VA RESEARCH 

Discovery and Collaboration for Exceptional Health Care 

SPRING 2011 Published in commemoration of National VA Research Week 2011 

T o da y
 

 Taking brain imaging to the next level 

 Targeting homelessness among Veterans 

 MVP: Building a genomics database 

 Probing blasts’ auditory effects 

 Making the most of electronic health records 

 Nature’s answers to cancer 

SPRING 2011 i 
 

 

mESSAGE
 

VA-ACAdEmIC PARtNERSHIPS: A CoRNERStoNE 

of mEdICAl RESEARCH ANd CARE IN tHE U.S. 

As you read through the feature stories in this year’s VA Research Today—our second 

annual edition of the magazine— you’ll see a consistent theme: VA and its university 

partners working together to foster advances in research and patient care. 

The collaboration between Va’s health care system and the nation’s medical schools began 

in 1946, with an historic agreement known as Memorandum Number Two. Today, Va has affiliations with nearly 

130 of the nation’s medical schools, and in essence has become the largest provider of health care training in the 

nation. Some 30,000 medical residents and 20,000 medical students rotate through Va facilities each year. 

over the past 65 years, this public-private partnership has enriched the learning environment in Va facilities as well 

as university medical schools and teaching hospitals; spurred remarkable progress in medical research; and notably 

improved health care for Veterans and all americans. 

another facet of this partnership is that most Va investigators also teach at an affiliated university medical school, 

and in many cases provide patient care at the university’s hospital. open the pages of any leading journal, such as 

the New England Journal of Medicine or the Journal of the American Medical Association, and you’ll see studies by 

authors with dual affiliations—the Va Connecticut Healthcare System and yale University School of Medicine, for 

example, or the Va San diego Healthcare System and the University of California, San diego. 

another legacy of Memorandum Number Two is the many research centers of excellence nationwide that are 

under the joint auspices of Va and an affiliated university. Examples include the Cleveland Functional Electrical 

Stimulation (FES) Center, which involves Va and Case Western Reserve University, along with other partners; and 

the Human Engineering Research Laboratories, a project of Va and the University of Pittsburgh. 

It should be noted that some of the nation’s leading research centers that involve Va researchers are collaborations 

among Va, its university partners and the department of defense. one example, featured on the cover of this 

magazine, is the Center for Imaging of Neurodegenerative diseases, in San Francisco. another is the McKnight 

Brain Institute in Gainesville, Fla., which is under the auspices of the University of Florida but has relied on critical 

input from Va and dod. 

other federal agencies, too—namely the National Institutes of Health—play a critical role in helping to fund much 

of the vital work that Va- and university-affiliated researchers conduct nationwide. 

In today’s economic climate, such partnerships are invaluable. They enable researchers to share and leverage 

resources—from equipment to expertise—in ways that vastly improve efficiency and productivity. 

In the pages that follow, you’ll read about some of the results of this work, and about some exciting new projects 

under way. along with our partners, we look forward to continuing to serve Veterans and find innovative ways to 

improve their lives. 

Sincerely, 

Joel Kupersmith, Md 

Chief Research and Development Officer 

Veterans Health Administration 
2 High-tech imaging center hunts for clues on Veterans’ brain ailments 

The Center for Imaging of Neurodegenerative Diseases is a leading site for 

studies on Alzheimer’s, PTSD, Gulf War illness and numerous other brain disorders 

7 Researchers look to nature for potent cancer fighters

Turmeric and green tea may not sound like the stuff of cancer treatment, 

but many tumor-thwarting drugs in use today derive from natural compounds 

11 Neurosteroids—the ‘forgotten molecules’—may yield new 

hope for illnesses from schizophrenia to PTSd

Brain substances such as pregnenolone, studied long ago by researchers, 


have recently come to the fore once more
 

14 Infectious disease studies seek to protect troops abroad

VA researchers are helping to build a new understanding of infectious 


diseases that are common in areas where U.S. troops are deployed
 

19 Reshaping primary care to target homelessness among Veterans

Offering many services under one roof—including mental health care 


and housing support—is one of the keys to success
 

32	 Vets helping Vets: Peer support proves popular and effective 

 for those coping with chronic disease 

For illnesses such as diabetes and hypertension, peer support can be just what the doctor ordered 

36	 at the heart of Va health care: Research effort boosts quality 

in cardiac cath labs nationwide 

An innovative system for collecting and monitoring data from cath labs has helped raise 

VA heart care to new heights 

41	 Million Veteran Program: Va-Veteran partnership explores 

genes’ role in health and disease

In what is expected to be a landmark genomics effort, Veteran 


volunteers will help inform the course of medicine in the future
 

46 Making the most of electronic health records

A consortium of several VA medical centers and universities is exploring new technology 

to squeeze more value out of electronic records for research and quality improvement 

51	 Reaching out to alzheimer’s families: Research leads 

to nationwide Va program to ease stress on caregivers

‘REACH VA,’ the result of a federal-academic collaboration, 


is changing lives for Veterans and their caregivers across the nation
 

57	 For Veterans coping with subtle auditory problems, studies may 

point to solutions

Researchers and clinicians with VA and the military are learning how to identify 

and treat cases in which the ear-brain pathway is damaged, despite normal hearing 

 

 

CoNtENtS
 

dISCoVERy ANd CollAboRAtIoN foR ExCEPtIoNAl HEAltH CARE
 

51 25

feaTure sTories	 aBouT Va research
 

25 Va-aCadEMIC PaRTNERSHIP: 

aN HISToRICaL TIMELINE 

28	 PRoGRaM oVERVIEW 

30	 RESoURCES 

60	 IN THE NEWS 

Cover: With imaging 

technicians Katherine Wu 

at the monitor and Stephen 

Kriger at the “magnet,” a study 

participant prepares to undergo 

an MRI scan at the Center for 

Imaging of Neurodegenerative 

Diseases at the San Francisco 

VA Medical Center. See feature 

on page 2. 

for questions or additional copies contact:
 

r&D communications (12)
 

103 south Gay street, ste. 517
 

Baltimore, MD 21202
 

(410) 962-1800 x223 

research.publications@va.gov 
2 V A R E S E A R C H T O D A Y 

 

tHE bRAIN
 

HIGH-tECH ImAGING CENtER HUNtS foR
 

ClUES oN VEtERANS’ bRAIN AIlmENtS
 

The Center for Imaging of Neurodegenerative Diseases is a leading site 

for studies on Alzheimer’s, PTSD, Gulf War illness and numerous other disorders 

i

n 1980, as a nephrologist and the new chief of 

hemodialysis at the San Francisco Va Medical Center, 

Michael Weiner, Md, performed basic experiments 

using the earliest form of a technology that had just 

been developed—magnetic resonance imaging (MRI). 

He says he never dreamed he would one day direct 

a high-tech research facility such as the Center for 

Imaging of Neurodegenerative diseases. Today, CINd 

is the only imaging center in Va exclusively devoted to 

MRI of the human brain. as such, it plays a key role in 

clinical research on alzheimer’s disease, posttraumatic 

stress disorder, Gulf War illness, traumatic brain injury, 

Parkinson’s disease, and other maladies affecting the 

brain and central nervous system. 

In the vanguard of medical imaging from its earliest days 

Even in those early days of MRI, Weiner foresaw the 

potential impact on research and health care. 

“My work with rats, when I created techniques for using 

NMR [nuclear magnetic resonance—an earlier form of 

MRI] to study whole animals, happened to be one of the 

first biological applications of NMR,” he says. “Because 

I was a physician with a broad clinical background, I 

could see that once they made magnets big enough to 

hold people, the potential diagnostic applications of this 

new technology were going to be huge. But nobody in 

their wildest dreams predicted the speed at which the 

field would grow.” 

When he first began his experiments, Weiner found a 

total of 60 papers on biological applications of NMR 

in the scientific literature. “Today, there are hundreds 

of papers published every day on MRI. I had the 

extreme good fortune to become involved in the field 

at its very beginning.” 

In growing his MRI program from a basement laboratory 

to an internationally renowned center with a staff of more 

than 70, Weiner has never hesitated to think big. 

In 2005, he was named lead investigator for the 

alzheimer’s disease Neuroimaging Initiative (adNI), a 

$140-million, 10-year clinical trial involving more than 

1,000 patients at 55 centers in the U.S. and Canada. 

Supported by a consortium that includes the National 

Institutes of Health, private industry and the Canadian 

government, adNI is designed to validate biomarkers for 

detecting and monitoring progression of alzheimer’s. 

“Currently, we use subjective clinical measures such as 

memory tests or activities of daily living, which have a lot of 

variability from one day to the next,” explains Weiner. “The 

beauty of a biomarker is that it doesn’t have that variability. 

This objective consistency will become extremely 

important in identifying alzheimer’s at an early stage and 
SPRING 2011 3 

 

 

 

 

 

’

Brain power—Dr. Norbert schuff and imaging 


technician Monica camacho review Mri brain scans 


from a recent study. schuff is the lead physicist
 

at Va s center for imaging of Neurodegenerative 


Diseases and a professor of radiology at the 


university of california, san francisco. 


State-of-the-art MRI: Zooming in on the brain 

A new high-powered MRI system soon to be installed at 

the Center for Imaging of Neurodegenerative Diseases will 

dramatically improve imaging of brain anatomy, blood vessels, 

blood flow, white matter and brain metabolites, says CIND 

senior scientist Norbert Schuff, PhD. 

In fact, the powerful 7 Tesla MRI, which is used only for 

research and not routine clinical diagnosis, will enable 

scientists to view brain anatomy that was previously unseen. 

Schuff offers three examples of how the new magnet will 

further research: 

 Improved spatial resolution will help researchers measure 

changes in the hippocampus, which loses volume in both 

Alzheimer’s disease and PTSD. “Different hippocampal 

subfields are affected in each condition,” notes Schuff. 

“This will help us distinguish between the two.” 

 Increased signal-to-noise ratio will result in much more 

accurate measures of brain metabolites—chemicals 

important for brain function—through proton MR 

spectroscopy. “We can spread the signal out and see 

metabolite levels in much greater detail,” according to Schuff. 

 Nerve fiber bundles, or white matter, which are damaged 

in traumatic brain injury, appear in much greater detail in 

diffusion tensor imaging—a form of MRI—performed on 

a 7 T machine. 
—

 

 

Center director cited for long,

fruitful career in brain imaging 

Michael Weiner, MD, director of VA’s Center for Imaging of 

Neurodegenerative Diseases and a professor at the University 

of California, San Francisco, accepted the Ronald and Nancy 

Reagan Research Award from the Alzheimer’s Association in 

April 2011 on behalf of the nationwide Alzheimer’s Disease 

Neuroimaging Initiative, which Weiner leads. 

In 2006, Weiner received the William S. Middleton Award, VA’s 

highest scientific honor, in recognition of his contributions to 

the field of magnetic resonance imaging and his exemplary 

service to VA. 

Weiner says the VA honor was especially meaningful to him 

because at the outset of his VA career, four decades ago, he 

had the opportunity to know Middleton. “He was instrumental 

in implementing the system of affiliations between VA medical 

centers and medical schools, such as the affiliation between 

the San Francisco VA and the University of California, San 

Francisco. This collaboration has been of incredible mutual 

benefit to the VA and to doctors around the United States.” 

Looking back on his career, Weiner says: “I’ve been very lucky. 

I was lucky to be in the right place at the right time in the 

development of the field of MRI, and I’ve been equally lucky 

in my colleagues and collaborators. Most importantly, I’ve 

been extremely fortunate to spend my entire career in the VA 

system, which has been a hugely supportive environment for 

medical research.” 

measuring both the progression of the disease and the 

success of new treatments as they are developed.” 

To date, adNI researchers have published more than 

170 peer-reviewed papers and are, according to Weiner, 

“zeroing in” on biomarkers based on brain imaging, 

cerebrospinal fluid and blood. “I’m very optimistic that 

we will succeed,” he says. 

at Weiner’s direction, adNI investigators share 

all their raw data on the Internet without embargo 

(adni-info.org and adni.loni.ucla.edu). The success of 

this strategy has led Weiner to become a passionate 

advocate for the widespread sharing of scientific data 

(scientificdatasharing.com). “Imagine a time when 

all published papers include raw data at the time of 

publication,” he says. “This will become a huge resource 

that will transform the scientific community, create 

new types of research, lead to accelerated discovery and 

improve treatments. It may even stimulate the economy 

by creating new value and new businesses.” 

Working with the Department of Defense 

CINd is also home to a very different research 

partnership: the Neuroscience Center of Excellence, 

a collaboration among the department of defense 

(dod), Va, and NCIRE-The Veterans Health Research 

Institute, the nonprofit institute that supports biomedical 

research at the San Francisco Va. Since 2004, with 

Weiner as principal investigator, dod has supported 

more than $35 million in research projects in PTSd, 

traumatic brain injury (TBI) and other neurotraumas, 

Parkinson’s disease and basic neuroscience. 

Weiner, an air Force Veteran who served during 

the war in Vietnam, emphasizes the relevance of the 

Neuroscience Center to the mission of Va. “Today’s 

active service members are tomorrow’s Veterans. The 

hazards they are exposed to today, such as TBI and 

PTSd, will increase their risk for neurodegenerative 

diseases as they age. I’d love to see many more research 

collaborations between the Va and dod.” 

Thomas Neylan Md, director of the PTSd Program 

at the San Francisco Va, says the Neuroscience Center 

has been a huge help to his team’s work. “Mike and his 

team have had many PTSd-related grants, projects 

Imaging pioneer in 1980, Dr. Michael Weiner was 

one of the first investigators in the nation to use 

nuclear magnetic resonance—which later evolved 

into magnetic resonance spectroscopy, a technique 

related to Mri—to study metabolism of organs inside 

a living animal. 

4 V A R E S E A R C H T O D A Y 
SPRING 2011 5 

—

’

Team effort study coordinator Jennifer hlavin 

(top) is one of more than 60 staff at Va s center 

for imaging of Neurodegenerative Diseases— 

investigators, postdoctoral fellows, computer 

programmers, technicians and others—who 

contribute to research on brain changes that occur 

in normal aging and various disorders. 
6 V A R E S E A R C H T O D A Y 

MRI Central—ciND investigators and technicians 

are among the nation’s top experts in advanced 

Mri research techniques such as susceptibilityweighted Mri and Mr spectroscopy. 

and publications over the last 14 years. and CINd is a 

key component of the Sierra Pacific Va Mental Illness 

Research and Education Clinical Center.” 

Weiner notes that a unique strength of CINd is the 

diversity and expertise of its staff. “our research group 

is composed not just of medical people, but physicists 

and computer scientists who are largely focused on 

developing new techniques and improving the ability of 

our machines to acquire and process data. That’s made 

our productivity greater. We rarely repeat the work of 

others, thanks to our enhanced capabilities.” 

Ramping up the ‘toolkit’ with mighty new magnets 

Currently, CINd uses two magnets for its MRI studies: 

a 1.5 Tesla unit for large-scale clinical studies, and a 4 

Tesla machine for research involving highly detailed 

brain images (Tesla is a measure of magnetic strength; 

the higher the number, the more powerful the magnet). 

Soon, that toolkit will be upgraded significantly with 

the arrival of a new 3 T unit for clinical studies and an 

advanced, state-of-the-art 7 T instrument for specialized 

research. Both magnets are funded by Va. 

The new 3 Tesla machine “will lead to huge increases 

in speed, image quality, flexibility, and efficiency,” 

according to CINd senior scientist Norbert Schuff, 

Phd. Researchers will be able to combine imaging 

modalities, he says, analyzing not only brain structure 

but profusion (blood flow) and diffusion (water) 

simultaneously in one session. Finally, says Schuff, 

“Because there are so many other 3 T systems in use 

throughout the world, we will have a better chance to 

compare our results with data from other sites, which 

will improve the power of our studies.” 

The 7 Tesla unit will enable highly detailed imaging 

of brain structure, function and physiology. “With a 

stronger magnet, we will have increased signal-to-noise 

ratio,” says Schuff. “Then there’s spatial resolution—we 

will be able to probe smaller brain structures in a more 

detailed way, and at higher contrast. The 7 T will give us 

two to three times the spatial resolution of the 4 T. We 

will go from millimeter scale to submillimeter scale.” 

Gulf War Veteran and wife among many study volunteers 

For their imaging studies, CINd researchers depend 

not only on patients who have been referred to them, 

but also on healthy volunteers who serve as controls. 

Many are Veterans. Retired Navy Captain Mike 

Pivonka has volunteered for two imaging studies at 

CINd, one on Gulf War illness and one on memory 

and risk of cognitive decline. Pivonka, who is without 

cognitive difficulties, volunteered for the Gulf War 

study on the thought that “if it could help people who 

had problems, especially Veterans who had problems 

after the Gulf War, that would be a good thing to do. 

That appealed to me.” He found the experience of being 

scanned “kind of relaxing. It took about 45 minutes, 

and I took a nap every time.” He would volunteer again, 

he says: “I have recommended the experience to others, 

including my wife, who has volunteered herself.” 

at any given time, says CINd study coordinator Jennifer 

Hlavin, there are 10 to 15 imaging studies under way 

at CINd. “I really enjoy working with our Veteran 

volunteers,” says Hlavin. “Not only do they know their 

way around the Va, but they are really happy to help, and 

very interested in being involved. Many healthy volunteers 

come here because a family member or friend is affected by 

alzheimer’s or another serious condition. Many are repeat 

volunteers, and we are happy to have them.” 
 

 

CANCER
 

RESEARCHERS look to NAtURE 

foR PotENt CANCER fIGHtERS 

Turmeric and green tea may not sound like the stuff of cancer treatment, 

but many tumor-thwarting drugs in use today derive from natural compounds 

i

s it possible to treat cancer with compounds made 

from nature? a better question may be: Is it possible 

to treat cancer without them? 

Many common cancer drugs are based on natural 

sources, including paclitaxel (from yew leaves), 

daunorubicin and doxorubicin (from bacteria), and 

vincristine and vinblastine (from the periwinkle plant). 

In fact, natural products have been the basis for more 

than half of all drugs in use today, including penicillin 

(mold) and aspirin (willow bark). 

according to a 2007 published review, 100 drugs were 

approved as anticancer agents between 1981 and 2006. 

of those, 63 were natural products or based on natural 

products. a recent example: In January 2011, the Food 

and drug administration approved Halaven for the 

treatment of breast cancer. The drug is a synthetic form 

of a compound found in a sea sponge. 

Natural products are “alive and well in cancer research,” 

says david J. Newman, dPhil, chief of the Natural 

Products Branch at the National Cancer Institute and 

coauthor of the review. Newman spent nearly 20 years 

involved in research on halichondrin B, the sea-sponge 

compound that eventually resulted in Halaven. 

To capitalize on this noteworthy track record, Va funds 

several investigators studying the promise of natural 

products to prevent or treat cancer. 

Spices as sources 

adhip Majumdar, Phd, dSc, is a professor at Wayne 

State University’s School of Medicine and an investigator 

with the John d. dingell Va Medical Center in detroit. 

Some of his work focuses on the potential of curcumin, a 

potent anti-inflammatory compound found in the spice 

turmeric, against colorectal cancer. 

about half of those diagnosed with colorectal cancer 

will experience a recurrence—the cancer comes back 

after treatment appears to have destroyed it. Some 

research suggests that recurrence is due to cancer stem 

cells. Normal stem cells are like factories that can churn 

out multiple types of daughter cells. Cancer stem cells 

are similar, with a deadly exception: They produce more 

cancer cells. 

“They are a small population of cells, and highly resistant 

to chemotherapy,” Majumdar says. “We want to find 

something that would destroy them.” 

His lab may have found an answer in curcumin. It 

appears to stop cancer cells or cancer stem cells from 

growing in animal models. Moreover, an initial clinical 

trial found that curcumin had no side effects. “It’s very 

nontoxic,” he says. “you can take up to eight grams a day.” 

Majumdar has also studied curcumin in combination 

with FoLFoX, a three-drug regimen used to treat 

SPRING 2011 7 
8 V A R E S E A R C H T O D A Y 

The science of saffron—Dr. sushanta Banerjee 

and his team at the Kansas city Va Medical 

center have studied crocetin, among other 

natural products, as a potential anti-cancer agent. 

crocetin is a compound found in the spice saffron. 

colorectal cancer, and with resveratrol, 

an antioxidant found in grape skins. Both 

strategies appear promising, says the researcher. 

Recent experiments in his lab have also yielded strong 

results from standard chemotherapy combined with a 

curcumin analog—a synthetic molecule that mimics the 

natural compound. 

Notwithstanding Majumdar’s successes, one hurdle to 

curcumin studies is that the body doesn’t easily absorb 

the compound. a team with Va and the Jonsson 

Comprehensive Cancer Center at the University of 

California, Los angeles, created an injectable form of 

curcumin. In october 2010, that group reported that 

this form of curcumin made the anticancer drug cisplatin 

more effective in destroying head and neck cancer cells. 

Saffron and green tea also show promise 

Sushanta Banerjee, Phd, director of the Cancer 

Research Unit at the Kansas City (Mo.) Va 

Medical Center and a professor at Kansas 

University Medical Center, is studying another 

spice. His group has found that crocetin, a compound 

in saffron, has anticancer properties. But his work 

highlights the fact that not all compounds will work 

well together. “We found that if we give crocetin 

with gemcitabine”—first-line chemotherapy for 

pancreatic cancer—“that crocetin blocks that drug’s 

action,” he says. 

Banerjee’s group is now looking into combining 

gemcitabine with other natural products. He has 

found a compound from the bitter orange tree that 

makes gemcitabine up to five times more active against 

pancreatic cells in the laboratory. If the results hold, 

adding the bitter-orange molecule to treatment could 

reduce the necessary doses of gemcitabine to levels that 

cause no toxic effects. 
—

“If we can establish that this [combination] works and go 

to clinical trials, I’m optimistic that we can change the 

treatment profile for pancreatic cancer,” says Banerjee. 

Banerjee’s group also has discovered a breast cancer gene 

called CCN5 that appears to be a marker for noninvasive 

tumors. If the gene could be activated in all breast cancer 

cells, it would theoretically stop them from spreading, 

or metastasizing. Interestingly, Banerjee’s lab discovered 

that a compound in green tea, epigallocatechin-3-gallate 

(EGCG), seems to activate CCN5. 

Green tea is one of several tumor-fighting compounds 

that Santosh Katiyar, Phd, has studied over the past 

two decades. His work at the Birmingham Va and the 

University of alabama has also highlighted the anticancer potential of grapeseed extract, silymarin from 

milk thistle, and honokiol, a compound derived from 

magnolia bark. 

Katiyar also studies EGCG by itself. He has shown 

that applying this green tea compound to the skin in 

mice and humans will inhibit photo-damage caused by 

ultraviolet (UV) radiation. Sunlight overexposure is a 

major factor in skin cancer, which affects more than one 

million americans each year. 

“The polyphenols in green tea have strong antioxidant 

and anti-inflammatory properties,” explains 

Katiyar. His research shows that these compounds 

promote dNa repair by boosting the production of 

interleukin-12, an immune-system protein. 

His work also has shown the preventive effect of 

consuming green tea: Mice given green tea polyphenols 

in their drinking water had a lower risk of UV-induced 

cancerous changes in the skin, compared with mice not 

given the green tea polyphenols. Katiyar notes that the 

concentration of green tea extracts is low enough that if 

people drink the beverage regularly, they should garner 

the same benefits. “Four to five cups a day can prevent 

UV-induced damage at the same level as in animal 

models,” he says. 

Though other research suggests that drinking green tea 

may have wide-reaching health benefits, the jury is still out. 

In September 2010, the Fda warned the makers of two 

products with green tea as an ingredient that they could 

SPRING 2011 9 

Food as medicine curcumin, from the spice 

turmeric (left), and resveratrol, an antioxidant found 

in grape skins, are among many nature-based 

compounds being studied by Va investigators and 

others for their cancer-fighting properties. 
10 VA RESEARCH TODAY

not make unsubstantiated claims about its health benefits. 

Promoting green tea as a health beverage, however, is 

different than showing anticancer activity for a specific 

compound, which many labs—including the Va groups 

mentioned above—have done through numerous 

rigorous studies. admittedly, the notion of a food or 

whole herb having therapeutic value still meets with 

skepticism in the scientific world. 

Part of this attitude may stem from the Western idea 

of one drug, one effect. “one roadblock in natural 

products research is the mindset that we have to have 

a drug to affect only one small aspect, one pathway,” 

says Majumdar. He contrasts this with the approach 

of ayurvedic medicine, the traditional healing system 

in India, which he says “deals with a concoction of 

natural products. There are active ingredients but they 

have supporting elements. In allopathic medicine, it 

has to be a drug.” 

This debate aside, isolating the active compound in 

a plant or other natural substance and developing it 

as a drug makes sense in many cases because it would 

be impossible for a patient to get a therapeutic dose 

otherwise. Similarly, coming up with synthetic analogs 

of these compounds in the lab—rather than attempting 

to harvest the natural product on a large scale—often 

seems to make economic and practical sense. 

In any case, in the face of what continues to be one of 

mankind’s most dreaded diseases, scientists like Va’s 

Majumdar, Banerjee and Katiyar—and their dedicated 

teams—are determined to continue pursuing nature’s 

potential cures. 

Award-winning research 

To read about VA investigators recognized during 

National VA Research Week for their groundbreaking 

work, visit www.research.va.gov/researchweek. 

Loss of mother to breast 

cancer fuels scientist’s 

quest for natural cures 

A native of India who became a U.S. citizen in the 1990s, 

Santosh Katiyar, PhD, drinks two cups a day of green tea. 

The VA and University of Alabama researcher says people 

with fairer skin, who are at higher risk for skin cancer, may 

need to drink up to six cups per day to derive benefit. For the 

perfect cup of tea, he advises that people boil water, remove 

it from the heat, and then steep the leaves, covered, for four 

or five minutes. “In that time, most of the polyphenols will 

dissolve in the warm water. If you boil it with the leaves in it, 

the polyphenols may get oxidized and polymerized and reduce 

their activity.” 

The researcher, who has been funded by VA as well as the 

National Center for Complimentary and Alternative Medicine 

and National Cancer Institute, believes military personnel may 

be at special risk for skin cancer, given their increased exposure 

to sunlight. That is part of what motivated him to join VA in 

2003 and conduct research on behalf of Veterans. More than 

a decade earlier, his initial passion for exploring natural cancer 

therapies centered on quite a different population: mothers. 

“I lost my mother to breast cancer,” shares Katiyar. “I had 

done my PhD in nutrition, and I realized that my parents had 

devoted a lot of time and energy to my education. Yet, I could 

not help my mother. So I resolved to do something to help all 

the other mothers who are still here. I decided I would work 

on cancer—how it can be prevented, particularly by dietary 

supplements and nutrients.” 

10 V A R E S E A R C H T O D A Y 

Tea time—The lab studies of Dr. santosh 

Katiyar, with Va and the university of alabama, 

Birmingham, suggests that green tea holds 

numerous health benefits, including preventing 

and repairing DNa damage caused by 

ultraviolet radiation—a factor in skin cancer. 
SPRING 2011 11 

tHE bRAIN
 

NEURoStERoIdS—tHE ‘foRGottEN molECUlES’— 

mAy yIEld NEw HoPE foR IllNESSES fRom 

SCHIzoPHRENIA to PtSd 

Brain substances such as pregnenolone, studied long ago by researchers, 

have come to the fore once more 

Pilots and factory workers seemed to perk up from 

a substance called pregnenolone in studies of stress 

and fatigue done as long ago as the 1940s. But then a 

half-century went by with little attention paid to the 

compound, which occurs naturally in the brain and is 

believed to play an important role in stress, memory and

other vital mental functions. 

Pregnenolone, which belongs to a class of compounds 

called neurosteroids, caught the attention of durham 

Va Medical Center and duke University psychiatrist 

Christine Marx, Md, Ma, for its auspicious 

preliminary research—and the dearth of follow-up 

clinical studies. 

“I thought, ‘This can’t possibly be. My literature search 

must have been done incorrectly. I have to be missing 

something,’” says Marx, co-director for research at Va’s 

Mid-atlantic Mental Illness Research, Education and 

Clinical Center. Seizing the opportunity to make strides

in this wide-open area of study, Marx first focused on 

neurosteroids such as pregnenolone to treat some of the 

most onerous symptoms of schizophrenia. Based on 

promising results, her research has mushroomed into 

other areas that are particularly relevant for combat 

Veterans, including posttraumatic stress disorder 

(PTSd) and traumatic brain injury (TBI). 

“While I first became interested in neurosteroids for 

their possible relevance to schizophrenia,” Marx says, 

“I saw compelling characteristics that made them 

logical candidates for study in various psychiatric and 

neurological disorders.” The potential uses of these longoverlooked molecules for brain disorders are severalfold, Marx says. They could be biomarkers for various 

disorders, either identifying those at risk or hinting at 

the earliest stages of illness. They could also serve as the 

basis for new therapies where current treatments are 

falling short. additionally, they could indicate how well 

a therapy is working. 

Starting with schizophrenia 

Currently, schizophrenia is treated mainly with 

antipsychotic medications. By and large, they are 

helpful for hallucinations and delusions, but less so 

for “negative” symptoms such as lack of emotion and 

motivation, or cognitive earmarks of the disease such 

as trouble with attention and memory. But a Marx-led, 

Va- and National Institutes of Health-supported pilot 

study in 21 people with schizophrenia has provided 

hope that neurosteroids may be effective against the 

negative and cognitive sympt

disabling disease. 

oms of this frequently 
 

—

 

Healing for Heroes soldiers from the fourth
 

infantry Division operate in Kandahar Province,
 

afghanistan, earlier this year. research on
 

neurosteroids could lead to new therapeutic tools for
 

deployment-related conditions such as PTsD and TBi.
 

Neurosteroids may eventually figure in PTSD, TBI treatment 

In a recent study, VA and Duke University psychiatristresearcher Christine Marx, MD, MA, and her colleagues 

linked reductions in a neurosteroid called allopregnanolone 

with various symptoms of posttraumatic stress disorder. 

Allopregnanolone is a substance produced when 

pregnenolone—the substance Marx has been studying in 

schizophrenia—is metabolized. Based on the finding that 

allopregnanolone levels spiked substantially in those patients 

who received pregnenolone, researchers are hopeful that 

pregnenolone will prove useful as a PTSD therapy. 

Marx’s work on traumatic brain injury points to therapeutic 

possibility for neurosteroids in this condition, as well. A 

small study in Veterans signaled possible improvement from 

pregnenolone in certain PTSD symptoms common after TBI, 

such as irritability, sleep problems and trouble concentrating. 

Marx has another, larger study in the works to clarify the 

substance’s potential in mild TBI in particular. 

In the Durham VA researcher’s most recent study, levels of 

some neurosteroids were found to be significantly reduced 

in returning Veterans who had sustained a blast-related 

TBI, compared with those who had not. Marx believes 

neurosteroids may not only lessen PTSD symptoms 

following brain injury but also represent useful biomarkers 

for identifying TBI. Look at a Veteran’s post-injury levels of 

neurosteroids, Marx theorizes, and you may be able to foretell 

TBI symptoms and PTSD symptoms, and perhaps predict 

whether neurosteroid treatment could promote recovery. 

12 V A RESEARCH RESEARCH TODAY 
SPRING 2011 13 

—

 —

’

The clinical trial built on Marx’s prior animal studies 

showing that blood levels of neurosteroids correlated 

with brain levels—meaning researchers could potentially 

get a virtual peek inside the brain by simply studying the 

blood. It was also based on work by other researchers 

showing that rodents’ learning and memory improved 

on pregnenolone. (She notes that while pregnenolone 

is available over the counter, her team tested a carefully 

controlled and purified formulation that could be a far 

cry from versions sold as dietary supplements.) 

In Marx’s research, reported in 2009 in the journal 

Neuropsychopharmacology, people who received 

pregnenolone reported a significant lessening of 

negative symptoms, compared with the placebo group. 

Marx’s research team—representing not only duke 

and Va, but also four other universities—found clues, 

too, that measuring steroids in the blood may help 

predict the effectiveness of neurosteroid treatment for 

cognitive symptoms. 

While stressing that additional study is needed, Marx 

and her coauthors concluded that “pregnenolone may 

represent a novel therapeutic advance for the treatment 

of cognitive and negative symptoms in schizophrenia.” 

In Marx’s words, the findings are “very promising, 

especially given the lack of options currently for 

negative symptoms and cognitive symptoms in those 

with schizophrenia.” 

Cautiously optimistic—Dr. christine Marx, with Va 

and Duke university, is hopeful that neurosteroids 

hormone-like substances produced in the brain 

will emerge as an effective treatment for conditions 

ranging from schizophrenia and alzheimer s 

disease to PTsD and TBi. 

The psychiatrist-researcher, who is a co-applicant on 

a U.S. patent for the use of neurosteroids in central 

nervous system disorders, is pursuing larger studies of 

neurosteroids for schizophrenia. She is also exploring 

their usefulness in other conditions such as PTSd and 

TBI. “all of these disorders are impacting very large 

numbers of today’s Veterans,” she says of the spectrum 

of brain-associated conditions she is studying (added 

most recently to the list: alzheimer’s disease). 

Says PTSd expert Jonathan davidson, Md, “If we can 

find something to help people with the toughest-totreat symptoms of schizophrenia, then it makes sense it 

would have a fighting chance of being useful in PTSd.” 

davidson, a duke University emeritus professor and 

collaborator on Marx’s PTSd research, says about Marx 

herself: “She has become a world authority in the field 

of neurosteroids. With the integrity and precision she 

brings to her research, you know the work she does is of 

the absolute best quality.” 

Will Marx’s findings translate into improved patient 

care? She expresses guarded hope, now that the research 

spotlight has been refocused on these long-neglected 

neurosteroids: “our studies are at a very early stage, 

but support is continuing to accrue for the theory 

that neurosteroids may in time serve as effective 

interventions.” 
14 V A R E S E A R C H T O D A Y 

dEPloymENt
 

H E A l t H 
 

INfECtIoUS dISEASE StUdIES SEEk 

to PRotECt tRooPS AbRoAd 

VA researchers are helping to build a new understanding of infectious 

diseases that are common in areas where U.S. troops are deployed 

Given the threats they face each day, troops in Iraq 

and afghanistan likely don’t worry much about bug 

bites. But two diseases—leishmaniasis and malaria— 

can infect them through insect bites, and both diseases 

carry the potential for serious consequences. another 

infectious disease common in areas of the world where 

U.S. troops are deployed, tuberculosis, is spread directly 

from human to human. With no effective vaccines yet 

available for any of these diseases, Va researchers are 

among those seeking better ways to prevent, diagnose 

and treat the illnesses. Part of the work involves 

studying the human immune system’s reaction to these 

invisible dangers. 

Sand fly bites: More than a nuisance 

Worldwide, about 350 million people are at risk for 

leishmaniasis, which has multiple forms. all are caused 

by one-celled Leishmania parasites of the that are spread 

by sand fly bites. 

U.S. troops in recent years have sustained only a handful 

of cases of visceral leishmaniasis—the most serious form 

of the disease, which is usually fatal without treatment. 

a far more common—and milder—form of the disease 

is cutaneous leishmaniasis, which produces sores around 

the bite. Some patients develop only an insignificant 

sore that disappears on its own. others develop deeper 

sores. Without treatment, the sores usually disappear 

over time, though they can last for months and form 

scars, or become chronic, non-healing lesions. 

Cutaneous leishmaniasis is rare in the U.S.—cases 

have been found in Texas, near the border with 

Mexico—but it is much more common in the Middle 

East. afghanistan’s capital, Kabul, is a high-risk site 

for leishmaniasis. according to the World Health 

organization, about 200,000 cases occur there each 

year. a 2003 study found that about three percent of 

Kabul residents had active leishmaniasis, and another 

22 percent had scarring from past infections. 

Since 2003, there have been about 3,000 documented 

cases of leishmaniasis in U.S. troops, with almost all 

of them being the cutaneous form, says Col. alan 

Magill, Md, former division director of experimental 

therapeutics at the Walter Reed army Institute of 

Research and attending physician with the infectious 

disease service at Walter Reed army Medical Center. 

In 2003 and 2004, nearly 1,400 U.S. personnel in Iraq and 

afghanistan were diagnosed with cutaneous leishmaniasis, 

in the largest recorded outbreak of the disease. Magill says 

that now, cases stand at about 100 per year. “Protective 

clothing, dEET [an army-developed chemical that 

today is used in most insect repellents], bed nets, they all 
SPRING 2011 15 

Immunity booster—Dr. Laurence Buxbaum, an 

infectious-disease specialist at the Philadelphia 

Va Medical center and university of Pennsylvania, 

is studying how to bolster the body’s immune 

response to the parasite that causes leishmaniasis. 
16 VA RESEARCH TODAY 

Malaria maven—Dr. Michael riscoe, with the 

Portland Va Medical center and oregon health and 

science university, is working on new drugs to 

combat malaria. The disease, spread by mosquitoes, 

kills a million people worldwide each year and 

poses a threat to u.s. troops who are unable to keep 

up with preventive steps such as taking a daily 

doxycycline pill. 

work well as prevention,” he says. “The vast majority of 

cases occurred in the first year or so, when many people 

were sleeping out in the desert. Now it’s a more mature 

environment, and cases have dropped dramatically.” 

But Magill estimates that for every diagnosed case of 

leishmaniasis, there are three to five others that are 

never seen because the lesions aren’t serious enough for 

troops to seek medical treatment, or because they do not 

want to leave their units. 

Laurence Buxbaum, Md, Phd, a physicianscientist at the Philadelphia Va Medical Center 

and University of Pennsylvania, studies the body’s 

immune response to the Leishmania parasite. In 

general, there are two types of immunity: innate 

immunity, a general response by the body that’s 

required to fight off pathogens; and adaptive 

immunity, a specific response in which the body 

creates antibodies and mounts cell-mediated 

responses against an invader. 

Buxbaum has discovered that the antibodies created by 

the adaptive immune system in response to the parasite 

might be doing more harm than good. They induce the 

body to make a protein called interleukin-10, which in 

turn suppresses the cell-mediated phase of the adaptive 

immune response. 

“IL-10 normally prevents an immune response to 

infection from getting out of hand,” he says. “But 

in leishmaniasis, you don’t want that to happen; the 

immune system response is dampened when you 

actually want it strengthened.” 

He’s now studying what part of the parasite attracts the 

antibodies. If he can pinpoint that part, “We could block 

the antibody response by creating a drug that looks like 

the target,” he notes. “The antibody would bind to the 

drug instead of the parasite, no IL-10 would be produced 

and your body could fight off the parasite more strongly.” 

a vaccine for this disease is not an immediate 

possibility, he says. “Vaccines work by using protective 

antibodies, and in leishmaniasis it’s likely that any 

antibody response you’d get would make things worse.” 

Mary Wilson, Md, of the Iowa City Va Medical Center 

and the University of Iowa, studies the genetics of 
SPRING 2011 17 

outcomes to leishmaniasis infection. She and colleagues 

have collected information on more than 1,400 people 

who live where leishmaniasis is endemic. They hope to 

determine whether certain genes are associated with risk 

of infection, and whether others are linked with better or 

worse outcomes after infection. Wilson’s research could 

lead to gene-based treatment or prevention strategies. 

Malaria: Common to Afghanistan’s river valleys 

Each year, malaria strikes about 250 million people 

worldwide, killing 1 million. Like leishmaniasis, there 

are multiple types of malaria. all result from infection 

by Plasmodium parasites, carried from person to 

person by mosquitoes. 

While there is no malaria in Iraq, both P. vivax and P. 

falciparum forms have infected troops in afghanistan, 

says Magill. “It’s seasonal there, and not urban,” he says. 

“But there is malaria in the river valleys.” 

Military personnel are prescribed a daily preventive 

pill for malaria. “If they take it daily, they’re unlikely to 

get malaria,” according to Magill. “But like anything 

you have to do every day, it doesn’t always happen.” In 

addition to taking the pill, troops are advised to use 

dEET products and cover their skin to help ward off 

mosquito bites in the first place. 

Magill recalls only a few severe, complicated cases of 

malaria since 2003, with service members being treated 

in Germany or at Walter Reed army Medical Center. 

He’s also seen cases of vivax malaria in Veterans who 

have been back in the U.S. for weeks or months. The 

vivax parasite can lie dormant in the liver for months 

and then cause a relapse, making it complex to diagnose. 

“We’ve had relapsed vivax cases in which someone 

shows up with a bad fever, a headache,” he says. Under 

those conditions, “We assume that if they were in 

afghanistan within the year, they have malaria until 

proven otherwise.” But most hospitals in the U.S. are 

not going to diagnose malaria, he says, because it’s not 

on the radar: Basically, the disease doesn’t exist here. 

Battling drug-resistant malaria 

drug treatment options for malaria are few; all 

strains of the disease are now resistant to quinine and 

chloroquine, which used to be standard treatments. 

Michael Riscoe, Phd, at the Portland Va Medical 

Center has several projects under way to find new drugs. 

Supported by Va, the National Institutes of Health 

and the Medicines for Malaria Venture, Riscoe’s team 

and colleagues at the University of South Florida are 

designing and testing drugs that will block the function 

of parasite mitochondria while leaving human cells 

untouched. Mitochondria are the energy-creation 

centers of cells; without them, cells die. The potential 

drugs, in a class called quinolones, could be tested in 

humans within the next two to three years, Riscoe says. 

He is also working on synthesizing a “chemical cousin” 

of chloroquine that works without the problem of 

drug resistance. Riscoe says that drug, which he is very 

optimistic about, is three or four years from clinical testing. 

one roadblock to discovering malaria drugs is that 

the parasite takes on several forms. after infection by 

a mosquito, the parasite hides in the liver, replicating 

for a week or two. Then a different form is released into 

the bloodstream, causing a high, spiking fever. The 

bloodstream form invades red blood cells and replicates 

there. a third form can be picked up by a feeding 

mosquito and transmitted to another person. 

The chloroquine-like drug that Riscoe envisions would 

work against the bloodstream parasites, but not the other 

two forms. The quinolone drugs—which block parasite 

mitochondria—appear active against all three forms of 

the parasite. “The great hope,” says Riscoe, “is that 

we could use these drugs to both treat and 

prevent malaria.” 
18 V A R E S E A R C H T O D A Y 

Tuberculosis test, vaccine in the works
 

Tuberculosis (TB) is endemic in both Iraq and Afghanistan, 

putting U.S. troops at risk for infection, says Suman Laal, PhD, 

a research career scientist with VA and an associate professor 

of pathology and microbiology at New York University. 

The bacterium that causes the infection—Mycobacterium 

tuberculosis—usually attacks the lung and is spread through 

coughing. When a TB patient coughs, droplets carrying 

bacteria are released into the environment. Any person who 

breathes in these droplets can get infected. Treatment involves 

multiple drugs and lasts at least six months. 

M. tuberculosis grows slowly, so it can be months or years 

between infection and symptoms developing. So military 

Field test—Dr. suman Laal, with Va and New York 

university, is developing a rapid, point-of-care test 

for tuberculosis that can be used in war zones and 

other settings. 

personnel infected in Afghanistan or Iraq may develop TB 

several months or years after returning stateside. There is no 

effective prevention for TB, and there are no simple tests to 

diagnose it in the field. Moreover, says Laal, the tests that are 

available work only after symptoms are present, not before. 

Laal’s research focuses on developing a rapid, point-of-care 

test for this disease. Her group has found several candidate 

antigens—bacterial proteins—that could be used in such a 

test. They also have identified antigens that appear to play 

roles in the initial infection by the bacteria. These antigens 

could be used to design a TB vaccine to prevent infection 

altogether, she says. 
SPRING 2011 19 

HomElESSNESS
 

RESHAPING PRImARy CARE to tARGEt 

HomElESSNESS AmoNG VEtERANS 

Offering many services under one roof—including mental 

health care and housing support—is one of the keys to success 

tefan Kertesz, Md, MSc, today a physician­ sresearcher at the Birmingham Va Medical Center 

and the University of alabama, recalls a patient he saw 

at a homeless shelter in the 1990s. The man had high 

blood pressure and a mood disorder. Clinical guidelines 

and performance measures called for aggressively 

managing the blood pressure. But Kertesz sensed that 

if he were to go that route during their initial meetings, 

it would drive the man away and stifle their budding 

patient-doctor relationship. 

“I felt if I pushed my agenda—treating his blood 

pressure—I would have to not focus on the problems 

that he was presenting to me,” says Kertesz. “I would 

have to minimize the time and energy we put into his 

mood issues and the concerns he was having about his 

ability to reside in that shelter.” 

Kertesz followed his instincts: He held off on treating 

the high blood pressure. as a result, he was gently 

reproached by his medical director. Looking back, 

though, he doesn’t regret his action. In fact, he sees 

the episode as a cautionary tale about why standard 

approaches to primary care may not work for those who 

are homeless. He was inspired by the encounter—and 

many similar ones—to study what primary care for 

the homeless should look like. What do patients need 

and want most? What will draw them into a Va clinic, 

keep them coming back, and improve their health and 

social outcomes? do standard guidelines and quality 

measures—which often focus narrowly on managing a 

single disease—work for this population? 

His findings—from interviews with homeless Veterans 

and clinicians and managers involved in their care, both 

in and outside Va—confirm that one critical factor is 

trust. Without it, he says, primary care for the homeless 

is a non-starter. 

Kertesz: “Homeless patients are very experienced 

with stigma, and they are accustomed to finding that 

doctors, social workers and other authority figures 

tend to discount their concerns and agenda in favor 

of what the expert clinician judges to be the problem 

that merits attention. This fosters distrust. We stand 

a better chance of achieving our clinical goals over 

the long term if we can first establish a durable and 

sustainable relationship.” 

His research has a “heavy emphasis,” he says, on 

enlisting patients who are homeless to help define 

quality. In addition to surveying homeless Veterans 

about their experiences with Va primary care, Kertesz 

plans to compare existing models within the Va system 

and learn which features work best. 
20 V A R E S E A R C H T O D A Y 

—

Lack of chronic-disease care shortens lives 

as many as 400,000 Veterans experience homelessness 

each year. Many are coping with mental illness or 

substance abuse, although Robert Rosenheck, Md, 

who has studied homeless programs for Va for more 

than two decades, asserts that “homelessness is clearly 

a function of two things: low incomes and high rents.” 

Rosenheck is with yale University and Va’s Northeast 

Program Evaluation Center. 

Va has been a national leader in homeless programs 

overall since the 1980s, including efforts spanning 

housing, work rehabilitation, substance abuse treatment, 

and mental health. But the agency has been less successful 

at engaging homeless Veterans in primary care. 

That is crucial, because chronic diseases typically 

managed in primary care—diabetes, hypertension, heart 

disease—are widespread among the homeless. and they 

account, in large part, for a sharp rise in mortality. Life 

expectancy for people living on the streets is 30 years 

less than for americans on average. 

The Va health system is working to brighten that 

picture. as of today, most Va medical centers still 

deliver primary care to homeless Veterans through 

On the path to housing army Veteran 

roosevelt Williams, who has been struggling with 

homelessness for a decade, fills out forms during an 

information session on Va supported housing, held 

at the West Los angeles Va Medical center. 

mainstream clinics. Veterans are usually referred from 

other Va homeless programs—such as one of Va’s 43 

Comprehensive Homeless Centers. These programs 

do outreach on the street and in shelters—and even 

sometimes in county jails—to find Veterans who are 

homeless and link them with the Va services they need, 

including housing. 

Some Va sites have added primary care providers 

to their mental health clinics, to speed up access to 

primary care. Conversely, with the changeover now 

under way in Va nationwide to a new model of primary 

care called patient-aligned care teams (PaCT), standard 

primary care clinics will increasingly have mental health 

therapists and social workers on staff. This shift to a 

more comprehensive primary care model may hold some 

benefits for Veterans who are homeless, but services 

will still need to be tailored substantially to meet their 

needs. That’s the view of most experts, including Lillian 

Gelberg, Md, MSPH, a family physician and health 

services researcher who is studying how the PaCT 

model can serve homeless Veterans. 

“If people don’t have a home, and they’re coping with 

mental illness or substance abuse, and housing and food 
SPRING 2011 21 

—

instability, and they’re having a lot of trauma and violence 

in their life, there is definitely some tailoring that needs 

to be done,” says Gelberg, a professor with the University 

of California, Los angeles, who consults for Va. 

She says that in standard primary care, providers might 

not even know who among their patients is homeless. 

and those who are homeless will often not volunteer 

the information, because of the stigma. So a doctor, for 

instance, could prescribe a drug that needs refrigeration 

without realizing the patient doesn’t have a refrigerator. 

Primary care tailored to the homeless 

Several Va medical centers around the country have 

recognized the need for tailored care and moved 

in this direction. The goal at these sites is to blend 

primary care with a full array of homeless services. 

Rather than having to navigate through a maze of 

various services at different locations on different 

days, Veterans can see an internist, psychologist and 

vocational rehabilitation counselor, for example, all 

in one morning. Missed appointments—a common 

problem with homeless patients—are minimized. 

Primary care becomes the hub of treatment, rather 

than one element to be coordinated with others. 

one of the best-known examples of this approach is 

the Mental Health outpatient Treatment Center on 

the Va campus in West Los angeles—a city sometimes 

called the homeless capital of america. The center was 

funded by Va in 2002 as a demonstration project. an 

18-month study published in 2009 by a team including 

Rosenheck, Gelberg and James McGuire, Phd, a social 

work researcher at the Los angeles Va, showed the 

clinic had boosted access to primary care and curbed 

reliance on emergency rooms. 

Today, the clinic, part of the larger Comprehensive 

Homeless Center at the West La Va, has about 30 staff 

members. They do medical assessments for Veterans 

who have been living on the street or in shelters and 

provide primary and mental health care. They also help 

determine if patients are eligible for Va benefits and 

offer assistance with vocational rehabilitation. They can 

also help with placements in residential drug treatment, 

transitional housing or permanent housing, as 

appropriate. Significantly, all these services occur under 

one roof: one-stop service for people with multiple, 

complex health and social needs. 

andre Guyton, age 50, was living on the street four 

years ago. He needed pain medication because of a hip 

Getting back on his feet former Marine ray 

stromoski (left), 49, is now in transitional housing 

in santa Monica. During his recent visit to the West 

Los angeles Va he was helped by registered nurse 

David Yentes. 
22 VA RESEARCH TODAY 

—

”

Giving back after living on the streets for 10 

years, army Veteran Michelle o’Neil turned her life 

around: she now goes to school and works as a 

medical support assistant with the Va Greater Los 

angeles healthcare system. she has also done 

outreach for Veterans struggling with homelessness. 

o’Neil: “My experiences here motivated me to want 

to help Vets on a higher level, especially female Vets. 
SPRING 2011 23 

” 

Greetings and gratitude—Kenny Wasson, 50, is a 

reception clerk in a primary care clinic at the West 

Los angeles Va that tailors care to Veterans who are 

homeless. Wasson, who himself was homeless in 

2006, says he loves his Va role: “This job was made 

for me. i get to help people. 

problem, and he found his way to the clinic at the West 

La Va. one thing led to another, and the broad-chested 

army Veteran landed a job with Va in the recycling crew. 

“a lot of people on the street don’t have anywhere to go 

and don’t know where to go,” he says. “But if you’re a 

Vet, this place here is the best place to help you get on 

your feet, if you’re serious about it.” 

another success story—one that is still in progress—is 

that of patient Juanita Chapman, who served in the army 

in the late 1970s. Not long ago, she was sleeping in her 

car. Today, she is at a family shelter in North Hollywood. 

“I find myself moving forward,” she says. “I’ve gotten the 

medical attention I needed. Just having the fundamental 

things—sanctuary, medical attention, a plan—makes 

all the difference in the world in wanting to go on. Even 

though I would never kill myself, sometimes you just 

don’t want to go on. I’m so thankful. This was a lifesaver.” 

Chapman adds: “I’ve been through a lot of services. This 

Va at West La is a well-oiled machine. Ninety-nine 

percent of the time they’ve been on-point.” 

Recent additions to the West La clinic include a 

fast-track system to get patients to dentists, and home 

telehealth services for formerly homeless Veterans who 

now live in their own apartments. The model’s success 

has inspired a similar, though not as extensive, Va clinic 

in nearby southern Nevada. 

Gelberg, of UCLa and Va, says telehealth figures in 

other outreach efforts at the Los angeles Va. as part 

of her group’s implementation research, social workers 

with the Housing and Urban development-Veterans 

affairs Supported Housing (HUd-VaSH) program—a 

long-standing partnership between federal agencies that 

places homeless Veterans in their own apartments—are 

identifying Veterans who are eligible for home telehealth 

because of medical, mental health or substance abuse 

issues. a related effort relies on peer counselors in the 

Vet to Vet program (http://vet2vetusa.org) to help enroll 

and retain homeless Veterans in primary care and home 

telehealth, and assist them with keeping appointments 

and following prescribed treatments. 

“This is community-oriented primary care,” says Gelberg. 

“We’re going out to this community of homeless Veterans 

and helping them access the system and stay connected. 

We want to identify barriers and find solutions.” 

Motivating Veterans to seek care 

another program focused on linking homeless Veterans 

with primary care is led by physician-researcher Thomas 

o’Toole, Md, at the Providence Va Medical Center 
 

 

 

 

 

in Rhode Island. Walk-ins are welcome at his clinic. 

Patients can see primary care doctors as well as mental 

health providers, social workers, and benefits and 

housing counselors. Referrals to Va substance abuse 

programs are made as necessary. “We try to have open 

access and sensitive care,” says o’Toole. 

Part of his research is on how to motivate Veterans to visit 

the clinic in the first place. “They are a treatment-resistant 

population,” he says. “But if we can somehow increase 

their motivation, they will seek out care.” one approach 

the group has tried is sending a nurse along with a social 

worker to do outreach at local shelters and soup kitchens. 

The nurse does personalized health assessments and uses 

motivational interviewing to try to engage the Veterans 

in taking steps toward accessing medical care at the clinic. 

o’Toole’s team has also studied patient outcomes. In 

a study published in december 2010 in the American 

Journal of Public Health, the researchers found that 

“tailoring primary care to homeless Veterans can 

decrease unnecessary emergency department use 

and medical admissions and improve chronic disease 

management.” The study involved 177 homeless 

Veterans who received care throughout one year at 

either the special clinic or a general primary care clinic. 

Those who received the tailored care had more favorable 

outcomes in terms of blood pressure, blood sugar and 

Veterans and homelessness 

 Roughly a third of U.S. adults who are homeless are 


Veterans. Some 131,000 Veterans, about 97 percent 


male, are estimated to be homeless on any given night. 


 Many other Veterans are considered at risk for 


homelessness because of poverty, lack of social 


support, and dismal living conditions in cheap hotels or 


substandard or overcrowded housing. 


 About 45 percent of Veterans who are homeless have 


mental illness, and more than 70 percent suffer from drug 


or alcohol abuse. There is considerable overlap between 


the two groups. 


For more information on VA’s current programs for Veterans 

experiencing homelessness, visit www.va.gov/homeless. 

24 V A RESEARCH RESEARCH TODAY 

cholesterol. and when they relied on the emergency 

room, it was more likely to be for true emergencies. 

Measuring results based on health and housing 

o’Toole, Kertesz and other experts have little doubt 

at this point that primary care for Veterans who are 

homeless works best when it’s integrated with the 

other homeless services that Va offers—housing, work, 

mental health, addiction treatment. “These are crucial 

pieces for the homeless, and they are obvious strengths 

of Va,” notes Kertesz. But how exactly all the pieces 

should fit together remains to be determined. The 

Los angeles and Providence Va models seem fairly 

successful, but researchers are still working to nail down 

the optimal approach and replicate it across the entire 

Va system. 

Most critical is the housing piece. o’Toole measures 

outcomes at his clinic based not only on how many 

Veterans come in for primary care, and how their health 

metrics change, but also on how many eventually end 

up with housing. “We’re trying to connect people to 

resources so they’re able to go, say, from an emergency 

shelter into per diem housing or a domiciliary. Those 

environments are going to be more conducive to better 

chronic disease management.” 

another key element, perhaps less tangible, is the 

attitude with which care is provided. Through his 

research, Kertesz is learning to craft questionnaires for 

homeless patients that will enable providers to gauge 

how well they are doing in this regard. 

o’Toole echoes Kertesz on the importance of building 

relationships and respecting these Veterans’ concerns and 

needs—even when they seem to compete with medical 

goals per se. “Unless we spend time understanding what 

the patient’s priorities are and meet them halfway,” he 

asserts, “our agenda will be dead in the water. 

“We need to convey expectations about high quality and 

patient engagement—the same humanity and dignity 

that would be afforded any other patients. Patients who 

are homeless clearly respond to that.” 
H I S t o R y 

VA-ACAdEmIC PARtNERSHIP: AN HIStoRICAl tImElINE 

On the following pages, a snapshot of milestones in the partnership between 

VA and the nation’s medical schools, now celebrating its 65th anniversary 

Continuing the legacy—Dr. Theresa Pape 

studies brain injury at the hines (ill.) Va Medical 

center and Northwestern university. in 1946, the 

two sites signed the nation’s first Va-academic 

affiliation agreement. SPRING 2011 25
 
Public law 293 is passed by the 79th Congress and signed into law by President Harry S.Truman, establishing 1946 the Department of Medicine and Surgery within the Veterans Administration (later to become the Department of Veterans 

Affairs).The law allows VA to greatly expand and enhance its physician workforce, enabling it to care more effectively for 

millions of returning World War II Veterans.Within six months, some 4,000 physicians are recruited into the VA system. 

In follow-up to Public Law 293,VA issues Policy Memorandum No. 2, providing the legal basis for affiliations between 

VA and the nation’s medical schools and embarking upon “a program that is without precedent in the history of Federal 

hospitalization.”The move not only improves VA care and bolsters U.S. physicians’ training, but sets the stage for 

significant growth in VA’s medical research program. 

Northwestern University Medical School and the University of Illinois College of Medicine become the first medical 

schools to enter into partnerships with VA hospitals, followed soon after by the University of Minnesota Medical School. 

by early 1947, VA medical centers—which had no resident physicians in training before 1946— 1947 now had some 1,000 residents. The influx of physicians comes to play an important role in VA’s ability to conduct 

groundbreaking studies, including large multisite clinical trials—an effort that would later evolve into VA’s Cooperative 

Studies Program.According to one journalist at the time,“VA medicine has undergone a revolution,” and the changes 

have “infused the whole hospital program with a spirit of modern, scientific medicine.” 

by this year, VA researchers—most with dual VA-university appointments—are publishing more than 1951 800 articles per year in medical journals, compared to fewer than 100 per year in the mid-1940s. 

Public law 785 is enacted by the 89th Congress, establishing medical training as a formal component of 1966 VA’s medical care mission and authorizing VA to enter into agreements with medical schools to share resources such 

as equipment, personnel and lab space. The measure is referred to by some as the “Magna Carta” of the partnership 

between VA and the nation’s medical schools. 

the VA medical School Assistance and Health Manpower Training Act expands existing medical education 1972 programs and facilities and establishes several new medical schools near existing VA hospitals. One example is East 

Tennessee State University’s James H. Quillen College of Medicine, affiliated with the Mountain Home VA Medical Center. 

the Veterans omnibus Health Care Act of 1976 is signed into law by President Gerald Ford. 1976 Among other provisions, the bill provides statutory authority for VA’s research mission. The goal is to protect the VA 

research program from potential reductions in funding that could jeopardize VA affiliations with medical schools and 

adversely affect patient care and physician recruitment. 

26 VA RESEARCH TODAY 
SPRING 2011 27 

1988 Public law 100-322 authorizes VA to establish nonprofit research institutes to facilitate the flow of 

non-VA funds—for example, from federal agencies such as the National Institutes of Health, or from private industry 

sponsors—to support VA research. Today, there are 82 such institutes. The largest is NCIRE-The Veterans Health 

Research Institute, supporting research at the San Francisco VA Medical Center. 

1990 the friends of VA medical Research (foVA) is founded to advocate for appropriate funding 

for research and other health programs serving Veterans. Today, FOVA is a diverse coalition of more than 80 member 

organizations, including academic, medical and scientific societies; voluntary health and patient advocacy associations; 

and industry partners. 

1998 the Association of American medical Colleges holds the first meeting of what comes to be 

known as the Group on Research Advancement and Development (GRAND). The mission of GRAND, formalized in 

2002, is to “provide a national forum for the promotion, support, development, and conduct of biomedical research in 

medical schools and teaching hospitals [including VA medical centers] through the exchange of information and the 

examination of issues critical to the research enterprise.” 

2006 the 60th anniversary of VA Policy memorandum No. 2 is commemorated at the 117th 

annual meeting of the Association of American Medical Colleges. At the meeting, VA’s Office of Academic Affiliations 

debuts a video titled “Still Going Strong: The History of Academic Affiliations.” 

2009 the blue Ribbon Panel on VA-medical School Affiliations, established by VA in 2006 to 

advise the agency on enhancing partnerships with medical schools, issues a report titled “Transforming an Historical 

Partnership for the 21st Century.” The report recommends that “VA and its academic partners redouble their efforts to 

develop new knowledge through collaborative research.” 

2010 An Association of American medical Colleges working group, comprising experts 

from VA, the National Institutes of Health, and medical schools and teaching hospitals, issues a report on information 

technology security and privacy in medical research. The report contains a series of recommendations, building on 

existing federal and VA-specific safeguards and regulations, intended to fulfill the group’s charge to “examine and 

develop standard practices and processes that assure data security, yet allow appropriate use of data in research.” 

2011 the 65th anniversary of VA Policy memorandum No. 2 is commemorated during National 

VA Research Week, both at VA headquarters in Washington, DC, and at VA facilities nationwide. 

L-R: >Dr. Melina Kibbe, with the Jesse Brown VA Medical Center 

in Chicago and Northwestern University, reviews lab results from 

a study on vascular disease with research fellow Dr. Nick Tsihlis; 

>Dr. Dustin Tyler (right), of Case Western Reserve University and 

VA ’s Advanced Platform Technology Center in Cleveland, instructs 

graduate students Erik Peterson and Smruta Koppaka on a 

prosthetics project; >Dr. Robert Gailey, a prosthetics researcher 

with VA and the University of Miami, watches Army Veteran 

Henry Diaz as he tries out a computerized artificial knee; >A 

bioengineering student from the University of Washington places 

reflective markers on a foot model at VA ’s Seattle-based Center of 

Excellence for Limb Loss and Prosthetic Engineering; >Drs. Paul 

Hamilton (left) and Nathan Ravi, with the St. Louis VA Medical 

Center and Washington University, use a robotic “lens stretcher” 

they built as part of an optics project; >Dr. Leonard Egede 

conducts health-disparities research at the Charleston VA Medical 

Center and Medical University of South Carolina. 
28 VA RESEARCH TODAY 

oVERVIEw


tHE VA RESEARCH ANd dEVEloPmENt PRoGRAm: 

IMPROVING VETERANS’ LIVES THROUGH HEALTH CARE RESEARCH
 

VA Research — Discovery, Innovation, Advancement 

For more than 85 years, the Veterans affairs (Va) Research and 

development program has been improving the lives of Veterans and 

all americans through health care discovery and innovation. n The Va 

Research program is unique because of its focus on medical issues that affect 

Veterans. It is part of an integrated health care system with a state-of-the-art 

electronic health record and has come to be viewed as a model for superior 

bench-to-bedside research. n The groundbreaking achievements of Va 

investigators—most of whom also provide direct patient care—have resulted in 

three Nobel prizes, six Lasker awards, and numerous other distinctions. n While 

realizing the advantages of an intramural program and embracing its close ties to 

academic affiliates, the Va Research and 

development program fosters dynamic “by spearheading research that 

directly advances the medical care collaborations with other federal of Veterans, the VA Research and 

agencies, nonprofit organizations, and Development program has become 

private industry—thus furthering an acclaimed model for conducting 

superior bench-to-bedside research.” 

the program’s impact on the health of — Joel Kupersmith, MD, Chief Research 

Veterans and the nation. and Development Officer Veterans 

Health Administration 
SPRING 2011 29 

 

 

 

 

 

 — 

VA’s Research and development program is an 

essential part of our mission to provide cuttingedge health care to our nation’s Veterans. 

Eric K. Shinseki, Secretary, Department of Veterans Affairs 

INtRAmURAl PRoGRAm, CollAboRAtIVE SPIRIt: 

FOUR MAIN RESEARCH SERVICES WORkING TOGETHER 

The VA Research program works to address the full spectrum of Veterans’ health needs 


biomedical laboratory 

Research and Development 

This division conducts preclinical research to 

understand life processes from the molecular, genomic, 

and physiological level in regard to diseases affecting 

Veterans. It includes research on animal models and 

investigations of tissues, blood, or other biologic 

specimens from humans, but does not include studies 

with people. 

clinical science 

Research and Development 

This division focuses on clinical trials and other 

research involving human volunteers to study new 

treatments, compare existing therapies, and improve 

clinical practice and care. 

The Cooperative Studies Program within this division 

is responsible for planning and conducting Va’s large 

multicenter clinical trials and epidemiological studies 

on health issues vital to our nation’s Veterans. 

health services 

Research and Development 

This division supports research to improve the delivery 

of health care to Veterans. among the areas studied 

are quality and organization of care; patient access and 

outcomes; and cost-effectiveness. 

The division’s Quality Enhancement Research Initiative 

(QUERI) is designed to translate research findings into 

advancements in Veterans’ care. 

rehabilitation 

Research and Development 

This division conducts research to discover knowledge 

and create innovations that restore Veterans who 

have become disabled due to injury or disease to their 

greatest possible functional capacity in their families, 

communities, and workplaces. 

cross-cutting components 

other programs are cross-cutting. The Program 

for Research Integrity Development and Education 

(PRIdE), for example, is responsible for policy 

development, guidance, training, and education 

in relation to the protection of human research 

participants throughout Va. and the Technology 

Transfer Program is dedicated to translating discoveries 

and inventions by Va researchers into practice. 

productive partnerships 

While embracing its status as an intramural program 

with close ties to its academic affiliates, the Va 

Research program also fosters and develops dynamic 

collaborations with other federal agencies, nonprofit 

organizations, and private industry. Such teamwork 

promotes the leveraging of resources, speeds the 

translation of study results into clinical practice, and 

maximizes the overall impact of Va Research. 
30 VA RESEARCH TODAY 

RESoURCES
 

RESEARCH fUNdING: VA R&D by THE NUMbERS
 

An overview of the resources that fuel VA’s innovative medical and rehabilitation studies
 

i

n fiscal year 2010, Va Research and development 

supported more than 2,100 research projects at Va 

medical centers nationwide, ranging from preclinical 

studies to health services research to multisite clinical 

trials.of Va’s 153 medical centers, 116 have the 

capacity to conduct research. Va’s vibrant nationwide 

community of bright, talented investigators publishes 

some 7,500 articles each year in the medical and 

scientific literature. Va researchers are frequent 

contributors to leading journals such as the New 

England Journal of Medicine, the Journal of the 

American Medical Association, and Science. 

Va funding for research can take several forms: 

 Investigator-initiated research (Merit Review) 

 Mentored research (Career development) 

 Large-scale, multisite clinical trials (Cooperative 

Studies Program) 

 Centers of Excellence 

 Service-directed research (sponsored by one of the four 

services that make up VA Research; see page 29) 

Va Research is an intramural program, meaning that 

only Va employees can conduct research under Va’s 

auspices. Typically, though, Va researchers collaborate 

with academic colleagues and others outside Va. 

proposals, which are then peer-reviewed. only the most 

meritorious projects are funded. To meet the needs of 

the entire Veteran population, Va Research invests in a 

balanced portfolio of studies. 

The congressional appropriation for Va Research for 

fiscal year 2011 is $590 million. Va studies are also 

supported in part by Va medical care dollars, as well 

as funding from non-Va sources, such as other federal 

agencies, nonprofit associations and industry partners. 

In fact, Va researchers are expected to leverage their 

Va funding whenever possible—that is, seek additional 

support for non-Va sources— to maximize the scope, 

quality and impact of their research and the resulting 

gains for Veterans. The National Institutes of Health 

is the most prominent source of such funding for Va 

investigators. another benefit of NIH funding is that 

it assures the public that Va and NIH research projects 

are of equal quality. 

Funding from industry comes mainly from drug 

companies and is typically administered through 

nonprofit corporations. In 1988, Congress passed 

legislation that empowered Va medical centers to 

establish Va-affiliated nonprofit research corporations. 

These entities provide flexible funding mechanisms for 

the administration of non-Va funds for the conduct of 

Investigators must compete for funding. They submit Va-approved research. 
SPRING 2011 31 

Congressional allocation for VA Research (in millions) 

$600 

$590 $580 

$500 $510 

$480 

$447 

$400 $412 

$390 

$300 

$200 

$100 

$0 

2005 2006 2007 2008 2009 2010 2011 

VA research funds spent in fiscal year 2010 

Other 8% 

Research Compliance 1% 

Service Directed 8% 

Centers of Excellence 12% 

Investigator Initiated 60% 

Career Development 11% 
32 VA RESEARCH TODAY 

 

 

CHRoNIC
 

dISEASES
 

VEtS HElPING VEtS: PEER SUPPoRt PRoVES 

PoPUlAR ANd EffECtIVE foR tHoSE CoPING 

wItH CHRoNIC dISEASE 

For illnesses such as diabetes and hypertension, peer support can be just what the doctor ordered
 

i

n the Milwaukee area, members of Veterans of 

Foreign Wars posts volunteered as peer health leaders 

and helped other VFW members stay on track with 

managing their high blood pressure. 

In Philadelphia, African American Veterans with 

diabetes served as peer mentors to others in their 

community to help them keep their blood sugar in check. 

In Ann Arbor, Veterans with diabetes who took part 

in a mutual peer support program did as well as—or 

even better than—Veterans who were assigned nurse 

care managers. 

These examples, all from recent VA research, show 

the benefits of an approach that is gaining increasing 

traction nationwide among doctors and health policy 

experts. Peer support, for one thing, is a smart way to 

leverage resources in strained health care systems. The 

arrangement also taps into a powerful social force— 

the ability of peers to motivate one another—that no 

medical system can replicate on its own. 

 “Patients know a lot about living with their condition 

and the strategies they have developed,” says Michele 

Heisler, MD, MPA. “They have a lot to share with 

others who are also struggling.” 

Heisler is a physician-investigator with the Center for 

Clinical Management Research at the VA Ann Arbor 

Healthcare System. She’s also an associate professor 

at the University of Michigan’s Medical School and 

School of Public Health. 

She observed firsthand the positive effects of peer support 

in a recent trial that involved 244 Veterans with diabetes. 

Some of the patients took part in mutual peer support, 

while others worked with a nurse care manager instead. 

In the peer group, Veterans were trained in 

communication skills and asked to talk with their 

partners by telephone at least once a week. They were 

encouraged to both give and receive support, focusing 

on self-care areas they and their partners were working 

on to boost their diabetes control. They also took part 

in nurse-run group sessions to exchange experiences 

with other patients. 

After six months, those on the peer program had 

achieved, on average, a small reduction in their blood 

sugar levels, compared with a slight increase in blood 

sugar among the nurse management group. Those in the 

peer group were also more likely to have started on an 

insulin regimen. That’s not necessarily a worse outcome, 

though. The researchers say peer support—especially 

from partners who were themselves already on insulin— 

may have helped Veterans overcome their resistance 

to an intensive therapy that was tough to adapt to 

but medically necessary. Those working with nurse 

managers may have been less able to adjust to the idea. 
SPRING 2011 33 

 

Peer pressure—Nurse manager Kelly Johnston of 

the ann arbor Va checks the blood pressure of allen 

shuh, who took part in a study of peer support for 

Veterans with diabetes. 

Veterans in the peer group, not surprisingly, also reported 

more diabetes-specific social support. Importantly, each 

peer who received support also gave it, and this aspect of 

the interaction yielded its own benefits. 

“The Veterans in our study were very motivated when 

they felt they were helping someone else,” says Heisler. 

“Our model was testing the hypothesis that a good way 

to activate patients was to give them some skills and 

encouragement to both help and be helped. Just as in 

education, they say that the best way to learn something 

is to try to teach it.” 

Training is essential 

Martha Mitchell Funnell, MS, RN, CDE, a colleague 

of Heisler’s at the University of Michigan, says peer 

support is an effective way to deliver tried-and-true 

behavioral strategies such as problem-solving and goalsetting. One challenge, though, is ensuring that peers 

receive proper training. Researchers still need to better 

understand this area, says Funnell. “Very little is known 

about the training required for peers to successfully 

implement behavioral strategies and even less is 

known about the supervision needed or the qualities 

or qualifications that enable a person to become an 

effective peer partner,” she wrote in a recent review 

article in the journal Family Practice. 

She, Heisler and other researchers in Ann Arbor 

are working toward creating and disseminating best 

practices to address this point. Earlier this year in the 

journal Diabetes Educator, they shared an approach 

they believe can be effective, even if it entails a 

serious commitment on the part of prospective peers. 

Their training program, developed over a year by a 

multidisciplinary team, involves 46 hours of training 

over 12 weeks. It covers both diabetes knowledge 

and communication and behavior-change skills. The 

training sessions are designed to be lively and interactive, 

featuring role plays, brainstorming and practice support 

groups. The materials are now available for use in similar 

programs at other VA medical centers. 

Other work at the Ann Arbor VA is exploring the role 

of peer support in depression. According to Marcia 

Valenstein, MD, a mental health researcher at the site, 

“Peer support interventions have been recommended by 
- 

—

‘ ’

-

 

Flying high, even with diabetes 

Until recently a pilot, and now a crew 

member, with the Civil Air Patrol, Glenn 

Cuff remembers when his military flying 

career was cut short because of his weight. 

“I went into the Air Force the first time for 

six years,” he says. “When I went to re up 

they said I was too fat to fly. I had gained 

too much weight and had unhealthy habits.” 

Cuff would go on to join the Army Reserve, 

then the Air Force Reserve. Later, he 

went to work for US Airways and worked 

his way up through various jobs with the 

company, eventually going back to school 

and getting his wings as a commuter pilot. 

Still, he struggled with health problems 

related to his weight even to the point 

where he found himself homeless for a 

stretch. At his heaviest, Cuff, 5 feet 10 

inches tall, weighed 365. 

“Back when I got so sick because of my 

weight and the complications, I became 

homeless, even though I had a college 

degree and a pilot’s license, and I had 

owned houses and cars,” recalls the 

Philadelphia resident. 

Through lots of hard work over several 

years, he managed to turn his life back 

around. He lost 125 pounds. Getting his 

diabetes under control was also part 

of the effort. 

“When I was first diagnosed with diabetes 

I was in bad shape and my [hemoglobin] 

A1C was up near 10. My primary care 

physician was really mad. Getting 

healthy was a team effort with my doctor, 

trial and error with exercise, diet and 

different medications.” 

Helping young people to soar 

Nowadays, aviation is a big part of his life, 

both in and outside of work. He’s proud 

of the search and rescue missions he 

takes part in for the Civil Air Patrol, and 

equally passionate about his service in 

the community. He volunteers at a middle 

school where he teaches young people to fly. 

“We teach them navigation and other 

basics at the school, and use aircraft 

at the Northeast Philadelphia Airport jet 

center for their pilot training. We’re not 

there to push the military, but they can 

start as a senior airman if they complete 

our program.” 

Cuff also volunteers at a Vet Center, the 

Philadelphia VA Medical Center, and a local 

Veterans of Foreign Wars post. He says 

he wants to “give back to my brother and 

sister Vets,” and remembers all too easily 

where he was a few short years ago. 

“At that time I made myself a promise that 

if I got back on my feet I would give back 

and now that’s what I do every day. You 

never know about people’s situations. At 

the Vet Center, I recently helped someone 

who is a lawyer and another who is a 

registered nurse, and they’re homeless 

right now because of circumstances.” 

The peer-mentor research at the 

Philadelphia VA was a natural fit for him. 

“Participating in this study was great for 

me because I already was talking with my 

peers to find out how I could help them,” 

says Cuff. “If we start on common ground, 

we can help each other. I’m not there to 

preach to them. We really became friends.” 

He recounts some of the ways in which he 

helped other Veterans in the study: “I told 

them to call me anytime. If they were at a 

family party and there was a peach pie on 

the table and they wanted to have it, they 

could call me and be honest about it. I’d tell 

them to have just a small slice of pie and 

next time whittle it down to a smaller slice.” 

Sometimes, we would just talk 

Cuff says shared medically sound advice 

that had paid off for him. “Don’t try to 

stick to unreasonable diets. When a 

person has been eating like that for years, 

you cannot cut them off cold turkey.” 

Reducing sugar intake was another 

strategy. “I’ve been sugar free for three 

years. For some of these guys, if you can 

cut out sugar, that’s half the battle.” 

Often, the conversations would extend to 

other areas. “Sometimes we would just 

talk, not just about diabetic things. I’d 

ask if they’ve been getting to their 

VA appointments.” 

Though the study has ended, Cuff has no 

intention of closing out the relationships 

with the Veterans he helped. “As long as 

they want me to, I’ll be there for them.” 

34 V A R E S E A R C H T O D A Y 
SPRING 2011 35 

prestigious national task forces and incorporated into 

the VA Comprehensive Mental Health Strategic Plan.” 

Mentors lead the way 

Unlike Heisler’s diabetes study, some peer research 

involves mentor, not reciprocal, relationships. This form 

of peer support appears equally effective. 

A team led by Judith Long, MD, of the Center 

for Health Equity Research and Promotion at the 

Philadelphia VA Medical Center, tested peer mentoring 

along with another strategy—financial incentives—to 

help minority Veterans manage their diabetes. 

The pilot study included 118 Veterans, all of whom were 

struggling to control their diabetes. One group received 

usual care, a second received counseling from trained 

peer mentors, and a third became eligible for payments 

of up to $200 if they succeeded in significantly lowering 

their hemoglobin A1C levels—a measure of blood 

sugar—over six months. 

Smart choices—Glenn cuff, who has served as a 

mentor to fellow minority Veterans with diabetes 

through a study at the Philadelphia Va Medical 

center, says he tries to share practical strategies on 

eating that have worked for him. (see sidebar on 

facing page) 

The peer mentors were Veterans who had overcome 

their own challenges in managing diabetes. After a brief 

training session, they earned a modest reward—$20 

per month— if they contacted the person they were 

counseling at least four times a month during the study. 

The results, presented in February at a national VA 

meeting, were very favorable for peer mentoring. 

Financial incentives failed to show the same benefit. 

Long is now doing further research on the peer model 

used in the study. 

Glenn Cuff, who took part in the Philadelphia research 

as a peer mentor (see sidebar), says he found the study 

worthwhile on several counts. “Although it’s not 

for everyone, peer support is an extremely beneficial 

supplement to the clinical experience. Additionally, the 

experience gave me the chance to establish friendships with 

other Veterans that I am still in contact with today.” 
36 V A R E S E A R C H T O D A Y 

 

 

C H R o N I C 
 

dISEASES
 

At tHE HEARt of VA HEAltH CARE: RESEARCH EFFORT 

bOOSTS QUALITy IN CARDIAC CATH LAbS NATIONWIDE 

An innovative system for collecting and monitoring data from 

cath labs has helped raise VA heart care to new heights 

David Taft gives new meaning to the phrase “cool 

under pressure.” 

a Navy surgeon who volunteered to serve in Vietnam 

and again in the Persian Gulf and Somalia, Taft was 

awarded the Navy Cross for saving a Marine’s life in 

1967. It was no ordinary surgery, even by militarymedicine standards—the young Marine had a live 

rocket embedded in his leg. 

Taft saw what needed to be done and cleared the 

operating room, except for a Navy corpsman who 

would stay nearby to assist. Taft carefully performed the 

surgery; the Marine’s leg had to be amputated, as all the 

nerves and blood vessels were destroyed. He then carried 

the limb outside, gently placing it in a hole that some 

troops had dug. 

When he returned to the operating room 

to finish up with the patient, he heard 

a loud boom—the 2.75-inch rocket 

had spontaneously detonated. 

Today, at 77, Taft is fighting 

health battles of his own, but 

he says he’s getting good care at 

the Va Puget Sound Healthcare 

System. In 2007, he had three 

stents placed in a blocked coronary 

artery. Last year, another angioplasty was needed for a 

different artery. Earlier this year, he had a pacemaker 

implanted to keep his heart beating steady. 

Taft is one of many thousands of Veterans each year who 

are benefiting from continual improvements in Va cardiac 

care over the past decade. Ischemic heart disease—reduced 

blood flow to the heart—is a top cause of hospitalization 

and death in the U.S. and among Veterans who use 

Va health care. The diagnosis affects half a million Va 

patients. So the area has been a prime target for quality 

improvement, and Va research has helped drive progress. 

one initiative, in particular, has focused on cardiac cath 

labs—the fast-paced areas in hospitals where doctors 

visualize the heart and blood vessels and diagnose and treat 

a wide range of heart problems (see sidebar). 

Past studies spark cardiac initiative 

a few years ago, Va got a warning signal about the 

quality and availability of its cardiac care—especially 

procedures requiring catheterization. 

In 2003, an article in the New England Journal of Medicine 

reported that Va patients were less likely than Medicare 

patients to undergo cardiac catheterization procedures at 

the time of their heart attack when such procedures were 

called for by existing health care guidelines. 
SPRING 2011 37 

Monitoring makes for good medicine—Va cardiac 

catheterization labs like this one at the Va Pittsburgh 

healthcare system feed data on every procedure into 

a national computer system that tracks quality and 

outcomes and identifies best practices. 

a Harvard study published the following year compared 

Va patients and Medicare patients who had suffered 

heart attacks in the late 1990s. It found that Va 

patients traveled farther than Medicare patients to reach 

the hospital; that they were less likely to be admitted to 

a hospital capable of cardiac catheterization; and that 

nearly 35 percent of these men and women under Va 

care died within a year, compared to about 31 percent of 

Medicare patients. 

Though some of the research was controversial because 

of concerns over methodology, Va nonetheless 

responded quickly and decisively. The agency created 

what became known as the Cardiac Care Initiative to 

boost Veterans’ access to top-notch heart care. Through 

the initiative, new state-of-the-art cath labs were built so 

more Va hospitals could perform the heart procedures 

that Veterans needed. Performance measures were set 

to track how individual hospitals were doing in cardiac 

care. and patient case histories were studied in-depth to 

learn how quality could be further improved. 

“This was a very ambitious and focused effort to 

improve cardiac care, on a very large scale, and it’s really 

paid off in a big way over the years,” says Stephan Fihn, 

Md, MPH, a Seattle-based physician with Va who is 

widely recognized for his research and policy leadership. 

Part of the overall cardiac initiative addressed 

catheterization. among other problems, Va leadership 

lacked an accurate picture of the types of procedures 

taking place in the system’s hospitals. Nor did they 

know the characteristics of the patients undergoing 

procedures—how sick they were, for example, or 

what other medical conditions they had. They also 

were uncertain as to how many patients experienced 

complications as a result of their cardiac procedures, 

and—perhaps most importantly—they didn’t 

know, except in individual cases, whether cardiac 

catheterizations had achieved the desired results. 

one of the solutions Va developed was a new national 

repository for Va cath lab data, along with a specialized 

software application. The effort has involved several 
38 V A R E S E A R C H T O D A Y 

Cath labs can save lives
 

Having a tube inserted into your heart is a scary proposition. But for 

millions of people, allowing a cardiologist to do so can help make a 

critical diagnosis, ease chest pain and even save their lives. 

The procedure is known as cardiac catheterization. Most often, 

it’s used as part of a coronary angiogram: Doctors thread a 

thin tube into an artery in the groin or wrist and gently move 

it toward the heart. They then inject dye into the tube. The 

dye fills the coronary arteries, which feed blood to the heart. 

Watching a live X-ray as the dye spreads, doctors can see 

where arteries are narrowed or blocked. 

Coronary angiograms allow doctors to confirm suspected 

problems, quantify the severity of heart disease and 

investigate symptoms that could be related to heart disease. 

Angiograms are often followed by angioplasty, in which 

doctors use an inflatable balloon to open blocked arteries and 

a mesh stent to keep them open. 

Several other procedures are typically performed in cath labs, 

such as an atherectomy—the cutting away of plaque inside 

arteries; pacemaker implantation and maintenance; and 

cardioversion, in which a shock is applied to the heart to 

re-establish a normal beat. 

Va offices. among those spearheading the project have 

been Fihn and two other physician-researchers with 

expertise in heart disease: John Rumsfeld, Md, Phd, 

of the denver Va Medical Center; and Robert Jesse, 

Md, Phd, previously with Va Patient Care Services 

in Washington, dC, and now the agency’s principal 

deputy under secretary for health. 

The project, called CaRT-CL (Clinical assessment 

Reporting and Tracking System for Cath Labs), was 

launched in denver in 2005 as a joint effort between 

Va’s Quality Enhancement Research Initiative 

(QUERI) program and the agency’s office of Patient 

Care Services. It then spread to other sites. Today, 

CaRT-CL collects data from all 77 Va cath labs 

nationwide and has become a model for using data to 

improve clinical performance. 

Software generates reports for electronic medical record 

among other features, CaRT-CL enables standardized 

data capture and reporting across all Va cath labs. Every 

lab provides the same kind of documentation on all 

cardiac procedures, including information about the 

health of patients before and after the procedures. The 

software automatically generates reports that show up in 

patients’ electronic medical records. 

Standardizing the data enables Va to make good 

comparisons of results among cath labs throughout the 

nation. Those with the highest levels of quality are asked 

to share their best practices with other Va hospitals; 

those who rank lowest are reviewed to ensure that they 

are performing their procedures correctly, or to see if 

there are problems that can be identified and corrected. 

Va now also compares its results with non-Va cath 

labs throughout the nation, using standards developed 

by the american College of Cardiology’s National 

Cardiovascular data Registry. 

“CaRT-CL has already had a positive impact on the 

care of Veterans with heart disease,” says Rumsfeld, 

who oversees the effort and also serves as Va’s national 

program director for cardiology. “We expect this to 

continue to grow as we use CaRT to further enhance 

the quality of care and patient safety for Veterans 

undergoing cardiac procedures.” 

another example of the benefits that CaRT-CL offers 

patients and Va cardiologists: Reports of adverse events 

are shared immediately throughout the Va system, and 

trained cardiologists at other Va facilities conduct “peer 

reviews” to determine whether the problem could have 

been avoided, and, if so, how. 

also, unexpected equipment problems that take place 

during cath lab procedures are quickly reported to the 

Food and drug administration. The Fda looks for 

trends to see if there are safety problems that warrant 

warnings to physicians or even equipment recalls. 

Today, the CaRT-CL database includes more than 

200,000 procedures performed at Va cath labs on more 

than 100,000 Veterans. among the research projects 

currently under way using the data is an evaluation of the 

short-and long-term value of coronary angioplasty, which 
SPRING 2011 39 

Vein pursuits —in cath labs, doctors can watch live X-rays 

to see where blood vessels are narrowed or blocked. 
40 VA RESEARCH TODAY 

—

cardiologists call percutaneous coronary intervention, or 

PCI. Va researchers are also studying how the radiation 

from fluoroscopy use (which allows for imaging during 

catheterization) varies among procedures and across sites, 

with the goal of improving patient safety. 

In denver, a group led by Rumsfeld is testing a new 

aspect of the CaRT program that notifies doctors, 

in real time, whether patients are picking up their 

clopidogrel prescriptions after a PCI procedure. 

Clopidogrel (sold as Plavix) is a medication used to 

prevent blood clots in patients with heart disease; 

those who have had stents implanted must take it for 

up to one year, or their risk of an adverse cardiac event 

increases sharply. 

Rumsfeld is also working, along with other Va 

researchers, on a new database, called CaRT-CPR, that 

will document what happens to patients who go into 

cardiac arrest while in the hospital and are resuscitated 

using CPR, or cardiopulmonary resuscitation. They 

are also working to expand CaRT to capture the 

implantation of pacemakers and defibrillators. Both 

these procedures are used to help control abnormal 

heart rhythms. 

The efforts make good sense to Va patient david Taft, 

who knows a thing or two about heart care. In fact—gutsy 

military surgeon that he is—he’s stayed awake during both 

his stent procedures, watching the catheter work its way up 

to his heart on the large monitor in the cath lab, chatting 

with the cardiologist doing the procedure. 

“I’ve done a lot of heart surgery myself, both in training 

and afterwards, and I know my way around,” he says. “I 

will tell you, they do a great job here.” 

Doctor dialogue former Navy surgeon Dr. David Taft 

(right), today a patient at the Va Puget sound healthcare 

system, reviews his heart care with Va cardiologists 

Drs. Michael stadius (center) and Peter McGrath. 
SPRING 2011 41 

 

 

GENomICS
 

mIllIoN VEtERAN PRoGRAm: VA-VETERAN PARTNERSHIP 

ExPLORES GENES’ ROLE IN HEALTH AND DISEASE 

In what is expected to be a landmark genomics effort, Veteran volunteers 

will help inform the course of medicine in the future 

T

oward answering some of the most crucial questions 

about genes—in particular, how they affect our 

health—Va Research has launched the Million 

Veteran Program, or MVP. The program is designed to 

collect genetic samples and health information from 

about a million Veterans who volunteer to participate, 

positioning Va to identify links between genes and 

health and to then translate this information into better 

medical therapies. “MVP promises to reshape the field of 

genomics—a sophisticated science poised to revolutionize 

health care for Veterans and others throughout the U.S. 

and around the world,” says Joel Kupersmith, Md, Va’s 

chief research and development officer. 

The promise of super-sized genomics dabatases 

Genes influence personal traits such as our eye and hair 

color, intelligence and personality. They also contribute 

to our risk for diseases—including common conditions 

such as heart disease, diabetes and cancer, and much rarer 

diseases such as hemophilia and cystic fibrosis. The effects 

of genes are usually not clear-cut, as they involve complex 

interactions with the environment and lifestyle factors. 

Building on gene-mapping efforts such as the Human 

Genome Project, which elucidated the basic layout of 

the human genetic structure, genomic researchers are 

now seeking new ways to prevent and treat illnesses. 

They are asking questions such as: Why are some people 

at greater risk than others for developing an illness? 

Why does a therapy work well only for certain patients? 

Why are some patients more vulnerable to adverse side 

effects from a certain drug? 

Predicting which drugs are going to work for a 

patient and which might cause harm—a field called 

pharmacogenomics—is a fertile area for the “first 

wins” in genomic medicine, according to Eric Wieben, 

Phd, director of the Genomics Research Center at the 

renowned Mayo Clinic in Minnesota. No argument 

from david oslin, Md, a psychiatry researcher at the 

Philadelphia Va Medical Center who is studying the 

role genes may play in the effectiveness of a common 

alcohol dependence treatment (see sidebar on page 44). 

The potentially huge and rich MVP database— 

together with the rapidly evolving technology that is 

used to analyze dNa—will be a precious resource for 

genomics research, according to experts. That’s because 

meaningful genomics research demands the collection 

and comparison of genetic samples and health data from 

large groups of people. amassing this type of extensive 

information to support reliable conclusions is one of 

the major challenges facing genomics researchers today, 

according to the Mayo Clinic’s Wieben. “Right now,” 

he says, “in terms of being able to blaze the trail in 
42 VA RESEARCH TODAY 

 

 

 

 

Genomics in action —at the Philadelphia Va 

Medical center, Dr. David oslin, center, is leading a 

study that aims to use patients’ genetic profiles to 

tailor their treatment for alcoholism. at the computer 

is nurse Trisha stump. read more on page 44. 

genomic medicine, one of the big limitations is the lack 

of sufficient samples that are matched with detailed and 

accessible medical information.” By helping to quench 

this research gap, Wieben says, MVP “could speed the 

science of genomics into medical practice.” 

Million-strong partnership 

MVP stands to become one of the world’s largest 

databases of genetic, military exposure and health 

information, with up to a million Veterans expected 

to participate during the project’s five- to seven-year 

time frame. “Veterans who volunteer to participate in 

MVP,” says Va’s Kupersmith, “are making a crucial 

contribution to genomics research and, in turn, to an 

improved understanding of how diseases might be 

prevented and treated.” 

Kicked off in Boston in January 2011 and launched 

already at several additional Va sites, MVP will 

ultimately be open to participation by Veterans across 

the country who receive Va care. The nationwide rollout begins this May as part of National Va Research 

Week. Veterans who volunteer to participate will: 

 Provide a blood sample 

 Complete a brief survey about health, lifestyle habits, 

military experience and family history 

 allow access to their medical records 

The samples and information submitted will be stored 

in a secure Va biorepository at Va’s Boston-based 

Massachusetts Veterans Epidemiology Research and 

Information Center (MaVERIC), with strict measures 

in place to protect Veterans’ confidentiality. Samples 

and information will be labeled with a barcode so that 

no one can directly identify participants. only a small 

number of authorized Va employees will have access 

to the key for the code. and those researchers who are 
SPRING 2011 43 

’

DNA and data—Dr. Donald humphries processes 

blood samples at Va s Massachusetts Veterans 

epidemiology research and information center, where 

a large, secure biorepository and data warehouse 

exist to serve the Million Veteran Program. 
 

 

 

 

 

—

 

approved to analyze samples and data will not receive 

any Veteran’s name, address, date of birth or Social 

Security number. 

Veterans’ genetic results, along with additional health 

information that Veterans provide, will be linked 

to their Va medical records. These state-of-the-art 

electronic health records, with the potential to include 

genetic information, will allow researchers to tap into 

abundantly detailed medical histories, some of them 

spanning decades. Importantly, while researchers will 

be able to make associations between genes and health 

conditions, all the information will be “de-identified” to 

protect the identity of individual Veterans. 

Pursuing customized care 

With the fast-growing focus on genomics research 

by Va and other top research institutions, experts 

Studying a drug that

sometimes packs a punch 

The anti-craving medication naltrexone, approved years ago to 

treat alcohol dependence, works very well in some patients but 

proves strikingly futile for others. Researchers at the Philadelphia 

VA Medical Center and University of Pennsylvania, led by 

psychiatrist David Oslin, MD, have identified a genetic change that 

seems to explain the night-and-day differences in effectiveness. 

Oslin is director of a VA Mental Illness Research, Education 

and Clinical Center and a University of Pennsylvania associate 

professor. About eight years ago, he was intrigued to observe 

that family history, known to be a strong factor in alcohol 

dependence itself, seemed to be a major factor in whether 

naltrexone worked or fell flat. Oslin and his colleagues conducted 

a preliminary study suggesting that a fairly common variation in 

a person’s genetic code—specifically, a variation in the “muopioid receptor”—can predict naltrexone’s effectiveness. 

Following up on the study’s finding of a strong link between a 

patient’s genetic makeup and treatment response—a finding 

confirmed by another research group—Oslin’s team is now 

in the midst of a carefully controlled study of the drug. The 

researchers are about halfway to recruiting the 200 to 250 

desired participants. They will compare responses in those with 

and without the genetic variation to naltrexone or placebo. 

Improving the success of treatment is crucial in alcohol 

dependence, which by Oslin’s description is “a very tough 

disorder” that may be successfully treated in just 50 percent 

of patients under the best therapeutic circumstances. Previous 

studies point to the possibility of an 80- to 85-percent response 

to naltrexone in those with the identified gene mutation. “If this 

pans out, it’s probably one of the most exciting things in the 

addiction field in a long time,” Oslin notes. 

Ultimately, a simple and inexpensive genetic test may be available 

to identify those most likely to benefit from naltrexone and others 

who might respond better to an alternative alcoholism therapy. 

And the naltrexone studies are the “tip of the iceberg,” according 

to Oslin, in terms of genomics’ potential to improve treatment. 

“Many examples are likely to arise where a simple genetic test 

will help drive treatment choices,” he says. “The better we 

understand the disease process, including a condition’s genetic 

components, the better we can treat the disease.” 

Breathing easy a breath alcohol test, given 

here by nurse Trisha stump, is part of the clinical 

exam for volunteers who are taking part in a Va 

study on naltrexone, a long-standing treatment 

for alcoholism. researchers are testing whether 

a certain genetic variation affects how patients 

respond to the drug. 

44 V A R E S E A R C H T O D A Y 
SPRING 2011 45 

 

predict that today’s one-size-fits-all treatments will 

gradually be phased out in favor of treatment strategies 

customized for each person’s individual health profile. 

In Kupersmith’s words, “Genomics provides additional 

information that can be used together by health 

professionals and their patients to determine the best 

care, moving one step closer to personalized health care.” 

Genomics is already being applied to individualize 

treatments in some cases. For example, a genetic test 

is sometimes used to help predict a patient’s response 

to the anticlotting drug warfarin and suggest an 

appropriate dose. and several cancer treatments take 

advantage of genetic testing. Further broadening of 

gene-based personalized medicine will come about as 

researchers learn more about the genes in our genome 

and the roles they play in our bodies. 

Kupersmith believes that within the next few years, 

researchers may pinpoint many of those genes that are 

keys to better health. 

Wieben, too, is optimistic. “Genomics is a slow process,” 

he acknowledges, “which makes any attempt to look 

into a crystal ball and set a precise date for routine use 

in medicine a fuzzy process.” But, he emphasizes, “I’m 

really excited even about the near future, with the first 

major inroads already being made to bring genomics to 

medical practice.” 

More information about MVP is available by visiting 

www.research.va.gov/mvp. 

Confidential code—Blood samples from which 

DNa will be extracted for a genomics study are 

“de-identified”; they have a code that can be traced 

back to individual research volunteers, but this 

information is not available to the research lab. 

Mini-glossary of genomics terms
 

dNA The basic molecule that makes up genes. 

Gene A length of DNA that codes for a protein and helps control a specific hereditary trait, 

such as hair color or disease risk. 

Genome All the DNA contained in a person or other organism. 

Genomics The study of genes and their functions. (Genetics, on the other hand, is the study of how traits are inherited.) 
46 V A R E S E A R C H T O D A Y 

 

INfoRmAtICS
 

mAkING tHE moSt of ElECtRoNIC HEAltH RECoRdS
 

A consortium of several VA medical centers and universities is exploring new technology 

to squeeze more value out of electronic records for research and quality improvement 

i

n early 2009, President Barack obama called for 

all medical records in the U.S. to be electronic 

within five years, in an effort to save dollars and lives. 

His predecessor, President George W. Bush, had set 

similar goals. 

Va is ahead of the game. Since the late 1990s, Va 

hospitals, clinics and other care sites nationwide have 

been linked by an electronic records system. a doctor 

seeing a Veteran in Louisiana, say, can easily find notes, 

X-rays and lab results from the patient’s previous Va 

visits in New york, alaska or anywhere else, for that 

matter. Electronic records at individual Va locations 

go back even farther, at least to the 1980s. 

Very few other health systems can make those claims. 

a study published in the New England Journal of 

Medicine in 2009 found that fewer than 2 percent of 

U.S. hospitals had a comprehensive electronic records 

system. 

yet, even Va’s state-of-the-art system has drawbacks. 

Much of the data in the electronic health record is free 

text—for example, notes typed in by doctors, nurses or 

therapists. This non-structured information has value in 

individual patient care, but it can’t easily be analyzed on 

a large scale—from thousands of records—for clinical 

research, decision-making or quality improvement. 

To address this gap, Va has launched the Consortium 

for Healthcare Informatics Research (CHIR). The 

project aims to squeeze more value out of Va’s electronic 

health records for researchers, clinicians, managers— 

and, ultimately, Veterans. 

Changing free text into structured data 

CHIR lead investigator Matthew Samore, Md, says: 

“If you can convert narrative text into structured 

data, you can improve your measurement of quality, 

improve surveillance of infectious diseases and adverse 

drug events, create new decision-support systems, and 

help clinicians improve documentation of problems 

in the medical record. There are a huge number of 

applications.” Samore is a clinician and epidemiologist 

at the Salt Lake City Va Medical Center. 

Besides his Utah group, CHIR involves research teams 

at the Va medical centers in Portland, Palo alto, 

Indianapolis, Nashville, Tampa, West Haven, Boston 

and Pittsburgh. The universities affiliated with each of 

these Va sites serve as research partners. The brain power 

being poured into the project represents an eclectic mix 

of specialties, spanning medical research and computer 

science: clinical epidemiology, health services research, 

applied informatics, knowledge representation, machine 

learning, natural language processing. 
SPRING 2011 47 

”

Studying the text—Va nurse Leann shipp in san 

Diego views a mock patient’s chart. Va researchers 

are exploring how to make “free text” in electronic 

medical records—for example, doctors’ notes— 

”computable, like structured data fields, so it can 

be useful on a large scale to track, analyze and 

improve care. 

aspects of natural language processing, or NLP, can 

be seen at work in products we use every day—search 

engines such as Google, for example. These applications 

recognize the combinations of words we type in—even 

when the grammar and syntax are garbled—and make 

sense of them. 

Va’s electronic records were designed to give doctors 

ample space to use free text to document patient care. 

Using structured data alone—for example, checkboxes 

or pull-down menus—wouldn’t achieve the same thing. 

Because free text is likely to endure in the nation’s 

medical records, learning how to make the best use of it 

is an important goal. 

“There’s a real limitation to asking clinicians to 

input only structured data when they are evaluating 

patients, recording those evaluations, describing 

what’s happening with the patient, documenting 

their decisions,” says Samore. “There’s a richness to 

free text, a communication benefit. It allows people 

to express themselves.” 

Merry Ward, Phd, who is overseeing CHIR for Va’s 

office of Research and development, agrees. “That 

narrative is very important for health care providers. 

Radio buttons, pull-downs, yes-no and other forced 

choices can only go so far in describing the patient’s 

condition. It’s much more complex than that.” 

Project will empower health researchers, improve care 

Samore offers an example of how CHIR will expand 

research: doctors often enter free-text notes about 

why they are prescribing certain drugs or how patients 

are responding. The only way for researchers to study 

the notes would be to manually review each chart. 

In studies involving thousands of charts, this would 
 

 

 

 

VA’s electronic medical record 

VA’s electronic medical record system is often referred 

to as the Computerized Patient Record System, or CPRS. 

Actually, CPRS is a Windows interface to the umbrella system 

known as VISTA (Veterans Health Information Systems and 

Technology Architecture), which contains more than 100 

clinical, financial and administrative programs. 

 Through VISTA, providers can securely access patient 

information at any VA care site nationwide. They can update 

a patient’s history, place orders, review test results, and view 

X-rays and other images. 

As of the end of 2009, VIStA contained: 

 1.3 billion text-based clinical documents, such as 

progress notes or discharge summaries (952,000 added 

each workday) 

 1.4 billion images (1.7 million added each workday) 

 1.6 billion vital-sign measurements (977,000 added 

each workday) 

Boning up—radiology technician Thomas Bielenda 

examines a patient’s electronic chart at the Va New 

York harbor healthcare system. 

48 V A R E S E A R C H T O D A Y 

take countless hours. The effort would be laborious, 

inefficient and probably inaccurate here and there. 

With NLP, computers could scan tens of thousands 

of de-identified patient records, find and extract the 

relevant notes, and convert the information into a 

structured format. Researchers could use computers to 

analyze it in huge batches. This could reveal new insights 

about the drugs that would otherwise remain hidden. 

according to Ward, such studies could reveal nuances— 

as expressed by doctors in free text—about the 

comparative benefits of one treatment over another. “If 

we can look at large numbers of patients, large amounts 

of data, we might be able to get a better sense of what is 

it about some patients that made them respond better to 

one treatment over another.” 

The technology would also boost genomic research— 

studies that link patients’ genetic information with 

their health risks, needs or outcomes. Ward says CHIR 

will allow the electronic medical record to be a “very 

powerful” tool in this regard—for example, by enabling 

researchers to analyze free text about clinical traits tied 

to certain genes. 

along with these applications, Samore says CHIR will 

also look at new ways to “de-identify” patient charts so 

researchers can access clinically relevant information 

without patient names or other identifiers. He says 

protecting Veterans’ privacy is a critical, overarching 

goal of the project. 

‘Rolling up’ data nationwide 

While CHIR will increase the number of data fields 

within the electronic health record that are available 

for research, a related project will greatly expand the 

number of patient records available for any given study. 

as of now, the records from each of Va’s more than 1,400 

care sites are gathered together only at the regional level. 

Most studies based on patient records use charts only 

from a facility-wide or region-wide sample—say, from the 

Southwest. Some administrative data are pulled out and 

made available in national databases, and Va researchers 

have been using these for years, but this represents only 

part of the data available in the actual records. 
SPRING 2011 49 

Learning environment—Nursing students 

Marissa hall (left) and Jacqui stotz from Lewis 

university, an affiliate of the hines (ill.) Va 

Medical center, view a patient’s electronic 

medical record. 
50 V A R E S E A R C H T O D A Y 

That will change, thanks to an initiative called 

Veterans’ Informatics, Information, and Computing 

Infrastructure. Known by the acronym VINCI, 

the project will “roll up” electronic medical records 

from Va sites nationwide into one secure, centralized 

data repository. 

“VINCI will make all the data available for researchers

in a highly secure fashion,” explains Samore. “The data 

will never be taken off the VINCI servers. and the too

to do natural language processing will be installed and 

available for use within the VINCI environment.” 

adds Ward, “Not only will the data that researchers 

have access to be much richer [because of the ability 

to analyze free text], but they’ll be able to include 

Veterans everywhere.” 

She notes that currently, Veterans seen at medical 

centers with no research program are far less likely to 

be included in database studies by Va investigators 

at other sites. The new paradigm will allow for more 

representative sampling of Veterans nationwide. 

Between CHIR and VINCI, experts expect that 

Va researchers will be in a position to conduct large, 

nationwide studies—in some cases covering decades of ls 

patients’ medical care, as documented in their electronic 

records—with unprecedented efficiency and precision. 

The end beneficiaries, notes Samore, will be Veterans. 

“Va research is always tied to care of Veterans and 

efforts to improve care,” he says. “It’s not just research 

for research’s sake.” 

Examples of CHIR projects:

Tackling bad germs, boosting

PTSD care 

Within the framework of the Consortium for Healthcare 

Informatics Research, VA investigators have launched several 

projects to help advance the development of natural language

processing and its clinical applications. 

One study, for instance, will look at methicillin-resistant 

Staphylococcus aureus, known as MRSA. The tough-to-treat 

germ has long been the nemesis of infection-control experts 

in hospitals. It causes tens of thousands of serious infections 

each year. The project will aim to capture more MRSA-related

information in the electronic medical record, beyond standard

coded data, so surveillance and control can be improved. 

A second project, on posttraumatic stress disorder, will 

examine whether free text in the electronic medical record ca

shed light on how the disorder progresses and how symptoms

may vary from one patient to the next. 

Other CHIR projects, of shorter duration, will look at several 

clinical topics that figure largely in care for heart disease, 

cancer and other diseases. 

n 

For the record—Nurse Tanya Woods updates an 

inpatient’s electronic medical record at the hines 

(ill.) Va Medical center. 
SPRING 2011 51 

CAREGIVING


REACHING oUt to AlzHEImER’S fAmIlIES: 

RESEARCH LEADS TO NATIONWIDE VA PROGRAM 

TO EASE STRESS ON CAREGIVERS 

‘REACH VA,’ the result of a federal-academic collaboration, 

is changing lives for Veterans and their caregivers across the nation 

‘ You deserve a break today,’ goes the famous 

advertising slogan. 

Researchers and clinicians may not call it a “break”— 

an “intervention” would be the more likely term—but 

that’s exactly what teams at Va sites nationwide are now 

preparing to deliver to thousands of americans who hav

one of the most stressful and demanding jobs around. 

The program is called REaCH, short for Resources 

for Enhancing alzheimer’s Caregiver Health. It’s 

now being implemented at Va sites nationwide, with 

the goal of providing much-needed support for a 

beleaguered caregiver population. 

Reducing caregiver risk 

about 80 percent of care for those with dementia is 

provided by family caregivers, but these devoted family

members often lack the skills to manage troubling 

patient behaviors and their own stress. as a result, they

can be at risk for depression, anxiety and other health 

problems. and their aging loved ones with alzheimer’s

are less likely to be able to remain at home. 

The REaCH effort began with two studies sponsored 

by the National Institute on aging and National 

Institute of Nursing Research and conducted by 

investigators with Va and several universities. The 

e 

researchers tested a six-month intervention designed 


to ease caregiver stress. It included 12 individual 


sessions in the home and by telephone, complemented 


by 5 telephone support-group sessions. The focus is on 


education, support and skills-building.
 

In the REaCH model, trained “interventionists” 

teach family caregivers how to reduce stress, solve 

problems and manage difficult behaviors by their 

family member. Role-playing and other strategies are 

used to develop coping skills. a caregiver notebook, 

written in very easy-to-understand language, covers 

dozens of topics, ranging from the physical care 

of the person with alzheimer’s to emotional and 

communication issues. 

“REaCH Va is designed for caregivers who are highly 

stressed,” says Jennifer Martindale-adams, Edd, an 

investigator with the Memphis Va Medical Center and 

the department of preventive medicine at the University 

of Tennessee Health Science Center. “It is easy for staff 

to use because it is structured, with a protocol and 

scripts. It meets the needs of caregivers and Veterans 

because it is targeted to their individual concerns 

through a risk appraisal.” 

The material is tailored to family members based on 

assessments of where they need the most help. For 
52 V A R E S E A R C H T O D A Y 

 

 

 

 

 

More in the works 

for caregivers 

Partly as a result of the Caregivers and Veterans Omnibus 

Health Services Act of 2010, an increasing network of 

services and resources is now available for family caregivers 

of Veterans. Here’s a sampling of what VA now provides and 

some of the new programs being tested: 

 Caregiver Support Coordinators—VA medical centers 

nationwide have been adding social workers in this role 

to help coordinate services for caregivers. 

 National VA Caregiver Support line (1-855-260-3274) 

—Established in early 2011, this service offers emotional 

support, information and referrals. It operates Monday 

through Friday 8 am to 11 pm, and Saturday 10:30 am6 pm (Eastern time). 

 Evidence-based Caregiver Support—REACH, featured 

in these pages, is one of two evidence-based programs 

for caregivers that VA is already putting into action 

nationwide. Originally for Alzheimer’s caregivers, REACH 

is being modified to also help caregivers of Veterans 

with spinal cord injury, with plans to further extend it to 

families coping with traumatic brain injury and chronic 

diseases. The second effort is Spouse Battlemind. 

Developed by the Army as a pre-deployment intervention, 

the telephone-based program has been modified by VA 

researchers to help prepare spouses to cope with their 

own reintegration difficulties and thereby ease the return 

home for Iraq and Afghanistan Veterans. 

 other help for dementia caregivers—Partners in 

Dementia Care, recently tested in five cities, is a joint 

program between VA and local Alzheimer’s Association 

chapters. Telephone calls provide health information, 

referrals to services and resources, emotional support, 

and outreach to family and friends who can help. Another 

program, the New York University Caregiver Intervention, 

is being evaluated at two VA sites. In prior studies, 

caregivers who received counseling and support through 

the program were able to delay placing their ill spouse in 

a nursing home by about a year and a half, compared with 

usual care. According to Kathy Horvath, PhD, RN, of the 

Bedford (Mass.) VA Medical Center, the program “is being 

successfully implemented in a variety of non-VA settings, 

but the unique features of VA are not yet addressed.” 

She says her team will identify the best way to apply the 

program in VA so “Veterans and their caregivers will have 

access to this high-quality, evidence-based counseling and 

support intervention.” 

For more information on VA’s programs for caregivers, visit 

www.caregiver.va.gov. 

example, some caregivers might simply need more 


knowledge about available resources or alzheimer’s 


symptoms, while others need to learn how to reframe 


their emotional responses.
 

“Risk priority assessment is the most innovative part 

of the program,” says Linda o. Nichols, Phd, a health 

educator and lead investigator for REaCH. “Targeting 

the intervention to the caregiver’s needs and not 

just to the behavior problems of the patient helps to 

individualize the program and to focus on high-risk 

areas first.” She is also with the Memphis Va and the 

University of Tennessee. 

VA acts on positive study findings 

Findings from the REaCH studies showed improvements 

across many areas. Caregivers reported less “burden” and 

depression, and improved emotional well-being overall. 

They also reported gains in the areas of self-care and 

healthy behaviors, social support, and management of 

problem behaviors on the part of their loved ones with 

alzheimer’s disease. Plus, they gained an hour a day of 

time that was not consumed with caregiving duties. 

“The intervention provided that most scarce of caregiver 

commodities—time,” wrote Nichols and coauthors in a 

2008 journal report. 

“We think the biggest outcome was in the increase in 

perceived free time of one hour,” adds Martindaleadams. “The extra non-caregiving time could allow the 

caregivers to do what they wanted.” 

Moreover, the extra soul-nourishing hour came relatively 

cheap—at a cost of about $5 per day for each caregiver, 

according to an analysis by the Memphis group. “We 

showed that you can do behavioral interventions,” says 

Martindale-adams. “There are a lot of people who have 

said they won’t work due to cost.” 

Based on these positive results, in 2007 Va began 

a “translation project” called REaCH Va, designed 

to parlay REaCH into an ongoing program to help 

caregivers of Veterans with alzheimer’s. The first step 

was showing how the program could work on a wide 

scale in Va. The six-month intervention was delivered at 

24 sites in 15 states through Va’s Home Based Primary 
SPRING 2011 53 

’

World War II Navy Veteran Raymond Boop, of 

North charleston, s.c., has alzheimer s disease and 

receives round-the-clock care and supervision from 

his wife, rose, or one of his five daughters, who live 

nearby. he also receives visits from the homeBased Primary care team at the charleston Va. 
54 V A R E S E A R C H T O D A Y 

— ’

Care programs. The Memphis Va Medical Center 

coordinated the effort, providing training to the clinical 

sites, certification of staff and evaluation of the results. 

By and large, the 127 caregivers who took part in 

REaCH Va—most of them spouses of Veterans— 

reported improvements similar to those seen in the 

earlier research. Significantly, 96 percent said the 

intervention program should be provided by Va to all 

caregivers. The full results were reported earlier this year 

in the Archives of Internal Medicine. 

‘Most rewarding aspect of my work with VA’ 

Saudia Major, Phd, a clinical psychologist with the Va 

ann arbor Healthcare System, has been involved with 

REaCH Va since late 2008. 

It’s been one of the most rewarding aspects of my work 

here,” she says. “When I joined the ann arbor Va and 

began making home visits, I experienced a frequent sense 

of sadness when I observed the caregivers. These people, 

often times spouses of the Veterans, appeared depressed, 

teary, isolated, and usually in poor physical condition 

due to self-neglect. I found that some caregivers would 

Through the years alzheimer s caregiver and 

research participant erma Taylor, of Memphis, 

tended devotedly to her husband, robert, a Korean 

War Veteran, until he passed away last year. 

attempt to monopolize my time during home visits, 

understandably due to lack of support, and I would have 

to spend a good bit of time redirecting them and my 

focus to the Veteran. 

The results from REaCH, she says, can often be 

dramatic. “It gives caregivers a sense of validation, helps 

them realize they are not alone, and that their needs 

have been heard. With this comes an increase in selfesteem and self-confidence. We see an improvement in 

their caregiving abilities and skills and then we observe 

declines in depression and stress. I’ve had a couple of 

caregivers tell me that that they felt that I, and the 

REaCH Va program, saved their lives.” 

Shelby Nemeth, one of the caregivers with whom Major has 

worked, says she feels “blessed” by the REaCH program. 

Her husband of 53 years, 85-year-old Lawrence, a 

Purple Heart Veteran of the Battle of the Bulge, has 

had alzheimer’s since 2003. She had looked after him 

around the clock ever since. 

“He has his good days and his bad days,” she says. “No, 

he doesn’t recognize me. But, he’s comfortable.” 
SPRING 2011 55 

 

 

 

 

 

Caregiving, Southern style —robin Weidberg, 

daughter of Navy Veteran raymond Boop, serves him a 

classic southern lunch of fried chicken and sweet tea. 

When Major and her team offered to enroll Nemeth in 

REaCH and some related respite services, at first she 

thought she would feel guilty about not being there 

all the time for her husband. Then, “I realized that my 

being healthy, letting go of some of that stress, was not 

only good for me, but it was just what Lawrence needed, 

for me to be strong enough to take care of him.” For 

Nemeth, preserving her own health was no small task: a 

few years ago, she suffered a heart attack and underwent 

a quadruple bypass. She relied on her and Lawrence’s 

children to help care for him while she recovered. 

“I am so grateful to the Va for the REaCH program,” 

says Nemeth. “I would absolutely recommend it to other 

Veteran families.” 

Alzheimer’s caregiving

at a glance 

 Almost 11 million Americans provide unpaid care for a person 

with Alzheimer’s disease or another dementia. In 2009, they 

provided 12.5 billion hours of unpaid care, valued at almost 

$144 billion. 

 In 2009, these caregivers provided, on average, nearly 22 

hours of care per week. About a third have been providing 

help for five years or longer. 

 About 60 percent of these caregivers are women. 

 More than 40 percent rate the emotional stress of caregiving 

as high or very high, compared with 28 percent of caregivers 

of other older people. These caregivers are more likely than 

non-caregivers to report that their health is fair or poor. 

 Tasks typically handled by caregivers include shopping for 

groceries, preparing meals and providing transportation; 

helping the person take medications and follow treatment 

recommendations; managing finances and legal affairs; 

supervising the person to avoid wandering and other 

unsafe activities; bathing, dressing, feeding and helping 

the person use the toilet or managing incontinence; making 

arrangements for medical and other care; and managing 

behavioral symptoms. 

Source: Alzheimer’s Association (www.alz.org) 

Now, REaCH Va is being rolled out on a national 

basis through Va’s Home-Based Primary Care 

programs. Training has started on a wide scale this year 

and will continue over the next few years. 

“The Home-Based Primary Care staff have been amazing 

in the translation,” notes Nichols. “They do the work 

because they see a need.” 

The needs of other Veterans and their caregivers— 

outside the alzheimer’s community—will be addressed 

as REaCH Va is modified for spinal cord injury and 

traumatic brain injury. 

Says Nichols, “We have had wonderful support from 

Va in moving REaCH from research to a program that 

will be available to caregivers around the country.” 
56 VA RESEARCH TODAY 

Reflections of courage —a Naval reservist uses 

a mirror to check for explosive material under a 

vehicle at the iraq-Kuwait border. Troops who are 

exposed to blasts, even from a distance, are at risk 

for auditory damage, among other injuries. 
SPRING 2011 57 

 

SENSoRy loSS
 

foR VEtERANS CoPING wItH SUbtlE AUdItoRy 


PRoblEmS, StUdIES mAy PoINt to SolUtIoNS
 

Researchers and clinicians with VA and the military are learning how to identify 

and treat cases in which the ear-brain pathway is damaged, despite normal hearing 

Blast-induced injuries have been a signature of the 

wars in Iraq and afghanistan. Even if the explosion 

doesn’t directly injure through shrapnel or a concussion, 

the blast wave can have effects from a distance. a few 

milliseconds of blast exposure can cause damage equal 

to that of a decade of low-level noise exposure. 

But blast damage doesn’t always lead to hearing loss; 

about half of blast-exposed Veterans have normal 

hearing. yet an increasing number, even those 

with normal hearing, are reporting problems with 

understanding and processing spoken information. This 

condition, called central auditory processing disorder, is 

under study by Va researchers—and colleagues in the 

military—who seek ways to identify affected Veterans 

and find treatments that could help. 

Targeting diagnosis, tailoring treatment 

a recent Va-funded study by investigators with the 

National Center for Rehabilitative auditory Research 

(NCRaR) and Walter Reed army Medical Center 

(WRaMC) sought ways to identify Veterans with 

auditory processing disorders. Researchers analyzed 

the usefulness of five common tests, given to 35 blastexposed Veterans and 23 non-exposed Veterans. 

abnormal scores on two or more of the tests generally 

indicate a central auditory processing disorder. In the 

study, more than 65 percent of blast-exposed Veterans 

fell into this category, compared with only 20 percent 

of the “controls.” about 40 percent of blast-exposed 

Veterans had abnormal results on three or more tests, 

compared with only 3 percent of controls. 

“The results were much stronger than I anticipated, in 

terms of the tests’ usefulness,” says Frederick Gallun, 

Phd, who was part of the NCRaR team, based in 

Portland, ore. The team was led by Marjorie Leek, 

Phd, and Stephen Fausti, Phd. 

Blast-exposed Veterans without a diagnosis of traumatic 

brain injury (TBI) had similar test scores as Veterans 

with mild TBI. This finding underscores the subtlety of 

the symptoms of mild TBI, points out Gallun. “There 

are delicate connections between the ear and other 

parts of the brain, and recent studies suggest that blast 

exposure stretches and twists these parts of the brain, 

which could compromise nerve fibers.” 

WRaMC clinicians have begun to use some of the 

tests in evaluating active duty service members. Therese 

C. Walden, aud, of WRaMC notes that researchers 

at her facility are now working on a series of studies on 

how auditory processing disorder affects fitness for duty. 
58 V A R E S E A R C H T O D A Y 

Tuning in —iraq Veteran Louis Lamp, who 

experienced auditory-processing problems as the 

result of his deployment, says he has benefited 

from a “frequency modulation” (fM) system he 

was fitted with as part of Va clinical trial. The 

system uses a microphone that transmits signals 

to an earpiece via radio waves. 

They also hope to establish functional test protocols 

for auditory processing before deployment, to provide 

baseline information. Service members already receive a 

standard hearing test prior to deployment. 

Testing a therapy that may help 

at the NCRaR in Portland and the James Haley Va 

Medical Center in Tampa, another study—also funded 

by Va—is testing two interventions for Veterans 

with auditory processing problems. one, a frequency 

modulation (FM) system, uses radio waves to transmit 

signals directly from a microphone to an earpiece to 

make a speaker’s voice clearer, relative to other sounds. 

The second, a “brain-training” computer program, 

leads users through tasks that involve following spoken 

instructions or interpreting sounds. 

Each of 128 Veterans in the study is randomly assigned to 

one of four groups. all four groups will receive educational 

counseling. In addition, one group will receive the FM 

system for eight weeks; a second group will use the computer 

program for the same period. a third group will receive 

both interventions. The researchers hope to learn which 

combination of these interventions will be most effective at 

helping these Veterans with auditory processing problems. 

Problem may be more widespread than thought 

army Veteran Louis Lamp was deployed to Iraq in 

2003. He helped capture Talil airbase. “We were going 

through an uncleared mine field, and a couple of mines 

went off, but nothing within about 100 meters of me,” 

recalls Lamp, 29. “There were some mortars, a rocketpropelled grenade.” 

during his tour, Lamp was also exposed to noise as a 

gunner in a Humvee, and as an occasional passenger in a 

Chinook helicopter and C-130 cargo plane. 

When he applied to join the NCRaR/Tampa study in 

2010, Lamp hadn’t realized how, or how much, he was 

compensating for his auditory processing problems. He 

was easily exhausted in social situations because he had 

to both listen and lip-read to understand conversations. 

Lamp was an accomplished and passionate violinist, 

but after returning from Iraq he stopped composing 

music and performing, except when he felt “dutybound” to play. 

“once I realized I was compensating and why, I 

started watching other Veterans,” he says. “a lot of 

them are locked right on my face as we’re talking. 
SPRING 2011 59 

—

’

I think this will wind up being realized as a much 

more common problem.” 

Lamp may be right. In a recent survey, Va audiology 

researchers surveyed Va audiologists nationwide, asking 

them how often they were seeing Iraq or afghanistan 

Veterans with normal or near-normal hearing but with 

auditory-processing problems. of the 88 audiologists 

who responded, 53 percent said they saw one to three 

such Veterans each month. Nearly 40 percent said they 

saw at least four per month. 

Given the absence of an established standard of care in 

this area, the survey also asked audiologists what they 

were doing to treat the problem. about one in three 

said they were providing patients with an FM system. 

a slightly lower percentage said they were offering 

auditory training, similar to the computer program 

offered in the NCRaR/Tampa study. However, 30 

percent said they did not know what to do. 

That’s why the NCRaR/Tampa trial is so important, 

says study investigator Gabrielle Saunders, Phd. “From 

a clinical perspective, it will be good if we can show that 

either intervention is beneficial. an audiologist can try 

Sorting sounds research audiologist anna 

Diedesch works with Jeremiah oertel in the 

anechoic chamber at Va s National center for 

rehabilitative auditory research. oertel, a former 

Marine, took part in a study on the effects of blasts 

on auditory processing. 

a hearing aid or some other interventions, but there’s no 

evidence that they work.” 

Getting back to the violin 

Lamp received an FM system as part of the NCRaR/ 

Tampa study. While he has encountered some glitches 

with the technology, it has helped him in many ways. 

He finds he doesn’t need to lip-read as much, or at all, 

so he feels less drained in social situations. He says that 

his violin now sounds to him like it used to, which has 

boosted his confidence for playing and composing. 

The system also has restored parts of the Veteran’s life 

that he hadn’t realized were lost. 

For example, “I’d gotten used to hearing rain as a dull 

thudding,” he says. “I was in the airport recently and 

it started raining really hard. Using the FM, I was 

hearing a lot more, and the sounds brought back a lot of 

memories I hadn’t thought of for years. I thought, ‘oh, 

this is cool!’ 

“My long-term memories are coming back in different 

ways because of this, and I hadn’t the faintest idea that it 

was even an issue.” 
60 V A R E S E A R C H T O D A Y 

IN tHE NEwS
 

RECENt AdVANCES by VA RESEARCHERS
 

A sampling of important new scientific findings reported by VA investigators
 

For cardiac bypass, arm artery and leg vein work equally 

well as grafts 

i

n a clinical trial involving 757 patients at 11 Va 

medical centers, coronary artery bypass surgery had 

similar outcomes whether doctors used the radial artery 

(from the forearm, wrist and hand) or the saphenous 

vein (from the leg) to reroute blood flow to the heart. 

Contrary to what many surgeons have come to believe, 

using the arm artery didn’t result in improved patency 

(the graft remaining open). 

Steven Goldman, Md, of the Southern arizona Va 

Health Care System and the University of arizona 

Sarver Heart Center in Tucson led a team that 

compared the two approaches in study volunteers 

who were undergoing elective, first-time heart 

bypass surgery. The main outcome measure was graft 

patency at one year after the operation, confirmed by 

an angiogram. other outcomes tracked in the study 

were graft patency after one week, and adverse events 

such as heart attack, stroke, repeat revascularization, 

and death. 

The researchers found no significant difference in 

one-year graft patency between the two methods. Both 

achieved a patency rate of 89 percent. also, there was 

Solving surgery debate—a clinical trial at 11 Va 

sites has shed light on which blood vessel works 

best as a graft for rerouting blood flow to the heart 

in coronary artery bypass surgery. 
SPRING 2011 61 

no difference in one-week patency or in the number and 

types of adverse events. 

Notwithstanding the new study results, the rates of 

radial artery grafts have been rising in the U.S. because 

of widespread belief among doctors that the technique 

improves patency, says Goldman. Va’s Cooperative 

Studies Program, which funded the initial trial, is now 

supporting further research that will look at five-year 

outcomes—especially graft patency—among Veterans 

in the initial study. 

( Journal of the American Medical Association, Jan. 12, 2011) 

Alcohol screenings: Do they yield accurate results? 

urrent methods of identifying patients who have cdrinking problems may not be good enough, 

according to a Va study. 

The researchers, from the Va Puget Sound Health Care 

System, compared results from two different methods of 

alcohol screening among more than 6,800 Va patients 

nationwide. 

The patients had completed a brief, well-validated 

alcohol questionnaire known as the aUdIT-C in two 

different settings, no more than 90 days apart: once 

during a clinic visit, and another time as part of a mailed 

survey. The three-question form, which Va has used 

for routine screening since 2006, asks how often people 

have an alcoholic drink; how many drinks they have 

on a typical day; and how often they have six or more 

drinks on one occasion. 

The study found that 6 in 10 of those who screened 

positive for alcohol misuse on the mailed survey 

screened negative when asked the same questions in Va 

outpatient clinics. In other words, some patients may 

have been reluctant to disclose their consumption habits 

when speaking face-to-face with their doctor or other 

health care provider, but were more open when filling 

out the survey at home. 

as a result, suggest the researchers, “Many patients who 

could benefit from brief alcohol counseling are being 

missing by clinical screening.” They say that while Va 

overall has excellent rates of alcohol screening, more 

attention needs to be paid to the accuracy of those 

screenings. one idea they 

recommend: Have patients 

complete mental health 

questionnaires—including 

those relating to alcohol or 

substance abuse—on paper 

while they wait, rather 

than in a conversation 

with the clinician. They 

say, also, that Va staff who 

conduct alcohol screenings 

should be educated about 

this potential pitfall of 

the process. 

( Journal of General Internal 

Medicine, March 2011) 

Review sheds more doubt on routine prostate tests 

i

n an update to an earlier study, an international team 

including dr. Timothy Wilt at the Minneapolis Va 

Medical Center and University of Minnesota found 

that routine prostate cancer screening using the PSa 

blood test had no impact on how many men died as a 

result of the disease. 

The team reviewed five randomized clinical trials that 

together included more than 341,000 men. While 

three of the trials may have been methodologically 

flawed, according to Wilt and colleagues, an analysis of 

combined data from the studies found no significant 

difference between screened and non-screened men in 

mortality from prostate cancer or any cause. 

Current guidelines from the american Cancer Society 

recommend that men discuss their individual risk 

factors and the option of screening with their doctors. 

The aCS says, “Research has not yet proven that the 

potential benefits of testing outweigh the harms of 

testing and treatment.” Similarly, the U.S. Preventive 

Services Task Force says there is not enough evidence 

to make a recommendation for men under age 75. For 

those older than 75, the group advises against screening. 

For these men, the potential benefits are typically 

outweighed by the risks—for example, unnecessary 

biopsies, which could involve infection, bleeding or 
62 VA RESEARCH TODAY 

pain; and anxiety over receiving a cancer diagnosis, eve

though the tumor might be slow-growing and unlikely 

to cause any symptoms during the patient’s lifetime. 

Researchers in Va and elsewhere are working to resolve 

the question of how and when men should be screened. 

one idea is to test only for certain forms of PSa that 

can reliably indicate aggressive cancers—those that 

undeniably require treatment. another approach is to 

clarify how certain risk factors—such as obesity—can be

used along with PSa to help predict disease progression. 

(British Journal of Urology, March 2011) 

Genetic clues to the deadliest staph infections 

staph infections account for some 15 percent of 

all healthcare-related infections and can often be 

deadly. Va researchers in Iowa City and colleagues fro

several universities have discovered a genetic twist they 

say may provide important clues to guide prevention 

and treatment. 

Their study, which took place at a university medical 

center, found higher death rates among patients 

infected with isolates of Staphylococcus aureus that 

contain a certain genetic defect. S. aureus are the nasty 

n 

m 

bacteria that cause staph infections. The data suggest 

that the defect, known as accessory gene regulator 

(agr) dysfunction, previously linked to longer-lasting 

infections, may also be a culprit in deadlier infections. 

The dysfunction involves a system of genes that turn 

other genes on and off. 

among 814 patients whose hospital stay was 

complicated by staph infections, 22 percent were 

infected with S. aureus isolates that contained the 

genetic flaw. overall, 18 percent of patients with the 

dysfunction died, compared with 12 percent who were 

infected with S. aureus without the dysfunction—about 

a 30-percent higher risk. 

The study is the first to show a link between agr 

dysfunction and death rates among severely ill hospital 

patients, according to the authors. To address the issue, 

they recommend the use of a readily available lab 

test that they say may be a simple and 

inexpensive way to predict which 

patients are most at risk, and to tailor 

antibiotic therapy accordingly. 

( Journal of Antimicrobial Agents 

and Chemotherapy, March 2011) 

Staff against staph—Nurse rafael sepulveda 

dons rubber gloves before tending to a patient in the 

emergency room at the Miami Va Medical center. 

staff at Va and other health care facilities follow strict 

measures to curb the spread of staph germs and 

other pathogens. 
SPRING 2011 63 

Amazing feet —randall Tipton, wearing the iWalk 

Powerfoot BioM, gets a check-up from nurse and 

certified prosthetist Mark Benveniste at the houston 

Va. The computerized ankle-foot prosthesis, 

developed in part through Va research, is now 

available to Va patients. 

Special Forces Veteran is first in VA to receive 

bionic ankle 

randall Tipton, a 20-year army Special Forces Veteran who served in Iraq and afghanistan, 

recently became the first Va patient to be fitted with the 

iWalk PowerFoot BIoM. The computerized prosthesis, 

in part the product of Va research, replaces the action 

of the foot, achilles tendon and calf muscle and offers a 

near-normal gait for amputees. 

Tipton was fitted with the ankle at the Michael E. 

deBakey Va Medical Center in Houston, just weeks 

after the device became available at Brooke army 

Medical Center in San antonio and Walter Reed 

army Medical Center in Washington, dC. 

The bionic ankle was invented by Hugh Herr, 

Phd, of the Massachusetts Institute of Technology 

Biomechatronics Group. Herr is also with the 

Center for Restorative and Regenerative Medicine, a 

collaboration among Va, MIT and Brown University. 

The ankle has been shown to reduce fatigue and improve balance. according to Herr, it also improves amputees’ overall 

health because it leads to higher levels of physical activity. 

The device has robotic features: Two microprocessors 

and six environmental sensors continuously evaluate 

and adjust ankle position. as a result, users can walk 

over even ground, slopes and stairs with a fluid, natural 

gait. They feel far less of the fatigue and back pain 

associated with older artificial foot models. 

“We have seen a significant difference in function in this 

device over the other 200-plus [prosthetic] feet we have 

used here at the deBakey Va,” said certified prosthetist 

Mark Benveniste. “It is the most improvement over 

conventional prosthetics in the last 20 years.” 

Tipton had this to say about the device: “I feel like I 

have my leg back and I can do the things I used to do. 

It just helps out a lot. It takes the strain off my back, my 

hips. I don’t feel as tired at the end of the day.” 

(February 2011) 
64 V A R E S E A R C H T O D A Y 

(The illustration is a modified version of the actual test that was used in the study and published in Optometry and Vision Science.) 

Face-recognition test may help in diagnosing, treating 

vision problems 

Vision problems such as age-related macular 

degeneration—the leading cause of vision loss 

among older americans—can mean a reduced ability to 

recognize faces, which is a big part of social interaction. 

But researchers have paid little attention in the past to 

learning how to measure this problem. 

That’s why a team of Va vision experts has created a 

“face discrimination” test. They say it can help quantify 

the impact of vision loss and track the benefits of lowvision therapy. 

The test involves sets of color photos showing male and 

female faces. a person being evaluated is shown a “test” face 

surrounded by eight reference images. one of the reference 

faces is the same as the test face, although it could be shown 

from a different angle and with a different expression. The 

test-taker has to pick the reference image that matches 

the test image, and determine the expression of the test 

image—normal, smile or frown. 

The researchers tried the test with older people with 

age-related macular degeneration in both eyes, and with 

younger and older healthy controls. Not surprisingly, 

performance was best among the young volunteers. They 

responded quickly and made almost no mistakes. The 

older controls—those without macular degeneration— 

had somewhat slower response times, and made some 

errors, mainly in identifying the expressions. Those with 

macular degeneration were slower and made more errors 

in identification than did the older controls. For all 

those who took part in the evaluation, visual acuity and 

contrast sensitivity affected performance. 

The researchers say the test would be easy to reproduce 

across all Va sites and could be used to “quantify 

low vision patients’ complaints of difficulty with 

face perception, and to evaluate possible changes in 

performance with low vision rehabilitation.” 

(Optometry and Vision Science, February 2011) 

About face—Va researchers in atlanta and Palo 

alto developed a face-recognition test to help 

assess symptoms of macular degeneration and 

other vision disorders. 
SPRING 2011 65 

In high-risk schizophrenia, no edge for injectable, 

long-acting drug 

i

n a clinical trial led by a Va and yale University team, 

Veterans with severe schizophrenia who received 

biweekly injections of a long-acting antipsychotic drug 

fared no better than those treated with standard oral 

drugs. Schizophrenia affects more than 2.2 million 

americans and some 100,000 Veterans who use Va 

health care. 

The study results were somewhat surprising, said lead 

author Robert Rosenheck, Md, a psychiatry researcher 

with yale and the Va New England Mental Illness 

Research, Education and Clinical Center. “Some earlier 

studies had shown that by ensuring sustained levels of 

drug in the blood, long-acting injections could improve 

symptoms and reduce hospitalizations, relative to oral 

antipsychotics. In our study, though, the injectable drug 

showed no advantage in symptom control, quality of life 

or hospitalization for these high-risk patients.” 

The study included 369 Veterans. all were considered 

high-risk because of their recent need for hospital care. 

about half received injections of long-acting risperidone 

(sold as Risperdal Consta). The others received oral 

antipsychotics chosen by their psychiatrists. 

after two years, roughly 4 in 10 patients in both groups 

had been hospitalized. The two groups also had similar 

symptoms and overall quality of life. Side effects known 

as extrapyramidal symptoms—involuntary movements 

or muscle stiffness—were more common in the 

injection group, as were headaches and soreness from 

the injection. 

Schizophrenia can be manageable for many patients, 

but sticking to drug regimens is critical. Long-acting 

injections have been seen as a way to ensure steadier 

doses of medication, especially for those with more 

severe symptoms. The new Va study does not support 

that view, says Rosenheck. He says further trials with 

larger groups of patients could provide more conclusive 

evidence on the benefits and risks of the injectable drug, 

both for high- and lower-risk schizophrenia patients. 

(New England Journal of Medicine, March 3, 2011) 
66 V A R E S E A R C H T O D A Y 

On the horizon: Blood marker for cognitive decline 

Low blood levels of beta-amyloid 42, a protein-like 

substance, were linked with the risk of significant 

cognitive decline within nine years in a group of nearly 

1,000 older study volunteers. The research was led by 

Kristine yaffe, Md, chief of geriatric psychiatry at the 

San Francisco Va Medical Center and a professor at the 

University of California, San Francisco. 

another finding was that among elders with low 

blood levels of beta-amyloid 42, cognitive decline was 

less marked in those who had higher literacy, or more 

education, or who lacked the aPoE e4 gene known 

to predict a greater risk of dementia. The researchers 

describe this set of conditions as “cognitive reserve.” 

“We show that a blood test for beta-amyloid 42 might 

be a good way to predict those at risk for cognitive 

decline,” said yaffe. “also, for the first time, we show 

that cognitive reserve—a general level of resiliency in 

the brain—might modify that risk in the elderly.” 

yaffe said that currently “there is no reliable method of 

predicting ahead of time who will experience cognitive 

decline and go on to develop dementia. a blood test 

would be a huge step forward.” 

Beta-amyloid 42 has long been known to collect in the 

brain of patients with alzheimer’s disease. Low levels of 

beta-amyloid 42 in the blood or spinal fluid, explained 

yaffe, indicate high levels in the brain, “which acts as a 

sink for beta amyloid in alzheimer’s disease.” although 

an experimental test for beta-amyloid in cerebral spinal 

fluid already exists, said yaffe, “a blood test would be far 

easier, less invasive and less expensive than the lumbar 

puncture required to obtain spinal fluid.” 

The researchers saw the “cognitive reserve” finding as good 

news. “We might actually be able to modify the risk of 

dementia before it becomes manifest,” said yaffe. “If you 

find out that you have low beta-amyloid 42, but you haven’t 

yet experienced any obvious cognitive decline, you might 

try and increase your cognitive reserve by staying mentally 

active—reading, taking classes—and thereby mitigate or at 

least delay the damage.” 

( Journal of the American Medical Association, Jan. 19, 2011) 

For those with paralysis, brain implant allows 

point-and-click cursor control 

i

n one of the latest reports on their innovative 

BrainGate technology, researchers with Va and 

Brown University showed that recording signals from 

only a tiny cluster of brain cells—only 40 or so, out of 

billions in the brain—can enable effective control of a 

computer cursor for patients with total paralysis. 

The study, part of ongoing research involving patients 

with conditions such as spinal cord injury, aLS (Lou 

Gehrig’s disease) and brainstem stroke, included 

two patients with paralysis of all four limbs. Using 

BrainGate, they were able to control the motion of 

a cursor on a screen and click on targets. The error 

rate was small—under three percent for one of the 

participants. 

BrainGate (www.braingate2.org) uses a sensor in the 

brain to pick up signals from neurons. The impulses 

are decoded by an external computer and translated 

into commands for electronic or robotic devices. 

The implant, an electrode array about the size of a baby 

aspirin, is made of biocompatible materials such as 

silicon and titanium and is placed in the motor cortex, 

which controls movement. a small pedestal is visible 

on the surface of the skull and allows for the internal 

sensor to be wired to the external decoder. a wireless 

version of the system is under development. 

“The current investigational device represents the 

first step in a cycle of innovation and clinical research 

that we hope will yield ever-improving restorative 

technologies for people with neurological disorders, 

injuries or limb loss,” said investigator Leigh 

Hochberg, Phd. He noted that his group is currently 

testing BrainGate as a control system for a high-tech 

upper limb prosthesis, known as the dEKa arm, 

that was funded by the defense advanced Research 

Projects agency and is being field tested with 

Veterans at several Va sites. 

(IEEE Transactions on Neural Systems and Rehabilitation 

Engineering, online Jan. 28, 2011) 
SPRING 2011 67 

—

”

 

Mending minds occupational therapist annemarie 

rossi works with Veteran Lonny ellison during a 

session of the “GoaLs cognitive rehab program being 

studied at the san francisco Va. The training may help 

patients with brain injuries boost their attention and 

executive function. Looking on are neuropsychologist 

Dr. Tatjana Novakovic-agopian and Dr. Gary abrams, 

rehabilitation section chief. 

Training boosts cognitive function even 

in long-term brain injury 

i

n a pilot study led by Va researchers, a new cognitive 

rehabilitation method helped patients with longstanding brain injury—in most cases from traumatic injuries 

or stroke—stay focused on goals and complete everyday 

tasks such as schoolwork or meal planning. 

Neuropsychologist Tatjana Novakovic-agopian, Phd, 

and neurologist anthony Chen, Md, both lead authors 

on the study, said the results show that cognitive function 

can improve even years after a brain injury. “developing 

interventions for these problems is extremely important, 

given the large number of young men and women 

coming back from active duty deployment in Iraq and 

afghanistan with traumatic brain injury and persistent 

symptoms of cognitive dysfunction.” 

Chen and Novakovic-agopian co-direct the interinstitutional Program in Rehabilitation Neuroscience 

and are affiliated with the San Francisco Va Medical 

Center, Va Northern California Healthcare System, 

and University of California, San Francisco. 

The training method developed by the researchers 

is called goal-oriented attentional self-regulation, or 

GoaLS. It teaches participants how to focus on 

goal-relevant information and hold it in mind while 

managing distractions, and then to apply those skills in 

managing their own real-life goals. 

Chen described one of the GoaLS strategies, called 

Stop-Relax–Refocus: “Stop, relax, refocus on the goal to 

be accomplished, and when your mind wanders, practice 

redirecting your attention back to the central goal. This 

is inspired by mindfulness training that’s been taught 

for thousands of years. The difference is that we have 

put a rehabilitation twist to it. This is not traditional 

meditation, but goal-oriented applied mindfulness.” 

The 10-week study included 16 participants in two 

groups. The first group had GoaLS training for 5 

weeks and educational instruction about brain injury 

during the second 5 weeks. The other group received 

the same interventions but in reverse order. after the 

first 5 weeks, the GoaLS group showed significant 

improvements in attention, executive function and 

completion of functional tasks. Those who had the 

education sessions showed no such changes. after 10 

weeks, the group that was switched from education to 

GoaLS training showed similar improvements. 

Importantly, the first group maintained the gains they 

had shown after the first 5 weeks. In fact, Novakovicagopian said that in follow-up research, almost all the 

participants reported using GoaLS strategies for up to 

two years after the study. 

a larger study of Veterans is under way. The research 

has been supported by Va and the California Pacific 

Medical Foundation. 

( Journal of Head Trauma Rehabilitation, online dec. 16, 2010) 
68 V A R E S E A R C H T O D A Y 

Sending test kits to patients’ homes boosts 

colorectal screening 

esearchers with the New Mexico Va Health Care rSystem and University of New Mexico found that 

mailing stool tests to eligible patients’ homes—rather 

than waiting for them to be routinely screened during 

office visits—was an effective preventive measure for 

colorectal cancer. 

In the study, more than 200 Veterans—many of them in 

rural areas—received fecal occult blood test kits in the 

mail, along with consent forms and a pre-paid return 

envelope. Nearly 6,000 patients in the region served as 

“controls” and did not receive the kits. all the Veterans 

were between ages 50 and 80. all were eligible for this 

type of screening, based on their medical status, and 

were due for the test. 

Nearly half of those who received the kits by mail 

completed the test, which is widely used as an initial 

screening for colorectal cancer. Those who tested 

positive were referred for further screening, usually 

a colonoscopy. 

You’ve got mail—Dr. richard hoffman, with Va and 

the university of New Mexico, shows the stool-test 

kits that were mailed to eligible Veterans at home as 

part of a study. The kits boosted colorectal cancer 

screening rates. 

among the control groups, who did not receive the kits 

by mail, fewer than a fifth of patients ended up getting 

screened for colorectal screening during the study 

period, either by stool test or colonoscopy. 

The findings suggest the mail method may be more 

effective than waiting to screen patients during routine 

primary care visits—especially for people who are 

healthier overall and less likely to show up for regular 

check-ups. The researchers also point to the value of 

Va’s electronic health record, which was used to identify 

patients eligible for the study and to track their care. 

Colorectal cancer is the third most common cancer in 

the U.S. and the third leading cause of cancer-related 

deaths. In the Va health system, there are some 4,000 

new cases each year. 

(American Journal of Managed Care, January 2011) 
VA RESEARCH todAy
 

Page 18: Lamel Hinton (VA New York Harbor Healthcare System) 

Pages 20 – 23: Nathan Morgan 

Page 25: Jerry daliege 

Page 26 (top left): Jason Miller (Pixelate Photography and Design) 

Page 26 (top right): Jim Bryant Photography 

Page 26 (left inset): Jerry daliege 

Page 26 (right inset): Larry Gilstad (Miami VA Medical Center) 

Page 27 (top): Jerry Naunheim Photography 

Page 27 (inset): Stacy Pearsall (Charleston Center for Photography) 

Page 33: Scott Soderberg (University of Michigan, Ann Arbor) 

Page 34: iStockphoto 

Page 35: Tommy Leonardi Photography 

Page 36: Getty Images 

Page 37: Glenn Hangard (VA Pittsburgh Healthcare System) 

Page 39: Getty Images 

Page 40: Jim Bryant Photography 

Page 42: Tommy Leonardi Photography 

Page 43: Frank Curran Photography 

Page 44: Tommy Leonardi Photography 

Page 45: Jeffery Bowen (Central Arkansas Veterans Healthcare System) 

Page 47: Kevin Walsh Photography 

Page 48: Lamel Hinton (VA New York Harbor Healthcare System) 

Pages 49 – 50: Jerry daliege 

Page 53: Stacy Pearsall (Charleston Center for Photography) 

Page 54: Teresa Moerman (Memphis VA Medical Center) 

Page 55: Stacy Pearsall (Charleston Center for Photography) 

Page 56: Chief Journalist Kevin Elliott (U.S. Navy) 

Pages 58 – 59: Michael Moody (Portland VA Medical Center) 

Page 60: Jeffery Bowen (Central Arkansas Veterans Healthcare System) 

Page 61: iStockphoto 

Page 62 (main photo and inset): Getty Images 

Page 63: Bobbi Gruner (Michael E. DeBakey VA Medical Center, Houston) 

Page 64: iStockphoto 

Page 65: iStockphoto 

Page 67: Roy Kaltschmidt 

Back cover: Nathan Morgan 

creDiTs 

VA Research Today is produced by: 

Va R&d Communications 

103 South Gay Street, Ste. 517 

Baltimore, Md 21202 

(410) 962-1800 x223 

research.publications@va.gov 

Editor 

Mitch Mirkin (mitch.mirkin@va.gov) 

Writing 

Ev Chasen 

Mitch Mirkin 

Tamar Nordenberg 

Hans Petersen 

Steve Tokar 

Nancy Volkers 

Design 

Project design Company, www.projectdc.com 

Photography 

Front cover: Roy Kaltschmidt 

Page 3: Roy Kaltschmidt 

Page 4: Ed Caballero (San Francisco VA Medical Center) 

Pages 5 – 6: Roy Kaltschmidt 

Page 7: iStockphoto 

Page 8 (top): Jim Spaw (Kansas City VA Medical Center) 

Page 8 (inset): Getty Images 

Page 9: Getty Images 

Page 10 (tea illustration): Missouri Botanical Garden 

Page 10 (right): Tim Teran (Birmingham VA Medical Center) 

Page 12: Spc. Breanne Pye (U.S. Army) 

Page 13: Linnie Skidmore (Durham VA Medical Center) 

Page 15: Tommy Leonardi Photography 

Page 16: Michael Moody (Portland VA Medical Center) 

Page 17: iStockphoto 
70 VA RESEARCH TODAY 

Homeless no more —army Veteran andre Guyton, 

50, was living on the street four years ago when he 

first came to a Va primary care clinic for Veterans 

coping with homelessness. Today, he has a job and 

a roof over his head. read more on page 19.