expert consensus. A systematic algorithm was developed for the evaluation including pre-exam data gathering, examination, education, and treatment, followed by maintenance and postradiation dental follow-up. This document is evidence-based, patient-centered, consistent with accepted practices of care and safety, and in accordance with applicable statutes and regulations.

The incidence of episodes of harassment and rape among military populations has only recently been examined. In the present study, a sample of 336 female veterans in a primary care setting was assessed. The incidences of lifetime sexual victimization, anxiety, depression, and impact of trauma for victims of specific trauma contexts are presented. Results of the study indicated that female veterans with a history of cumulative rape experiences and civilian rape experiences are more at risk for anxiety and depression than those with only a military experience of rape. No significant differences were found for impact of event scores for different contexts of rape, however. Reporting of trauma was not associated with psychological well-being for women veterans. The results highlight the role of the socioenvironmental context of abuse as an important variable to examine, especially in military populations.

This article presents a review of issues and considerations when developing a comprehensive military sexual trauma (MST) treatment program. A review of the current literature was conducted, which we argue is the first step in informing programmatic design. Next, information on how to obtain local public data and then a description of how we used this information to design the new MST program at our facility are discussed. Our clinic design reflects best practice while simultaneously incorporating real-world information and will be more likely to positively influence overall care to patients. As such, we recommend that clinicians involved in clinic development will use this process as a model for successful clinic planning and program development.

The authors present an existential framework for conceptualizing and intervening with adolescent females who are in violent relationships. Interventions involve addressing the adolescent female's anxiety associated with I. D. Yalom's (1980) constructs of meaning, death, isolation, and freedom. The goal of therapy is to assist the abused adolescent in the creation or transformation of meaning.

OBJECTIVES: To determine the prevalence of polypharmacy in patients presenting with dizziness to a tertiary neurotology clinic and analyze the association between polypharmacy and clinical characteristics. DESIGN: Retrospective, cross-sectional review. Demographics, symptoms, diagnoses, medications, audiometry, dizziness handicap index (DHI) scores, and cognitive failure questionnaire (CFQ) scores were extracted from charts of patients seen as new patients from September 1, 2019, to March 31, 2020, with a primary complaint of dizziness. RESULTS: A total of 382 patients were included. More than two-thirds of the patients (n = 265, 69.4%) met criteria for polypharmacy (≥5 medications), of which most (n = 249, 94.0%) were prescribed a potentially ototoxic drug. Approximately 10% of patients were taking five or more ototoxic medications (oto-polypharmacy). Polypharmacy was correlated to age and was more common for patients with diabetes, hypertension, other cardiovascular comorbidities, and depression (odds ratio [OR], 3.73-6.67; p < 0.05). Polypharmacy was twice as likely in patients with mild to moderate hearing loss (OR 2.02 [1.24-3.29] and OR 2.13 [1.06-4.27], respectively; p < 0.05) and ~1.5× more likely in patients who had moderate to severe DHI scores (OR 1.65 [1.05-2.59] and OR 1.63 [1.00-2.65], respectively; p < 0.05). Patients with polypharmacy also had higher CFQ scores compared to those without polypharmacy (CFQ 32.5 [19.0-48.0] versus CFQ 25.0 [13.0-40.0]; p = 0.002. Oto-polypharmacy was more common for patients with lightheadedness as a dizziness descriptor (OR 3.16 [1.56-6.41]; p < 0.01). However, oto-polypharmacy was only more common for patients with mild to moderate hearing loss (OR 2.69 [1.33-5.45] and OR 2.86 [1.31-6.20], respectively; p < 0.01) and severe DHI scores (2.31 [1.12-4.77], p = 0.02). CONCLUSIONS: The prevalence of polypharmacy in patients with vestibular disorders is high. Some of the medications that patients are on are also potentially ototoxic at variable degrees. Polypharmacy is more common when lightheadedness is one of the dizziness descriptors and seems to be associated with worse scores on patient-reported outcome measures (DHI, CFQ). Medication reconciliation and multidisciplinary involvement could help to better address polypharmacy in this patient population. However, further investigation is needed to elucidate polypharmacy's role in symptom presentation, vestibular testing results, and therapeutic strategies.

Purpose – The purpose of the paper is to extend prior research on the psychological effects of the Deepwater Horizon oil spill disaster by developing and testing a conceptual model in which exposure to the oil spill through clean-up activity, physical symptoms, worry about the impact of the oil spill on health, and the disruption of the gulf/ocean-related lifestyle were hypothesized as predictors of depressive symptoms. Design/methodology/approach – The analysis included a randomly selected sample of 354 subjects from the three most Southern Mississippi counties. The Center for Epidemiologic Studies Depression Scale was used to measure depressive symptoms. Findings – Results indicated that physical symptoms since the oil spill were related to depressive symptoms directly and indirectly through worry about the impact of the oil spill on health and the disruption of the gulf/ocean-related lifestyle. Worry about the impact of the oil spill on health was related to depressive symptoms directly and indirectly through the disruption of the gulf/ocean-related lifestyle. Originality/value – Study results highlight that uncertainty and worry about the impact of the disaster played a critical role in understanding the psychological effects of the oil spill disaster, especially among coastal residents whose lifestyles were bound up with the gulf/ocean.

BACKGROUND: Because healthy habits are established early in life, it is important to teach young children about foods that contribute to a healthy diet. One of the strategies recommended by the 2015-2020 Dietary Guidelines is to implement educational programs in community settings such as child care and preschool settings. Head Start is one such educational child care setting that serves young children ages 3 to 5 years old. METHODS: A community partnership was established between Jackson County Civic Action Agency and supported by the Mississippi Gulf Coast Youth Health Coalition's Childhood Obesity Initiative. A quasi-experimental nonequivalent 2-group pre/post-test study design was utilized to determine the effectiveness of a 12-week physical activity and nutrition education program delivered in a Head Start setting. RESULTS: There was a statistically significant improvement in fruit (F = 5.602, df = 1, p = .018) and vegetable (F = 16.061, df = 1, p < .001) recognition scores, and the number of "tried and liked" fruits (F = 5.579, df = 1, p = .019) and vegetables (F = 88.559, df = 1, p < .001) between children in the control group (n = 86) and intervention group (n = 303) when controlling for scores at baseline. CONCLUSION: Utilizing the Head Start program as a setting for health education program delivery is one available strategy to combat childhood obesity on a community level.

BACKGROUND: To identify patients with a high risk of 30-day mortality after elective surgery, who may benefit from referral for tertiary care, an institution-specific process using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) Risk Calculator was developed. The goal was to develop and validate the methodology. Our hypothesis was that the process could optimize referrals and reduce mortality. STUDY DESIGN: A VASQIP risk score was calculated for all patients undergoing elective noncardiac surgery at a single Veterans Affairs (VA) facility. After statistical analysis, a VASQIP risk score of 3.3% predicted mortality was selected as the institutional threshold for referral to a tertiary care center. The model predicted that 16% of patients would require referral, and 30-day mortality would be reduced by 73% at the referring institution. The main outcomes measures were the actual vs predicted referrals and mortality rates at the referring and receiving facilities. RESULTS: The validation included 565 patients; 90 (16%) had VASQIP risk scores greater than 3.3% and were identified for referral; 60 consented. In these patients, there were 16 (27%) predicted mortalities, but only 4 actual deaths (p = 0.007) at the receiving institution. When referral was not indicated, the model predicted 4 mortalities (1%), but no actual deaths (p = 0.1241). CONCLUSIONS: These data validate this methodology to identify patients for referral to a higher level of care, reducing mortality at the referring institutions and significantly improving patient outcomes. This methodology can help guide decisions on referrals and optimize patient care. Further application and studies are warranted.

Diabetes is the seventh leading cause of death in the United States and contributes to long-term complications that are costly to healthcare systems. Twenty-five percent of all veterans in the Veterans Health Administration (VHA) have diabetes. The purpose of this article is to describe the development and implementation of a quality improvement project to embed an evidence-based diabetes screening tool, based on Veterans Affairs/Department of Defense diabetes clinical practice guidelines, into the VHA electronic medical record. The objectives of the screening tool were threefold: to promote evidence-based care, to standardize care coordination, and to promote self-management and proper utilization of resources. Record reviews were conducted to evaluate the effectiveness of the screening tool. Results showed an 88 percent increase in the assessment of annual exams and/or labs, a 16.5 percent increase in disease management assessment and offering of services, and a 50 percent increase in goal-setting activity.

OBJECTIVES: (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. DATA SOURCES AND SETTING: We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. STUDY DESIGN: We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. DATA EXTRACTION: We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. PRINCIPAL FINDINGS: The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. CONCLUSIONS: Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.

OBJECTIVE: This study compared causes of death, crude mortality rates, and standardized mortality ratios (SMRs) between decedents with mental illness in Ohio's publicly funded mental health system ("mental illness decedents") and all Ohio decedents. METHODS: Ohio death certificates and Ohio Department of Mental Health service utilization data were used to assess mortality among decedents from 2004 to 2007. Age-adjusted SMRs and age-adjusted mortality rates were calculated across race and sex strata. RESULTS: Mental illness decedents accounted for 3.3% of all 438,749 Ohio deaths. Age-adjusted SMRs varied widely across the race and sex strata and by cause of death. Nonblacks with or without mental illness showed higher SMRs than blacks. Nonblack females with mental illness showed the highest SMRs in injury-related deaths. Higher SMRs were found for deaths associated with substance abuse; mental illness; diabetes; issues related to the nervous, cardiovascular, or respiratory systems; and injury. With and without mental illness, the top cause of death was violence for youths and cardiovascular disease for adults >35. CONCLUSIONS: Deaths from injury and violence, especially among those <35, should be specifically addressed to reduce excess mortality for persons with mental illness. Mental health care should be integrated with primary care to better manage chronic disease, especially cardiovascular disease. Methodological contributions included use of linked files to compare SMR and leading causes of death between mental illness decedents and all Ohio decedents. More research is needed on patterns in cause of death and any interactions from demographic characteristics and mental illness. Health care data silos must be bridged between private and public sectors and the Departments of Veterans Affairs and Defense.

This analysis was undertaken to better understand what factors may contribute to the relative strength or weakness of the clinical social work professional workforce. We explored the relationship between social work workforce numbers and social work licensure laws/policies. We also examined relationships between population factors and mental health workforce, including examining ratios of other mental health professions nationwide. Additionally, we explored mental health workforce strengths as it relates to state mental health needs and utilization of mental health services. Our findings were consistent with past research with respect to proportion of overall mental health workforce across mental health professionals. We did not find a direct relationship between licensure laws/policies and state social work workforce numbers. However, we found some relationships between the ratio of social workers to the population and state health rank, as well as the overall mental health workforce availability in a state. In addition, a relationship was found between ratio of social workers to the population and adults with mental illness not receiving care. Given the results, the authors posit that these findings could be used to promote the social work discipline in targeted ways, such as promotion of the discipline in states where mental health needs are underserved or in states with lower health rankings. Factors to consider at the macro and micro levels, as well as interprofessional issues in training and work, are discussed. We believe the findings from this analysis can be used to inform policy and promote the discipline of social work.