Acute effects of intraperitoneal versus subcutaneous insulin delivery on glucose homeostasis in patients with NIDDM. Veterans Affairs Implantable Insulin Pump Study Group

OBJECTIVE: The objective of this study is to compare the effect of intraperitoneal versus subcutaneous insulin injection on hepatic glucose production (HGP) and systemic glucose utilization (Rd) in patients with NIDDM. RESEARCH DESIGN AND METHODS: Eight male volunteers with NIDDM, each of whom had a programmable-rate, implantable insulin pump, were given an injection of insulin (0.15 units/kg body wt) by intraperitoneal or subcutaneous injection on separate days in randomized order. Plasma glucose was kept constant for 5 h using the glucose clamp technique, and HGP and Rd were measured using isotope dilution. RESULTS: Intraperitoneal insulin injection resulted in higher and earlier peak systemic insulin concentrations (1,469 +/- 245 vs. 454 +/- 48 pmol/l, P < 0.01). Glucose Rd doubled within 1 h after intraperitoneal injection and was greater than that attained with subcutaneous injection (3.91 +/- 0.27 vs. 2.60 +/- 0.19 mg.kg-1.min-1, P < 0.01). Intraperitoneal and subcutaneous injections suppressed HGP and plasma free fatty acid to a similar extent during the first 3 h, effects tht persisted through 5 h after subcutaneous insulin injection but waned 3-4 h after intraperitoneal injection. CONCLUSIONS: In patients with NIDDM, intraperitoneal insulin injection achieves more rapid and greater peak values for stimulation of glucose Rd than subcutaneous insulin injection. With regard to HGP and lipolysis, intraperitoneal and subcutaneous injections achieve similar initial suppression but this is maintained for a more limited duration with intraperitoneal as compared with subcutaneous injection. These differences in insulin action seem directly related to the rapidity of insulin absorption with intraperitoneal injection.     

Effects of Age and Hypertension Status on Cognition: The Veterans Affairs Normative Aging Study.

The authors examined the influence of age and hypertensive status (normotensive, controlled, untreated, or uncontrolled) on several cognitive tests via multiple regression in 357 nondemented, community-dwelling older men (mean age = 67 years) whose hypertensive status was stable over 3 years and who had no medical comorbidities. Age was negatively associated with performance on all but 1 test. Age interacted with hypertensive status on verbal fluency and word list immediate recall; older uncontrolled hypertensives exhibited significantly larger age decrements on these tests compared with normotensives. These findings suggest that uncontrolled hypertension produces specific cognitive deficits beyond those attributable to age alone. These and previous findings illustrate that health conditions such as hypertension should be regularly considered in studies of "normal" cognitive aging. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study

In a curative resection for advanced sigmoid or rectal cancer, an extensive dissection of the regional lymph nodes is generally required. This often necessitates the removal of the autonomic nerves around the inferior mesenteric artery. The present study was done in an attempt to clarify the influence of a neurectomy around the inferior mesenteric ganglion and plexus on the motility of the colon. In eight dogs, we resected the ganglion and plexus around the inferior mesenteric artery, together with an implantation of strain gauge force transducers in various parts of the colon, and 7-10 days later, colonic motility was examined. The percentage of contractile states and contractile forces increased at both the distal colon in fasting dogs, as well as at the middle colon in the late postprandial period. At the distal colon, contractile forces were noted in the early and late postprandial periods. These contractile abnormalities at the middle and distal colon may thus explain the frequent bowel movements or diarrhea often observed after extensive surgery in patients with sigmoid or rectal cancer.     

Heart protection: controlling risk factors for cardiovascular disease

Cardiovascular disease is the leading cause of illness and death in the United States. Clinical data continue to support primary prevention through the aggressive treatment of well-defined cardiovascular risk factors. Three risk factors that can be modified to lower the risk of cardiovascular disease and death are hypercholesterolemia, hypertension, and cigarette smoking. Even patients with asymptomatic cardiovascular disease have been shown to benefit from aggressive cholesterol-lowering therapy. New JNC-VI guidelines for managing hypertensive disease recommend that treatment decisions be based on level of blood pressure plus presence or absence of target organ damage or other risk factors. The risk of myocardial infarction in former smokers approaches that of nonsmokers after 3 years.     

Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group

A review of the mechanism of throwing is presented and split into the different phases. The presentation and history is often more important than the clinical signs which may only be present after repetitive throwing activity. The pathological relationship between instability and impingement is discussed. Arthroscopy has been found to be extremely helpful in extending knowledge of pathological anatomy as well as defining diagnosis and aiding treatment.     

Adverse effects of diabetes on multiple cardiovascular disease risk factors in women. The Strong Heart Study

OBJECTIVE: Many studies have shown that diabetes increases the risk of cardiovascular disease (CVD) in women to a greater extent than in men. One explanation could be that diabetes has more adverse effects on CVD risk factors in women than in men. We compared diabetes-associated differences in CVD risk factors in men and women in the Strong Heart Study, a population-based study of CVD and its risk factors in American Indians. RESEARCH DESIGN AND METHODS: A total of 1,846 men and 2,703 women between the ages of 45 and 74 years from 13 American Indian communities in three geographic areas underwent an examination that included a medical history; an electrocardiogram; anthropometric and blood pressure measurements; an oral glucose tolerance test; and measurements of fasting plasma lipoproteins, fibrinogen, insulin, HbA1c, and urinary albumin. RESULTS: Statistically significantly greater adverse differences in those with diabetes versus those without diabetes were observed in women than in men for waist-to-hip ratio, HDL cholesterol, apolipoprotein (apo)B, apoA1, fibrinogen, and LDL size. In multiple linear regression models adjusting for age, center, sex, and diabetes, the diabetes by sex interaction terms were statistically significant for waist-to-hip ratio, LDL cholesterol, HDL cholesterol, apoB, apoA1, fibrinogen, and LDL size. CONCLUSIONS: Compared with diabetes-associated differences in men, diabetes in women was related to greater adverse differences in levels of several CVD risk factors. Although the magnitude of the individual diabetes-related differences between men and women was not large, the combined effects of these risk factor differences in diabetic women may be substantial. The apparent greater negative impact of diabetes on CVD risk factors in women may explain, in part, the greater risk for CVD in diabetic women.     

Antihypertensive efficacy of treatment regimens used in Veterans Administration hypertension clinics. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents

There is continuing uncertainty about whether morbidity and mortality of treated hypertensive patients depends on the drug(s) used to treat or only on the level of blood pressure achieved. This study was undertaken in a sample of special Veterans Administration hypertension clinics to determine which antihypertensive drugs were selected by the involved healthcare providers and how effective they were in achieving normotension. Hypertensive veterans (n = 6100) were followed in six VA Hypertension Screening and Treatment Program clinics for 46 months beginning in May 1989. Their average age was 60.7 years; 53% lived in the Stroke Belt; 46% had target organ damage, 36% were black, 23% smoked, and 10% had diabetes mellitus. Antihypertensive regimens were divided into 12 all-inclusive categories. Blood pressures were averaged at the last study visit for all patients on a regimen. The regimens of diuretic or diuretic plus beta-blocker gave the lowest average pressures (140.6/82.3 mm Hg) and calcium antagonist the highest (149.0/86.5 mm Hg). ANOVA indicated that differences between seven common regimens and also between the four single drug regimens were highly significant (P<.0001). This pattern of low treated pressure with the "old" agents and higher treated pressure with newer agents was reflected in the percentage of patients controlled below 140/90 mm Hg and the percentage uncontrolled above 159/94 mm Hg. Blacks and patients with target organ damage resembled the entire cohort in average treated diastolic blood pressure, but the former had lower and the latter had higher treated systolic blood pressure than the entire cohort.     

Change in Life Satisfaction During Adulthood: Findings From the Veterans Affairs Normative Aging Study.

Change in life satisfaction was modeled over a 22-year period in 1,927 men. A curvilinear relationship emerged. Growth-curve models indicated that life satisfaction peaked at age 65 and then declined, but showed significant individual differences in rate of change. Extraversion predicted variability in change, with higher levels associated with a high and flat life satisfaction trajectory. Time-varying physical health and marital status were associated with higher life satisfaction. Proximity to death was associated with a decline in life satisfaction. On measurement occasions that were within 1 year before death, trajectories showed steeper decline, and this effect was not attributable to declines in self-rated physical health. The findings are at odds with prior (cross-sectional) research showing that subjective well-being improves with aging. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age relations of cardiovascular risk factors in a traditional Melanesian society: the Kitava Study

This study examined cross-sectional age relations of blood pressure, anthropometric indexes, serum lipids, and hemostatic variables in 203 subsistence horticulturists aged 20-86 y in Kitava, Trobriand Islands, Papua New Guinea. The population is characterized by extreme leanness (despite food abundance), low blood pressure, low plasma plasminogen activator inhibitor 1 activity, and rarity of cardiovascular disease. Tubers, fruit, fish, and coconut are dietary staples whereas dairy products, refined fat and sugar, cereals, and alcohol are absent and salt intake is low. Although diastolic blood pressure was not associated with age in Kitavans, systolic blood pressure increased linearly after 50 y of age in both sexes. Body mass index decreased with age in both sexes. Serum total cholesterol, triacylglycerol, low-density-lipoprotein cholesterol, and apolipoprotein B increased in males between 20 and 50 y of age, whereas high-density-lipoprotein cholesterol and apolipoprotein A-I decreased. There were no significant differences in these indexes with age in the few females studied. A slight linear age-related increase of lipoprotein(a) was present in males. Plasma fibrinogen, factor VII clotting activity, factor VIII clotting activity, and von Willebrand factor antigen increased with age in both sexes but plasminogen activator inhibitor 1 activity did not. The modest or absent relations between the indexes measured and age are apparently important explanations of the virtual nonexistence of stroke and ischemic heart disease in Kitava.     

Adapting the multifamily group model to the Veterans Affairs system: The REACH Program.

[Correction Notice: An erratum for this article was reported in Vol 41(4) of Professional Psychology: Research and Practice (see record 2010-17073-006). The copyright for this article was incorrectly listed. This article is in the Public Domain. The online version has been corrected.] The Oklahoma City Veterans Affairs (VA) Medical Center modified an evidence-based model of family psychoeducation (the multifamily group model; McFarlane, 2002) and implemented it for the first time in a VA setting and with veterans living with posttraumatic stress disorder (PTSD). Named the REACH Program (Reaching out to Educate and Assist Caring, Healthy Families), the 3-phase program begins with 4 weekly “joining sessions” with the individual veteran and his/her family focused on rapport building, assessment, and goal setting. Phase II consists of 6 weekly diagnosis-specific educational/support sessions for cohorts of 4 to 6 veterans and their families. In Phase III, veterans/families attend 6 monthly multifamily groups to support the maintenance of gains. This article describes the rationale for modifying the original Multifamily Group Program (MFG) for a unique setting (the VA) and the needs of families of veterans in a new diagnostic group (PTSD). The changes to the MFG curriculum are specifically described, and details of the new REACH intervention are explained. Attendance, retention, and satisfaction data for 2 diagnostic cohorts, PTSD and affective disorders, are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term quality of life after treatment of laryngeal cancer. The Veterans Affairs Laryngeal Cancer Study Group

OBJECTIVE: To assess long-term quality of life in surviving patients with advanced laryngeal cancer. DESIGN: A follow-up long-term quality-of-life survey of patients randomized to the Veterans Affairs Laryngeal Cancer Study No. 268 on induction chemotherapy and radiation (CT + RT) vs surgery and RT. SETTING AND PATIENTS: Forty-six (71%) of the 65 surviving patients with prior stage III or IV laryngeal cancer who could be contacted completed the survey: 25 from the surgery and RT group and 21 from the CT + RT group. Baseline demographic and clinical characteristics among survey respondents were similar, except that those in the CT + RT group were significantly older (mean, 61.2 years) than those in the surgery and RT group (mean, 55.7 years; P<.05). INTERVENTIONS AND MAIN OUTCOME MEASURES: Patients completed the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, the Medical Outcomes Studies Short-Form 36 (SF-36) general health survey, the Beck Depression Inventory as well as smoking and alcohol consumption surveys. RESULTS: Patients randomized to the CT + RT group had significantly better (P<.05) quality-of-life scores on the SF-36 mental health domain (76.0) than the surgery and RT group (63.0), and also had better HNQOL pain scores (81.3 vs 64.3). Compared with patients who underwent laryngectomy, patients with intact larynges (CT + RT with larynx) had significantly less bodily pain (88.5 vs 56.5), better scores on the SF-36 mental health (79.8 vs 64.7), and better HNQOL emotion (89.7 vs 79.4) scores. More patients in the surgery and RT group (28%) were depressed than in the CT + RT group (15%). CONCLUSION: Better quality-of-life scores in the CT + RT groups appear to be related to more freedom from pain, better emotional well-being, and lower levels of depression than to preservation of speech function.     

The SAFE Program: A family psychoeducational curriculum developed in a Veterans Affairs medical center.

One of the unintended positive consequences of deinstitutionalization and managed care restrictions has been an increased awareness of the impact of serious mental illness on the family. The Support and Family Education (SAFE) Program: Mental Health Facts for Families is a 14-session curriculum of monthly workshops for caregivers. In contrast to similar programs, the SAFE Program is facilitated by mental health professionals, is not diagnostic specific, and includes attention to posttraumatic stress disorder. Three years of outcome data reveal that program attendance is related to increased understanding of mental illness and enhanced awareness of Veterans Affairs resources. Workshop attendance is positively correlated with improvements in participants' self-care. The entire SAFE Program manual is available free of charge on the Internet (http://w3.ouhsc.edu/safeprogram). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Variation in utilization of cardiac procedures in the Department of Veterans Affairs health care system: effect of race

OBJECTIVES: Utilization rates for cardiac catheterization and cardiac surgery in the Department of Veterans Affairs (VA) health care system were studied to determine whether racial differences existed in a delivery plan in which access is not determined by patient finances. BACKGROUND: Prior studies have demonstrated significant differences in utilization of cardiac diagnostic and therapeutic resources by white and black patients. Reasons for the reduced utilization by black patients include socioeconomic, biologic and sociocultural effects. METHODS: Computerized discharge records of 30,300 patients with coronary artery disease and 1,335 patients with valvular heart disease who were discharged from any of 172 VA Medical Centers between October 1, 1990 and September 30, 1991 were studied. RESULTS: For patients with coronary artery disease, utilization rates of cardiac catheterization were significantly greater for white patients (503.4 procedures/1,000 patients) than for black patients (433.2/1,000 patients), with a relative odds ratio of 1.33. Rates for surgery (179.0 vs. 124.5/1,000 patients) were also greater for whites than for blacks, with a relative odds ratio of 1.53. For the subset with valve disease, the catheterization rate was significantly greater for whites than for blacks (575.4 vs. 432.6 procedures/1,000 patients), with a relative odds ratio of 1.78. Surgical rates were not significantly different (423.8 vs. 354.6 operations/1,000 patients). Racial differences for both catheterization and surgery varied widely as a function of geographic region and the level of complexity of the local VA facility. CONCLUSIONS: Racial differences in resource utilization exist in a health care system in which economic influences are minimized. The pattern of these differences depends on numerous variables and suggests both biologic and sociocultural factors as underlying causes.     

Transdermal estrogen replacement therapy: beneficial effects on hemostatic risk factors for cardiovascular disease

OBJECTIVES: To assess the effect of estrogen replacement therapy on hemostatic risk factors for cardiovascular disease (CVD) in postmenopausal women during 2 years of treatment. METHODS: In an open prospective study, patients (n = 42) were investigated before and during 2 years of treatment, and compared to an untreated postmenopausal control group (n = 18) followed during the same period, healthy premenopausal women (n = 20) being included as a reference group for premenopausal values. The patients underwent treatment with transdermal 17 beta-estradiol (E2) (50 micrograms/24 h), oral medroxyprogesterone acetate (5 mg/day) being added for 12 days every second month. RESULTS: After 2 years of treatment there was a significant increase in t-PA antigen (P = 0.01) and a significant decrease in F VII antigen (P = 0.01). PAI-1 antigen concentrations decreased slightly. Fibrinogen concentrations were already significantly decreased at 3-month follow-up (P = 0.01), and were still low after 2 years. By contrast, at 2-year follow-up the postmenopausal control group manifested significant increases in F VII and PAI-1 antigen and slight increases in fibrinogen, which resulted in significant differences between patients and controls. Regression analysis showed the increase in the serum estradiol concentrations to be inversely correlated to the decreases in the plasma concentrations of F VII antigen (r = -0.34, P = 0.001) and fibrinogen (r = -0.35, P = 0.001). There were no changes in AT III or protein C in any group. CONCLUSIONS: The increase in serum estradiol concentrations due to replacement therapy did not adversely affect the studied components of the fibrinolytic and protein C defense system against thrombosis, and resulted in beneficial decreases in F VII antigen and fibrinogen. These findings may help to explain the beneficial effects of estrogen replacement therapy in terms of protection from cardiovascular disease.     

Change in the Department of Veterans Affairs: what should be done?

Health care in the Department of Veterans Affairs is undergoing the most dramatic change since the era following World War II. The Congress has supported the Undersecretary for Health in his guidance of this change. Traditional hospital-based, specialty-focused care has given way to outpatient and primary care focused health care. Administrative authority has been shifted to 22 Veterans Integrated Service Networks (VISNs). Research goals are being reoriented, and neurology resident allocation is being reduced. VA neurologists and neurology chairs must organize strong service lines in their own VA facilities and in their networks to provide care for veterans with neurologic diseases. VA neurologists must also emphasize their role in principal care and increase their involvement in outcomes research.