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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER    |   |   |   |   |
|                                                          |   |   |   |   |
| ### *Annual Report: Fiscal Year [2006]{.underline}*      |   |   |   |   |
|                                                          |   |   |   |   |
| ######## Part II: Accomplishments                        |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** The **GRECC Annual Report** reflects status    |   |   |   |   |
| and accomplishments of **[GRECC Core Staff]{.underline}  |   |   |   |   |
| \*** (as defined below) [only]{.underline}. The          |   |   |   |   |
| **"Report Year"** is from [October 1, 2005 through       |   |   |   |   |
| September 30, 2006]{.underline}.                         |   |   |   |   |
|                                                          |   |   |   |   |
| You are welcome to use this report format for your own   |   |   |   |   |
| internal reporting purposes,                             |   |   |   |   |
|                                                          |   |   |   |   |
| in which case you may exceed the recommended limits of   |   |   |   |   |
| numbers of responses and their length                    |   |   |   |   |
|                                                          |   |   |   |   |
| ("list no more than..." "Describe the three most         |   |   |   |   |
| important..." "limit your response to five lines or      |   |   |   |   |
| fewer")                                                  |   |   |   |   |
|                                                          |   |   |   |   |
| ***\-\--BUT\--***                                        |   |   |   |   |
|                                                          |   |   |   |   |
| Please limit **to ten pages or fewer** the version       |   |   |   |   |
| **SUBMITTED TO VACO**.                                   |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **\*[GRECC Core Staff ]{.underline}**is limited to       |   |   |   |   |
| either **Primary Core**, **Affiliated Core**, or         |   |   |   |   |
| **Research Core**:                                       |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Primary Core =** positions authorized by the       |   |   |   |   |
|     original GRECC allocation plus any addition in       |   |   |   |   |
|     ceiling from VA Central Office specifically          |   |   |   |   |
|     designated for GRECC.                                |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Affiliated Core** = Staff who work full- or        |   |   |   |   |
|     part-time in [direct support]{.underline} of the     |   |   |   |   |
|     GRECC's research, education or clinical activity.    |   |   |   |   |
|                                                          |   |   |   |   |
|     -   May be either "contributed" by the VA Medical    |   |   |   |   |
|         Center or                                        |   |   |   |   |
|                                                          |   |   |   |   |
|     -   May have been acquired through centralized       |   |   |   |   |
|         enhancements/awards for programs\                |   |   |   |   |
|         (e.g., Home-Based Primary Care, Geriatric        |   |   |   |   |
|         Evaluation and Management Program, etc.)         |   |   |   |   |
|                                                          |   |   |   |   |
|     -   To be considered Affiliated Core, staff must be  |   |   |   |   |
|         organizationally aligned under the GRECC or      |   |   |   |   |
|         specifically identified by the Medical Center as |   |   |   |   |
|         **"GRECC-affiliated staff."**                    |   |   |   |   |
|                                                          |   |   |   |   |
| -   **Research Core** = Full-or part-time staff who      |   |   |   |   |
|     devote 51% or more of their total time to GRECC      |   |   |   |   |
|     research and whose salaries are supported by         |   |   |   |   |
|     research funds (either VA or non-VA). Includes all   |   |   |   |   |
|     GRECC staff whose salaries are paid from research    |   |   |   |   |
|     funds, e.g.:                                         |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Associate Investigator                           |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Assistant Research Scientist                     |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Senior Research Career Scientist                 |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Research Career Scientist                        |   |   |   |   |
|                                                          |   |   |   |   |
|     -   Advanced Research Career Scientist.              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **[IMPORTANT:]{.underline} Throughout this report,       |   |   |   |   |
| please AVOID/MINIMIZE JARGON. Each response is much more |   |   |   |   |
| likely to be included in secondary communications        |   |   |   |   |
| derived from the Annual Reports if it can be readily     |   |   |   |   |
| understood by a non-technical readership.**              |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **1. GRECC NAME/LOCATION**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **GRECC Name:** Baltimore GRECC                      |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Location** *(facility, VISN)*: Baltimore Veterans  |   |   |   |   |
|     Affairs Medical Center, VA Maryland Health Care      |   |   |   |   |
|     System, VISN 5                                       |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **2. CONTACT PERSON**                                    |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| a.  **Name:** Andrew P. Goldberg, M.D.                   |   |   |   |   |
|                                                          |   |   |   |   |
| b.  **Position:** Director, Baltimore GRECC              |   |   |   |   |
|                                                          |   |   |   |   |
| c.  **Phone, e-mail:** (410) 605-7183;                   |   |   |   |   |
|     agoldber@grecc.umaryland.edu                         |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **3. GRECC FOCUS AREA(S)**                               |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **NOTE:** Please succinctly list your GRECC's Focus      |   |   |   |   |
| Area(s), one per line below. After each focus area       |   |   |   |   |
| listed, please indicate with a check mark (****) which  |   |   |   |   |
| of the research type(s) suitably describes the work      |   |   |   |   |
| conducted (including planning, implementation, analysis, |   |   |   |   |
| and dissemination/publication) within that focus during  |   |   |   |   |
| the Report Year. Add additional lines by positioning     |   |   |   |   |
| your cursor at the lower right side of the table and     |   |   |   |   |
| striking the "Tab" key.                                  |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| **GRECC Focus Area**                                     | * |   |   |   |
|                                                          | * |   |   |   |
|                                                          | R |   |   |   |
|                                                          | e |   |   |   |
|                                                          | s |   |   |   |
|                                                          | e |   |   |   |
|                                                          | a |   |   |   |
|                                                          | r |   |   |   |
|                                                          | c |   |   |   |
|                                                          | h |   |   |   |
|                                                          | T |   |   |   |
|                                                          | y |   |   |   |
|                                                          | p |   |   |   |
|                                                          | e |   |   |   |
|                                                          | * |   |   |   |
|                                                          | * |   |   |   |
+----------------------------------------------------------+---+---+---+---+
|                                                          | > | > | > | > |
|                                                          |   |   |   |   |
|                                                          | * | * | * | * |
|                                                          | * | * | * | * |
|                                                          | B | A | H | R |
|                                                          | a | p | e | e |
|                                                          | s | p | a | h |
|                                                          | i | l | l | a |
|                                                          | c | i | t | b |
|                                                          | > | e | h | i |
|                                                          |   | d | > | l |
|                                                          | B | > |   | i |
|                                                          | i |   | S | t |
|                                                          | o | C | e | a |
|                                                          | m | l | r | t |
|                                                          | e | i | v | i |
|                                                          | d | n | i | o |
|                                                          | i | i | c | n |
|                                                          | c | c | e | * |
|                                                          | a | a | s | * |
|                                                          | l | l | * |   |
|                                                          | * | * | * |   |
|                                                          | * | * |   |   |
+----------------------------------------------------------+---+---+---+---+
| Exercise, weight loss, lipid and glucose metabolism in   | * |   |   |   |
| obese veterans                                           | * |   |   |   |
|                                                          | x |   |   |   |
| Functional genomics, genetics and metabolism in aging    | * |   |   |   |
| veterans                                                 | * |   |   |   |
|                                                          |   |   |   |   |
| Exercise rehabilitation and brain plasticity after       |   |   |   |   |
| stroke                                                   |   |   |   |   |
|                                                          |   |   |   |   |
| Muscle and adipocyte biology in aging, obesity and CVD   |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Exercise, weight loss, and CVD risk factor modification  |   | * |   |   |
|                                                          |   | * |   |   |
| Treadmill exercise, neuromuscular function and           |   | x |   |   |
| metabolism in stroke                                     |   | * |   |   |
|                                                          |   | * |   |   |
| Genes, lifestyle and CVD risk factors with aging         |   |   |   |   |
+----------------------------------------------------------+---+---+---+---+
| Exercise rehabilitation, quality of life and health      |   |   | * |   |
| outcomes in chronic stroke                               |   |   | * |   |
|                                                          |   |   | x |   |
|                                                          |   |   | * |   |
|                                                          |   |   | * |   |
+----------------------------------------------------------+---+---+---+---+
| Rehabilitation and tertiary prevention in chronic stroke |   |   |   | * |
| and cardiovascular disease                               |   |   |   | * |
|                                                          |   |   |   | x |
|                                                          |   |   |   | * |
|                                                          |   |   |   | * |
+----------------------------------------------------------+---+---+---+---+

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| **4. ADMINISTRATION**                                                 |
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| **GRECC Impact on Host VAMC in Report Year***: list **the** **most    |
| important ways** in which the GRECC has had specific impact on **host |
| VAMC's** research, staff education, program evaluation, or clinical   |
| care improvements for elderly veterans (i.e., how the GRECC has "made |
| a difference" in these areas within the entire host VAMC) during the  |
| Report Year. **Please limit your response to [5 or fewer]{.underline} |
| "ways"; and please limit your description of each of the five "ways"  |
| to [five lines or fewer]{.underline}. ***                             |
|                                                                       |
| -   GRECC faculty serve on VAMHCS committees: Dr. Goldberg on the     |
|     Executive and Performances Measures Committees; Dr Katzel chairs  |
|     and Drs. Sorkin and Ryan serve on the VA R&D committee; Dr.       |
|     Sorkin on the VA Information Security Committee; Dr. Shuldiner    |
|     works with Dr. Sabra, Chief Diabetes Service to improve diabetic  |
|     care; and Dr. Shaughnessy chairs the VAMHCS Nursing Practice      |
|     Council and serves on the VA Human Subjects Research              |
|     Subcommittee, the Planning Committee for the annual Nursing       |
|     Evidence Based Practice conference sponsored by the UM School of  |
|     Nursing and the VAMHCS Nursing Policy and Procedure Action Team.  |
|                                                                       |
| -   GRECC faculty train MD fellows and students in geriatrics on      |
|     inpatient and outpatient geriatric services in weekly teaching    |
|     conferences, Geriatric Evaluation and Management Unit, Home Based |
|     Primary Care, Geriatrics/Dementia/Cardiovascular Risk Clinic, and |
|     the Baltimore Rehabilitation and Extended Care Center (BRECC).    |
|     GRECC MD's attend on one general medical ward team, enhancing     |
|     geriatric medical education for housestaff and students. A        |
|     "VetFitness clinic" was established in GRECC to treat CVD risk    |
|     factors in conjunction with the VAMC MOVE! Program.               |
|                                                                       |
| -   The GRECC sponsors a 2 hr daily employee wellness exercise and    |
|     nutrition education program in the Senior Exercise Rehabilitation |
|     Center (SERC). Attendance has increased during FY2006 to          |
|     approximately 80 employees per week and 4000 visits per year.     |
|                                                                       |
| -   Dr. Macko submitted a proposal for a 16,000 ft Exercise &         |
|     Robotics Research Building attached to the Loch Raven Community   |
|     Based Outpatient Center facility that will provide space to       |
|     implement innovative interventions and provide better access to   |
|     disabled Veterans and those at high risk for cardiovascular       |
|     disease to rehabilitation and health promoting treatments.        |
|                                                                       |
| -   GRECC promotes the genetics and genomics research that explores   |
|     complex age-related disorders such as type 2 diabetes,            |
|     cardiovascular disease, stroke, obesity, hypertension and         |
|     osteoporosis. Insights into the genetic underpinnings of these    |
|     diseases are advocated by the CRADO as having the potential to    |
|     provide new preventive and therapeutic strategies for veterans.   |
|     GRECC researchers lead the Clinical Nutrition Research Unit of    |
|     Maryland, a NIH-funded center that provides genetic/genomic and   |
|     cell biology core resources for the conduct of nutrition-related  |
|     and obesity research among investigators in the VA.               |
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| a.  **GRECC Impact on VISN in the Report Year:** *list **the** **most |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host** **VISN's** research, staff education, program        |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VISN) during the rating period. **Please   |
|     limit your response to [5 or fewer]{.underline} "ways"; and       |
|     please limit your description of each of the five "ways" to [five |
|     lines or fewer]{.underline}. ***                                  |
|                                                                       |
| -   Baltimore VA RR&D Center of Excellence in Exercise and Robotics   |
|     in Neurological Disease uses GRECC exercise models to optimize    |
|     exercise prescriptions to improve cardiovascular health and brain |
|     plasticity, use robotics-assisted exercise, and                   |
|     Behavioral-Education Interventions for aging stroke patients.     |
|     This research will be extended to the BRECC, with the             |
|     construction of an Exercise & Robotics Research Building attached |
|     to the Loch Raven CBOC by 2011. The VISN plans to disseminate     |
|     these programs to improve the care of Veterans.                   |
|                                                                       |
| -   GRECC clinical teams led by Drs. May and Katzel, Dr. Colvin       |
|     (BRECC), and Dr. Heuser (Director, G/LTC) provide clinical,       |
|     hospice and palliative care to veterans. GRECC faculty provide    |
|     geriatric medicine training in long-term care, end-of-life care,  |
|     geriatric psychiatry, and rehabilitation to fellows, residents,   |
|     physicians' assistants, nurses, nurse practitioners, health       |
|     professional students, physical therapists, social workers,       |
|     exercise physiology and psychology interns from local             |
|     Universities and community colleges in VISN 5.                    |
|                                                                       |
| -   Dr. Heuser is the GRECC representative on the Geriatric Long Term |
|     Care Service Line Steering Committee, assists the managers of     |
|     programs at Washington and Martinsburg with systems, environment  |
|     of care, and program development. Dr. Shaughnessy reviewed        |
|     patient care programs at the BRECC as a member of the VISN        |
|     organized external task force.                                    |
|                                                                       |
| -   Dr. Katzel serves as chair of the VAMHCS R&D committee and played |
|     a major leadership role in revamping the R&D committee and        |
|     subcommittee standard operation procedures, and preparing the     |
|     VAMCS for a routine site visit by the Department of Veteran       |
|     Affairs Organization for Research Oversight (ORO).                |
|                                                                       |
| -   GRECC accomplishments enhanced national recognition of VISN5 as   |
|     Center of Excellence in geriatrics with renewal of the Claude D.  |
|     Pepper Older Americans Independence Center Grant, award of a VA   |
|     Special Fellowship in Geriatrics to fund 1 postdoctoral physician |
|     or Ph.D. allied health fellow trainee annually for 2-3 years of   |
|     research training in geriatrics, and receipt of 2 Geriatric and 2 |
|     Neurology Resident positions from VA Academic Affairs that will   |
|     enhance medical training in these high priority areas of care     |
|     starting in 2007.                                                 |
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| **GRECC Trend-Setting Innovations since October 1,                    |
| [2001]{.underline}**: *list **the** **most significant** GRECC        |
| research, education or clinical innovations in the past five years.   |
| For each item, provide date or date range, GRECC core staff           |
| responsible, and a description. **Please limit your response to 5 or  |
| fewer innovations; and please limit each of the five innovation       |
| descriptions to five lines or fewer. ***                              |
|                                                                       |
| -   Exercise therapies combining motor learning with aerobic exercise |
|     improve fitness and function, even a decade after a stroke. Our   |
|     data show 80% of chronic stroke survivors are diabetic or         |
|     pre-diabetic, and AEX improves glucose tolerance and insulin      |
|     sensitivity, which may reduce progression to diabetes and         |
|     recurrent stroke. These data were presented at the National       |
|     Academy of Science, and will be used by the DHHS to develop       |
|     national guidelines for physical activity. (Drs. Macko,           |
|     Hafer-Macko, Ryan, Sorkin, Ivey; 2002-6).                         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Obesity increases with aging due to inactivity, diet, and         |
|     declines in muscle, metabolic rate, fat oxidation, and sex        |
|     hormones. Exercise training (AEX) with weight loss (WL) is more   |
|     effective than WL alone because it increases energy expenditure,  |
|     prevents age-related declines in muscle, fat oxidation and        |
|     metabolism, and reduces visceral fat and cardiometabolic risk     |
|     factors. These metabolic changes augment WL, and may prevent      |
|     weight regain (Goldberg, Ortmeyer, Ryan).                         |
|                                                                       |
| -   Innovations in high-throughput genotyping process \> 500,000      |
|     single nucleotide polymorphisms from DNA samples for genome-wide  |
|     association analysis to identify candidate genes underlying       |
|     diabetes, obesity, hypertension, stroke and osteoporosis. GRECC   |
|     researchers identify genes for these complex diseases and test    |
|     these in studies of responses to lifestyle and pharmacological    |
|     interventions to determine clinical relevance. (Drs. Shuldiner,   |
|     Mitchell, Kittner, Sorkin, Goldberg, Katzel, Ryan, Prigeon,       |
|     Macko.)                                                           |
|                                                                       |
| -   Baltimore VA Cooperative Study "Robotic Assisted Upper-Limb       |
|     Neurorehabilitation in Stroke Patients" is a multicenter, phase   |
|     II trial to assess the efficacy of robot-assisted therapy for     |
|     veterans who have suffered a stroke. Studies examine brain        |
|     plasticity mechanisms by which robotics is effective and develop  |
|     innovative strategies to enhance training effects using selective |
|     neuronal (transcranial magnetic) stimulation. (Drs. Wittenberg,   |
|     Judkins, Bever, Whitall, 2006-2009).                              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   A cell culture model performs high through put siRNA screening to |
|     discover genes involved in accumulating and regulating the lipid  |
|     droplet compartment in liver cells. This research has the         |
|     potential to discover and identify new critical therapeutic       |
|     targets for the prevention and treatment of obesity and           |
|     lipodystrophy. A confidential agreement was signed with Dharmacon |
|     (Fisher biosciences) to implement this research. (Drs. Sztalyrd,  |
|     Fried; 2006).                                                     |
+-----------------------------------------------------------------------+
| **5. RESEARCH**                                                       |
+-----------------------------------------------------------------------+
| **a. Key Findings Published in the Report Year on projects for which  |
| GRECC Core Staff was PI or Co-PI:\                                    |
| ***list **five or fewer;** for each item provide GRECC Core Staff     |
| name(s), journal reference, and description of topic/                 |
| method/results/clinical significance.* *Please limit each response to |
| [5 lines or fewer]{.underline}.*                                      |
|                                                                       |
| -   Cynthia M. Ferrara, **Andrew P. Goldberg**, **Heidi K.            |
|     Ortmeyer**, and **Alice S. Ryan**. Effects of Aerobic and         |
|     Resistive Exercise Training on Glucose Disposal and Skeletal      |
|     Muscle Metabolism in Older Men. *Journal of Gerontology: MEDICAL  |
|     SCIENCES* 61A: No. 5, 480-487, 2006.                              |
|                                                                       |
| > Insulin resistance of aging is related to physical inactivity and   |
| > abdominal obesity. Hypothesis: aerobic (AEX) or resistive exercise  |
| > (RT) will improve glucose disposal (M) thru adaptations in skeletal |
| > muscle (SM). AEX increased VO~2~max by 16% (p\< .01) and RT         |
| > increased leg and arm strength by 45±5% and 27±5% (p\<.0001) in     |
| > obese 63 year-old men. AEX and RT increased M by 20-25% (p\<.05),   |
| > AEX increased SM glycogen synthase (GS) fractional activity more    |
| > than RT (279 ± 59% vs. 100 ± 28%, p\<.05), not GS total activity    |
| > reducing risk for metabolic syndrome and type 2 diabetes.           |
|                                                                       |
| -   **Larry W. Forrester**, Daniel F. Hanley, **Richard F. Macko**.   |
|     Effects of Treadmill Exercise on Transcranial Magnetic            |
|     Stimulation---Induced Excitability to Quadriceps After Stroke.    |
|     *Arch Phys Med Rehabil. 2006 Feb; 87(2):229-34*.                  |
|                                                                       |
| > This study tests the hypothesis that brain plasticity present years |
| > after stroke can be enhanced by a single bout of treadmill          |
| > exercise. A 20- minute exercise session increased brain signal to   |
| > the paralyzed quadriceps muscle (transcranial magnetic stimulation) |
| > in disabled stroke survivors. Thus, repetitive physical activity in |
| > the form of treadmill training can enhance brain signals to the     |
| > paralyzed leg muscle, even years after a disabling stroke. Results  |
| > support our ongoing studies of brain plasticity with task-oriented  |
| > exercise in chronic stroke.                                         |
|                                                                       |
| -   **Frederick M. Ivey**, **Alice S. Ryan**, **Charlene E.           |
|     Hafer-Macko**, Brian M. Garrity, **John D. Sorkin**, **Andrew P.  |
|     Goldberg**, and **Richard F. Macko**. High prevalence of Abnormal |
|     Glucose Metabolism and Poor Sensitivity of Fasting Plasma Glucose |
|     in the Chronic Phase of Stroke. *Cerebrovas Dis* 22: 368-371,     |
|     2006.                                                             |
|                                                                       |
| Impaired glucose tolerance (IGT) and diabetes predict a 2-3 fold      |
| increase risk for recurrent stroke. In 216 stroke patients 80% had    |
| either IGT or type 2 diabetes. Fasting plasma glucose (FPG) was only  |
| 49% sensitive for predicting abnormalities in the oral glucose        |
| tolerance test. Thus, abnormal glucose metabolism is under diagnosed  |
| and highly prevalent after stroke; supporting our research            |
| investigating the health benefits of exercise to improve insulin and  |
| glucose metabolism in chronic stroke.                                 |
|                                                                       |
| -   Coleen M. Damcott, Toni I. Pollin, Laurie J. Reinhart, Sandra H.  |
|     Ott, Haiqing Shen, Kristi D. Silver, Braxton D. Mitchell, and     |
|     **Alan R. Shuldiner**. Polymorphisms in the Transcription Factor  |
|     7-Like-2 (TCF7L2) Gene Are Associated With type 2 Diabetes in the |
|     Amish. *Diabetes* 55: 2654-2659, 2006.                            |
|                                                                       |
| Transcription factor 7-like 2 (TCF7L2), located on a region of        |
| linkage to diabetes (T2DM), regulates genes involved in cell          |
| proliferation and differentiation. Hypothesis: single nucleotide      |
| polymorphisms (SNPs) in TCF7L2 are associated with T2DM/ impaired     |
| glucose tolerance in older Amish. Genotypic frequencies of TCF7L2     |
| SNPs were high in T2DM compared to normals (p=0.01), and 2 other SNPs |
| associated with insulin secretion and sensitivity (p=.01) in          |
| non-Amish. Thus, TCF7L2 polymorphisms may increase diabetes risk.     |
|                                                                       |
| -   Mi-Jeong Lee and **Susan K. Fried**. Multilevel regulation of     |
|     leptin storage, turnover, and secretion by feeding and insulin in |
|     rat adipose tissue. *J. Lipid Res.* 47: 1984-1993, 2006.          |
|                                                                       |
| Newly synthesized leptin may be stored, secreted or degraded          |
| intracellularly before secretion from adipose tissue (AT).            |
| Hypothesis: nutritional status and hormone stimulation affect leptin  |
| release. Starvation decreased serum leptin, AT leptin content,        |
| biosynthesis and leptin secretion, but not leptin mRNA levels.        |
| Insulin did not increase leptin biosynthesis or degradation, but      |
| accelerated leptin secretion in fed, not starved rats. Lysosomes and  |
| proteosomes contributed to slower leptin degradation in AT of starved |
| vs. fed rats. Thus, feeding compared to starvation affects leptin     |
| production at multiple levels, and insulin-stimulated release of      |
| leptin after meals.                                                   |
+-----------------------------------------------------------------------+
| **b. Key Findings Published in the Report Year on work in which GRECC |
| Core Staff served as Co-Investigators to a Non-GRECC PI:** *list      |
| **five or fewer**; for each item provide GRECC Core Staff name(s),    |
| journal reference, and description of topic/method/results/clinical   |
| significance. Please limit each response to [5 lines or               |
| fewer]{.underline}.*                                                  |
|                                                                       |
| -   Yang, Rong-Ze, Mi-Jeong Lee, Hong Hu, Jessica Pray, Hai-Bin Yu,   |
|     Barbara C. Hansen, **Alan R. Shuldiner**, **Susan K. Fried**,     |
|     **John C. McLenithan**, and Da-Wei Gong. Identification of        |
|     omentin as a novel depot-specific adipokine in human adipose      |
|     tissue: possible role in modulating insulin action. *Am J Physiol |
|     Endocrinol Metab* 290: E1253-E1261, 2006.                         |
|                                                                       |
| To assess mechanisms relating central obesity to insulin resistance   |
| and diabetes, we sequenced 10,437 express sequence tags (ESTs) from a |
| human omental fat cDNA library and discovered omentin (OM), a novel   |
| visceral fat (VAT) depot-specific secretory protein. OM encoded a     |
| peptide in VAT stromal-vascular cells, but not subcutaneous (sc) fat  |
| cells. OM protein was secreted by omental, not sc fat explants, and   |
| is detectable in serum. OM enhanced insulin-stimulated glucose uptake |
| in human adipocytes, and may affect insulin action.                   |
|                                                                       |
| -   Rong-Ze Yang, Mi-Jeong Lee, Hong Hu, Toni I. Pollin, **Alice S.   |
|     Ryan**, Barbara J. Nicklas, Soren Snitker, Richard B. Horenstein, |
|     Kristen Hull, Nelson H. Goldberg, **Andrew P. Goldberg**,         |
|     **Alan R. Shuldiner**, **Susan K. Fried**, Da-Wei Gong.           |
|     Acute-phase serum Amyloid A: An inflammatory adipokine and        |
|     potential link between obesity and its metabolic complications.   |
|     *PLoS Med* 3(6): e287. DOI: 10.1371/journal.pmed.0030287 f        |
|     Obesity-associated inflammation is a risk for vascular disease.   |
|     Serum amyloid A (SAA) is expressed in adipocytes (ADO), and mRNA  |
|     levels and secretion correlate with BMI (p \<.01). SAA decreased  |
|     after rosiglitazone (ROSI) or weight loss (WL) (p=.01, p\<.03),   |
|     and correlated with WL decrease in insulin resistance (IR) (r=    |
|     -.74, p\<.05). SAA treatment of vascular endothelial cells and    |
|     monocytes increased lipolysis and IL-6, IL-8, TNFα, and MCP-1     |
|     production. Thus, SAA is a proinflammatory and lipolytic          |
|     adipokine that may cause IR and atherosclerosis; decreases in SAA |
|     production with WL and ROSI may reduce inflammation and IR.       |
|                                                                       |
| -   **Shari R. Waldstein** and **Leslie I. Katzel**. Interactive      |
|     relations of central versus total obesity and blood pressure to   |
|     cognitive function. *International Journal of Obesity* 30:        |
|     201-207, 2006**.**                                                |
|                                                                       |
| Relationships of central vs. total obesity and blood pressure with    |
| cognitive function were examined in 90 healthy older adults. After    |
| adjusting for age, education, and gender waist circumference and HTN  |
| were associated with diminished performance on tests of motor speed   |
| and manual dexterity, and executive function. Thus, older adults with |
| central and total obesity-associated HTN and the metabolic syndrome   |
| have worse cognitive function. Control of HTN and CVD risk factors    |
| and decreased obesity may preserve cognitive function with aging.     |
|                                                                       |
| -   David Tanne, **Richard F. Macko**, Yan Lin, Barbara C. Tilley,    |
|     Steven R. Levine. Hemostatic Activation and Outcome After         |
|     Recombinant Tissue Plasminogen Activator therapy for Acute        |
|     Ischemic Stroke. *Stroke* 37: 1798-1804, 2006.                    |
|                                                                       |
| Early thrombolytic therapy with intravenous tPA improves clinical     |
| outcomes following acute stroke. Markers of naturally occurring       |
| fibrinolytic capacity (ability to dissolve clot), thrombin generation |
| (tendency to form new clot), and markers of injury to the blood       |
| vessels (thrombomodulin) may hamper the efficacy of thrombolytic      |
| therapy following acute stroke. Results show reduced natural          |
| fibrinolytic capacity (elevated tPA antigen)is associated with the    |
| lower chance of favorable outcomes in the group that received         |
| recombinant tPA (thrombolytic) therapy, and higher levels of natural  |
| occurring thrombin generation and thrombomodulin levels predict poor  |
| outcomes and higher 3-month mortality. Thus, the profile of natural   |
| fibrinolysis and clot formation tendency following stroke affect      |
| responses to thrombolytic therapy.                                    |
|                                                                       |
| -   Onanong Kulaputana, Ioana Ghiu, Dana Phares, Robert Ferrell,      |
|     **Richard F. Macko**, **Andrew P. Goldberg**, and **James M.      |
|     Hagberg**. Genetic Markers of Fibrinolytic Responses of Older     |
|     Persons to Exercise Training. *International Journal of Sports    |
|     Medicine* 27: 617-622, 2006.                                      |
|                                                                       |
| Impaired endogenous fibrinolysis, the inability to lyse excess or     |
| inappropriate clots, is an independent risk factor for heart attack   |
| and stroke. Exercise training improves endogenous fibrinolysis. We    |
| hypothesized that common genetic polymorphisms may influence          |
| fibrinolysis and its response to exercise training. founding 50-75    |
| year old adults with 1 or more CVD risk factor, exercise training     |
| resulted in significant improvements in fibrinolyis profiles of tPA   |
| activity only in carriers of PAI 1-4G allele. The patients exercise   |
| to reduce heart and stroke risk.                                      |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE**: **DO NOT** list trainee and conference data                 |
| here**\--**those data are reported in the GRECC Electronic Database.  |
|                                                                       |
| **NOTE:** You may list educational activities here even if they were  |
| supported by funds that qualified for inclusion in the ePROMISE       |
| (RDIS) database if you wish.                                          |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year** (*list five or fewer. Please limit each item to [5  |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)*                                         |
|                                                                       |
| -   Reshaping Exercise Habits and Beliefs (REHAB) is an               |
|     educational/motivational program designed to use Social Cognitive |
|     Theory principles to educate stroke survivors about the benefits  |
|     of home-based exercise and motivate them to sustain physical      |
|     activity in the home/community following discharge from inpatient |
|     rehabilitation. Each participant is given a progressive walking   |
|     prescription, along with "homework" customized according to       |
|     specific neurological deficit profiles, and is monitored weekly   |
|     for 3 months.                                                     |
|                                                                       |
| -   Dr. Sorkin directed a mock Institutional Review Board for eight   |
|     new nurse researchers evaluating a new protocol at the request of |
|     the conveners of the John A Hartford Foundation pre institute for |
|     nurses attending the NIA Summer Institute on Aging Research. The  |
|     participants had no previous experience with human IRB reviews.   |
|     Dr. Sorkin's model will be used in the future for setting up      |
|     similar reviews at this conference.                               |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Dr. Shaughnessy serves on the planning committee and continues to |
|     work with the Office of Nursing Education and Research to         |
|     identify research questions and protocols from clinical practice  |
|     issues, particularly in the areas of falls and wound care. She    |
|     was a featured speaker for the VAMHCS Nursing Research Conference |
|     "Answering Why?" on September 26, 2006.                           |
|                                                                       |
| -   Dr. Katzel assisted in the design and implementation of a novel   |
|     4^th^ year medical student elective in Nutrition and Physical     |
|     Activity at the UMSOM. Thirty-two students come to the GRECC each |
|     year to receive training in nutrition, exercise testing and       |
|     training and to provide counseling in lifestyle modification to   |
|     patients.                                                         |
|                                                                       |
| -   GRECC investigators (Drs. Macko, Stuart, Shaughnessy, Ivey) have  |
|     developed a collaborative educational program with University of  |
|     Maryland, Baltimore County (UMBC) training undergraduates and     |
|     graduate students in Medical Anthropology and Sociology to study  |
|     models of exercise in aging and disability in the setting of the  |
|     GRECC and Exercise and Robotics Center in Baltimore VA, and the   |
|     extension of exercise models to the community in Italy.           |
|                                                                       |
| -   Dr. Katzel assisted in the design and implementation of a new     |
|     lunch brown bag seminar series co-sponsored by the UMB Human      |
|     Research Protection Office on research ethics and good clinical   |
|     practice guidelines and implementation practices. Unlike other    |
|     training that focuses on the investigators, 20 study coordinators |
|     and research staff meet quarterly to discuss hot-button topics    |
|     and other topics relevant to the safe and successful conduct of   |
|     clinical investigation.                                           |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** *List five or fewer of the most     |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in previous years ONLY if this is the [first            |
|     year]{.underline} they have been available for distribution.***   |
|                                                                       |
| -   Dr. Shaughnessy serves on the planning committee for the new      |
|     GRECC Audioconference Geriatrics Series that features research    |
|     and clinical updates with available CME through Librix for VA     |
|     employees for a limited time. Two audioconferences broadcast from |
|     Baltimore are scheduled for presentation in this series during    |
|     FY07. These audioconferences will be stored in the Librix         |
|     database indefinitely for ongoing age specific competency         |
|     education.                                                        |
|                                                                       |
| -   Dr. Goldberg worked with VAMHCS diabetes nurse educator and       |
|     dietician and Public Relations Service to develop a TV special    |
|     for distribution entitled "Managing Diabetes and the Obesity      |
|     Epidemic in the VA."                                              |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   GRECC investigators developed collaboration with UMBC, Local      |
|     Health Authority Area #11 in Tuscany that is supported by the     |
|     Istituto Superiori di Sanita (Italian NIH) training               |
|     undergraduates and graduate students in global health care        |
|     disparities in the care of individuals aging with disability and  |
|     cardiovascular disease. The educational program included a        |
|     seminar in Kandersteg, Switzerland attended by students, NIH      |
|     officials (e.g. Director, NCHHD, Center for Medical               |
|     Rehabilitation research; Director, NIH International Studies) and |
|     clinician scientists from the United States, Italy, and           |
|     Switzerland.                                                      |
|                                                                       |
| -   The conference entitled "Managing Geriatric Emergencies", held on |
|     March 31, 2006, produced 6 separate one-hour continuing education |
|     modules available to VAMHCS nursing and physician staff for       |
|     internal CE credit. Topics include: "Geriatric Trauma", "ER       |
|     Management of Falls", "Abdominal Emergencies", "Vascular          |
|     Emergencies", Management of Delirium in the ER", and "Effects of  |
|     Polypharmacy in the ER". Sponsors were Johns Hopkins GEC, GGEAR,  |
|     and the University of Maryland Department of Emergency Medicine.  |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   The module entitled "Early Recognition of Acute Illness in the    |
|     Extended Care Setting" was placed on the VAMHCS website and       |
|     inservices conducted for staff of VAMHCS extended care units to   |
|     identify behavioral, cognitive and functional changes and         |
|     expedite team assessment and treatment. Educational efforts were  |
|     well received and reports generated in CPRS are being monitored   |
|     for targeted recognition, assessment and follow up of at risk     |
|     residents. This work will be presented in GRECC symposia at GSA,  |
|     2006 and AGS, 2007.                                               |
+-----------------------------------------------------------------------+
| **7. CLINICAL DEMONSTRATION PROJECTS**                                |
+-----------------------------------------------------------------------+
| **NOTE:** A clinical demonstration [program]{.underline} is defined   |
| as:                                                                   |
|                                                                       |
| -   an ongoing, clinical, cooperative collaboration between the GRECC |
|     and host VA medical center;                                       |
|                                                                       |
| -   that carries out and evaluates assessment strategies, management  |
|     approaches and/or specialized investigations                      |
|                                                                       |
| -   of a targeted or focused group of elderly patients                |
|                                                                       |
| -   with the intention that findings will be disseminated for the     |
|     advancement of the field.                                         |
|                                                                       |
| A clinical demonstration program is comprised of one or more clinical |
| demonstration [projects]{.underline}, each of which is defined        |
| as**:**                                                               |
|                                                                       |
| -   a set of one or more clinical activities                          |
|                                                                       |
| -   integrated and coordinated under a specified protocol             |
|                                                                       |
| -   designed to permit evaluation(s) of processes and/or outcomes.    |
|                                                                       |
| Evaluation of a clinical demonstration program may be a comprehensive |
| assessment of the activity and/or the clinical outcomes.              |
| Alternatively, evaluation may concentrate on a prioritized and        |
| feasible set of more focused or specific, project-related questions,  |
| e.g. related to improved diagnosis, quality of care, patient          |
| satisfaction, drug compliance, functional status, etc. Ongoing and    |
| subsequent modifications of the care model may also be evaluated as   |
| may be the practicability and outcomes of exporting new clinical      |
| models or variations of models to general care settings and/or        |
| smaller, more resource-limited VA medical centers or outpatient       |
| facilities.                                                           |
+-----------------------------------------------------------------------+
| a.  **Clinical Demonstration Projects Underway in Report Year***:     |
|     list **all** GRECC Clinical Demonstration Projects underway. For  |
|     each item, indicate whether [N]{.underline}ew or                  |
|     [O]{.underline}ngoing in Report Year. You may include up to five  |
|     lines of descriptive text for each Project.\                      |
|     ***NOTE:** The number of Projects listed should be equal to the   |
|     number of Clinical Demonstration Projects you have listed and     |
|     named in the GRECC Electronic Database.                           |
|                                                                       |
| -   MOVE! (ongoing): The GRECC was one of the 17 VHA pilot sites for  |
|     the Managing Overweight and or Obesity for Veterans Everywhere    |
|     (MOVE!) standardized multidisciplinary and individualized weight  |
|     management program. Unique at the BVAMC site were the inclusion   |
|     of a variety of quantitative physiologic measures, including:     |
|     exercise capacity, glucose tolerance and lipid profile. This      |
|     pilot study has recently been completed and has led to the        |
|     implementation of Vet Fitness, a program that includes MOVE!      |
|                                                                       |
| -   [Vet Fitness (new)]{.underline}: This CDP is designed to improve  |
|     the management of cardiovascular disease risk factors in older    |
|     veterans referred after admission to the BVAMC for acute coronary |
|     syndrome, or in older outpatients that have suboptimal control of |
|     their CVD risk factors. The intervention employs a                |
|     multidisciplinary approach for medication/lifestyle optimization. |
|                                                                       |
| -   Geriatric Assessment Clinic (GAC) (Ongoing): The GAC focuses on   |
|     the medical characterization and assessment of CVD risk factors   |
|     in subjects volunteering for GRECC research studies. The GAC has  |
|     led to a number of ongoing studies such as GETFIT that focuses on |
|     medical comorbidity and function in older adults with HIV.        |
|     Findings from the GAC have led to the implementation of a new     |
|     CDP, Aging, health and functional performance.                    |
|                                                                       |
| -   Aging, health and functional performance (new): This CDP examines |
|     the inter-relationships of aging, lifestyle and comorbid medical  |
|     disease on functional performance in older veterans. This CDP     |
|     co-sponsored by the University of Maryland Pepper Center will     |
|     examine functional domains of strength, balance, fitness as well  |
|     as motor control and neurocognition. This CDP will provide        |
|     insight into the role of medical comorbidities in physical        |
|     function and disability.                                          |
|                                                                       |
| -   GETFIT (Ongoing): This CDP performed jointly with the Pepper      |
|     Center and Veterans Aging Cohort Study at the BVAMC examines the  |
|     impact of HIV and HIV-associated comorbidities on functional      |
|     performance in older adults with HIV. Data from this CDP led to a |
|     K23 award for Dr. Kris Ann Oursler that will examine the effects  |
|     of aerobic exercise training on skeletal muscle metabolism and    |
|     functional performance in older veterans with HIV.                |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Hospice and Palliative Medicine Training Initiative (new), led by |
|     Drs. Heuser, May and Harrison for expanded hospice and palliative |
|     medicine in the VAMHCS, as a clinical rotation for geriatric      |
|     fellows, is being implemented. This rotation will also serve as a |
|     training opportunity for geriatric fellows and other VAMHCS       |
|     trainees. This project will span across the continuum of          |
|     geriatric care.                                                   |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** *for each      |
|     GRECC Clinical Demonstration Project listed in 7a above,          |
|     summarize the evaluation activity. If no evaluation results are   |
|     available, be explicit as to the focus of the planned evaluation, |
|     and when it is anticipated to occur. If the project has been      |
|     completed during the Report Year, provide key findings and their  |
|     significance.*\                                                   |
|     **NOTE:** Do not list patient service use data here. Those data   |
|     are reported in the GRECC Electronic Database.                    |
|                                                                       |
| -   MOVE!: The MOVE! CDP enrolled 42 older, obese (BMI 34.6 kg/m2)    |
|     veterans. CVD risk factors were common in this population; 69%    |
|     had hypertension, 64% had hyperlipidemia; 40% had diabetes, and   |
|     64% had CAD. With intervention, there was a modest 5.2 lb decline |
|     in weight. There were significant decreases in TG (19%), total    |
|     cholesterol (5%) and LDL (5%) mg/dl) and a 10% increase in HDL in |
|     the subset that had lipids drawn. The success of MOVE! led to     |
|     implementation of a new CDP, Vet Fitness.                         |
|                                                                       |
| -   Vet Fitness: 225 veterans (mean age 64) have been enrolled in     |
|     this CDP. CVD risk factors were sub-optimally controlled in this  |
|     population. In the diabetic (112) patients, 41% had LDL\>100, 34% |
|     had TG\>150, and 80% had Hgb A1c \> 7%. This is not unexpected as |
|     poorly controlled diabetes was one of the triggers for referral   |
|     to this CDP. In the first 37 diabetic patients seen, there were   |
|     significant improvements in Hgb A1c (decreased by 14%), TG (-5%)  |
|     and LDL (-11%), and 12% decrease in BP.                           |
|                                                                       |
| -   Geriatric Assessment Clinic (GAC): A high % of subjects in GRECC  |
|     research studies have inadequate control of their CVD risk        |
|     factors. In 364 older stroke patients evaluated for GRECC and     |
|     Pepper Center studies, 80% had inadequate control of BP (systolic |
|     BP \>120 and or diastolic BP \>/80), and 60% had inadequate       |
|     control of LDL-C (LDL \>100mg/dl). Survey showed customer         |
|     satisfaction exceeded 90%.                                        |
|                                                                       |
| -   Aging Health and Functional Performance: This new CDP enrolls     |
|     healthy volunteers as well a subjects with hypertension,          |
|     metabolic syndrome, chronic kidney disease, stroke, peripheral    |
|     arterial disease and people who have had a hip fracture.          |
|     Preliminary results demonstrate impaired physical and             |
|     neurocognitive function in patients with chronic kidney disease   |
|     compared to patients with normal renal function.                  |
|                                                                       |
| -   GETFIT: Sixty veterans with HIV were enrolled into the            |
|     cross-sectional study. Peak aerobic capacity was reduced by 41%   |
|     in HIV+ compared to age-matched non-HIV. Other measures of        |
|     functional performances, 6 minute walk and grip strength were 10% |
|     reduced compared to age-matched normals. A subset of 30 had       |
|     electrical stimulation testing of the lower extremity in          |
|     association with strength testing. One-third had impairment in    |
|     central activation of their quadriceps muscle groups suggesting   |
|     that the deficit in strength was not solely due to reduced muscle |
|     mass.                                                             |
|                                                                       |
| -   Hospice and Palliative Medicine Training Initiative (new): No     |
|     outcomes to report as of yet.                                     |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year** *(list up to five examples, up to two lines  |
|     each; provide name of new clinical model, name of VA or non-VA    |
|     facility to which it was exported, and method of export, such as  |
|     "Falls Clinic protocol sent to [X]{.underline} VAMC"):*           |
|                                                                       |
| -   The treadmill exercise rehabilitation program for chronic stroke  |
|     patients continues at the Ruxton Nursing Home and Rehabilitation  |
|     Center as a demonstration project to test the translation of this |
|     effective laboratory based exercise intervention to a             |
|     community-based setting. The GRECC staff have provided initial    |
|     consultation, safety protocols and ongoing collaboration to this  |
|     effort which started at the end of FY 2005.                       |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation** = GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach** = GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| **a. Current Year Activity Outcomes** *(list up to five examples, up  |
| to two lines each; summarize specific outcomes realized from current  |
| year **consultation**, e.g., "Host VAMC instituted a Falls Clinic     |
| after consultation from GRECC staff;" or **outreach**, e.g.,          |
| [X]{.underline} VAMC instituted a Falls Clinic after GRECC outreach   |
| via series of videoconferences) Let's indicate whether outreach or    |
| consultation.*                                                        |
|                                                                       |
| -   Dr. Marianne Shaughnessy provided outreach in planning the        |
|     statewide conference for the Governor's Conference on Vital Aging |
|     II Health Fair and coordinated education and screening of older   |
|     adult attendees by University of Maryland and Coppin State        |
|     students. Dr. Marianne Shaughnessy provided outreach on the       |
|     planning committee for the Evidence Based practice Conference     |
|     co-sponsored by the VA and the University of Maryland School of   |
|     Nursing on April 6 & 7, 2006. Four VA nurses had poster           |
|     presentations.                                                    |
|                                                                       |
| -   The GRECC provided consultation to the co-sponsor a symposium     |
|     entitled "Managing Geriatric Emergencies." Dr. Thomas Scalea      |
|     spoke on managing geriatric trauma, Dr. David Loreck on           |
|     management of delirium in the ER, Dr. Nicole Brandt on            |
|     identification of polypharmacy in acutely ill elders. Sixty       |
|     physicians, nurses, nurse practitioners attendees requested a     |
|     second offering that includes management of other geriatric       |
|     syndromes.                                                        |
|                                                                       |
| -   Dr. Katzel consulted with the Human Research Protection Office of |
|     UMB to implement new quarterly training sessions in research      |
|     ethics and good clinical practice for researchers at UMB.         |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   Dr. Shaughnessy consulted on the planning committee for the       |
|     national program "To Drive or Not to Drive: What You Should       |
|     Know", a 3-part comprehensive video program for primary care      |
|     providers in the VA focusing on assessment of the elderly driver, |
|     and psychosocial, legal and ethical issues surrounding aged       |
|     drivers. The 3 one-hour video modules with available CE/CME will  |
|     air on September 13, 20 and 27^TH^.                               |
|                                                                       |
| -   Dr. Heuser has established a driver evaluation and training       |
|     program at the Washington, DC VAMC to assess and train elderly    |
|     veterans who have suffered amputations and active duty personnel  |
|     returning from the Afghan and Iraqi conflicts who have suffered   |
|     injuries.                                                         |
|                                                                       |
| -   Consultation with Italian NIH has developed community exercise    |
|     models to improve gait and balance in chronic stroke patients.    |
|     Presentations to US & Italian NIH generated plans to extend the   |
|     model to a population of 6 million throughout Tuscany.            |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes** *(list up to five         |
|     examples, up to two lines each; summarize specific outcomes       |
|     realized from previous years' [**consultation** to host           |
|     VAMC]{.underline} or [**outreach** to non-host                    |
|     facilities]{.underline}, where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
| -   Conference presentation "Minimizing Impact and Maximizing         |
|     Recovery Following Stroke" published as CE offering in ADVANCE    |
|     for Nurse Practitioners, September 2006.                          |
|                                                                       |
| -   Rehabilitation and Therapeutics in Myasthenia Gravis presentation |
|     led to development of pending pilot research protocol to trial    |
|     effectiveness of exercise program on fatigue symptoms in          |
|     Myasthenic patients.                                              |
|                                                                       |
| -   Southern Maryland Caregivers Conference participation led to      |
|     invitation for Dr. Shaughnessy to speak at next year's            |
|     conference.                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+