Jan Dyer

 What happens to patients at risk for suicide after they leave the emergency department (ED)? According to a new study funded by the National Institute of Mental Health and published in JAMA Network Open, people who presented to California EDs with deliberate self-harm or suicidal ideation were not just at risk for a future suicide—they were at extreme risk.

The researchers divided patients into 3 groups: 83,507 who had deliberately self-harmed with or without co-occurring suicidal ideation; 67,379 presenting with suicidal ideation but without deliberate self-harm; and 497,760 without either self-harm or suicidal ideation.

In the first year after the ED visit, the patients who had presented with deliberate self-harm had a suicide rate almost 57 times higher than that of demographically similar Californians. Among those with suicidal ideation, the suicide rate was about 31 times higher. The suicide rate for the reference group, while the lowest of the 3 groups, was still twice the rate among Californians overall.

The researchers found certain clinical and demographic characteristics predicted subsequent suicide. Men and patients aged > 65 years had higher rates of suicide when compared with women or people aged 10 to 24 years. In all groups, suicide rates were higher for non-Hispanic, white patients.

Comorbid diagnoses were associated with suicide risk but with “striking differences” among the groups, the researchers say. Among patients presenting with deliberate self-harm, those with a comorbid diagnosis of bipolar disorder, anxiety disorder, or a psychotic disorder were more likely to die of suicide. Among reference patients, those with bipolar disorder, depression, or alcohol use disorder had a higher risk.

Of note, the researchers say, patients in the deliberate self-harm group who presented with a firearm-related injury had a subsequent suicide rate of 4.4% in the following year, a far higher rate than that in any other patient group. The researchers urge ED physicians to be aware that patients who present with self-harm who use high-lethality methods at a nonfatal event remain at highly increased risk for future suicide.

To the researchers’ knowledge, this is the first US population-based study to examine 12-month suicide rates after an index ED visit. These findings reinforce the importance of universal screening for suicide risk in EDs and the need for follow-up care, the researchers add, “an approach that has been found to increase the number of ED patients identified as warranting treatment for suicide risk by approximately 2-fold, but which is also not yet widespread.”

 What happens to patients at risk for suicide after they leave the emergency department (ED)? According to a new study funded by the National Institute of Mental Health and published in JAMA Network Open, people who presented to California EDs with deliberate self-harm or suicidal ideation were not just at risk for a future suicide—they were at extreme risk.

The researchers divided patients into 3 groups: 83,507 who had deliberately self-harmed with or without co-occurring suicidal ideation; 67,379 presenting with suicidal ideation but without deliberate self-harm; and 497,760 without either self-harm or suicidal ideation.

In the first year after the ED visit, the patients who had presented with deliberate self-harm had a suicide rate almost 57 times higher than that of demographically similar Californians. Among those with suicidal ideation, the suicide rate was about 31 times higher. The suicide rate for the reference group, while the lowest of the 3 groups, was still twice the rate among Californians overall.

The researchers found certain clinical and demographic characteristics predicted subsequent suicide. Men and patients aged > 65 years had higher rates of suicide when compared with women or people aged 10 to 24 years. In all groups, suicide rates were higher for non-Hispanic, white patients.

Comorbid diagnoses were associated with suicide risk but with “striking differences” among the groups, the researchers say. Among patients presenting with deliberate self-harm, those with a comorbid diagnosis of bipolar disorder, anxiety disorder, or a psychotic disorder were more likely to die of suicide. Among reference patients, those with bipolar disorder, depression, or alcohol use disorder had a higher risk.

Of note, the researchers say, patients in the deliberate self-harm group who presented with a firearm-related injury had a subsequent suicide rate of 4.4% in the following year, a far higher rate than that in any other patient group. The researchers urge ED physicians to be aware that patients who present with self-harm who use high-lethality methods at a nonfatal event remain at highly increased risk for future suicide.

To the researchers’ knowledge, this is the first US population-based study to examine 12-month suicide rates after an index ED visit. These findings reinforce the importance of universal screening for suicide risk in EDs and the need for follow-up care, the researchers add, “an approach that has been found to increase the number of ED patients identified as warranting treatment for suicide risk by approximately 2-fold, but which is also not yet widespread.”

 What happens to patients at risk for suicide after they leave the emergency department (ED)? According to a new study funded by the National Institute of Mental Health and published in JAMA Network Open, people who presented to California EDs with deliberate self-harm or suicidal ideation were not just at risk for a future suicide—they were at extreme risk.

The researchers divided patients into 3 groups: 83,507 who had deliberately self-harmed with or without co-occurring suicidal ideation; 67,379 presenting with suicidal ideation but without deliberate self-harm; and 497,760 without either self-harm or suicidal ideation.

In the first year after the ED visit, the patients who had presented with deliberate self-harm had a suicide rate almost 57 times higher than that of demographically similar Californians. Among those with suicidal ideation, the suicide rate was about 31 times higher. The suicide rate for the reference group, while the lowest of the 3 groups, was still twice the rate among Californians overall.

The researchers found certain clinical and demographic characteristics predicted subsequent suicide. Men and patients aged > 65 years had higher rates of suicide when compared with women or people aged 10 to 24 years. In all groups, suicide rates were higher for non-Hispanic, white patients.

Comorbid diagnoses were associated with suicide risk but with “striking differences” among the groups, the researchers say. Among patients presenting with deliberate self-harm, those with a comorbid diagnosis of bipolar disorder, anxiety disorder, or a psychotic disorder were more likely to die of suicide. Among reference patients, those with bipolar disorder, depression, or alcohol use disorder had a higher risk.

Of note, the researchers say, patients in the deliberate self-harm group who presented with a firearm-related injury had a subsequent suicide rate of 4.4% in the following year, a far higher rate than that in any other patient group. The researchers urge ED physicians to be aware that patients who present with self-harm who use high-lethality methods at a nonfatal event remain at highly increased risk for future suicide.

To the researchers’ knowledge, this is the first US population-based study to examine 12-month suicide rates after an index ED visit. These findings reinforce the importance of universal screening for suicide risk in EDs and the need for follow-up care, the researchers add, “an approach that has been found to increase the number of ED patients identified as warranting treatment for suicide risk by approximately 2-fold, but which is also not yet widespread.”

Is the US Department of Defense (DoD) doing enough—or the right things—to attract and keep physicians and dentists? According to a new report by the Government Accountability Office (GAO), although the DoD is hitting the mark in some areas, there’s room for improvement in others.

It’s a crucial question. The GAO reported in 2018 that DoD officials cited “a number of challenges” that made it difficult to attract and retain physicians and dentists, such as national shortages and competition with the private sector. Indeed, military health system physicians and dentists make less than do their counterparts in the private sector, the GAO says. For 21 of 27 specialties studied in the new report, the maximum cash compensation was less than the civilian median within 4 officer pay grades (O-3 to O-6). Moreover, cash compensation even for the most senior military physicians and dentists was less than that of the civilian median at “key retention points,” such as after physicians and dentists fulfill their initial active-duty service.

The DoD provides “substantial” deferred and noncash benefits, the GAO notes, such as retirement pensions and tuition-free education, but adds that the value to service members is “difficult to determine.” The DoD also recruits with a package of incentives, including multi-year retention bonuses.

In general, the GAO found, the DoD applies several “effective human capital management” principles. For instance, it relies on clearly defined criteria on when to use incentives (such as rules-based pay plans). It also identifies and evaluates unique staffing situations. For example, to attract physicians and dentists in “critically short wartime specialties,” it offers a Critical Wartime Skills Accession Bonus.    

However, the report says, the DoD does not consistently collect information that could help inform its recruitment/retention decisions. At the time of the study, the DoD had not identified replacement costs for physicians or dentists as it does, for instance, with nuclear propulsion personnel. Nor did it gather current and historical retention information. Specifically, the GAO report says, Navy and Air Force officials said they don’t have readily available information to determine the percentage of those who accepted a retention bonus. Conversely, Army officials don’t have a framework in place that uses retention information to determine the effectiveness of retention bonuses (as do the Navy, Marine Corps, and Air Force).

Extending Service Obligations

The DoD is considering extending service obligations for students receiving DoD-funded assistance for physician or dentist education. Students in the DoD scholarship program have a 2-year minimum service obligation, with 6months of active-duty service obligations for each 6 months of benefits received. Medical students attending the Uniformed Services University of the Health Sciences (USUHS), have a 7-year active-duty service obligation.

The GAO held 8 focus groups with students and found 68% of USUHS students and 46% of scholarship students would be willing to accept 1 more year of obligation (although only 34% and 16%, respectively, would agree to 2). The participants expressed concern that longer service obligations would delay their eligibility for retention bonuses—resulting in a reduction of cash compensation over the course of a career. However, 80% and 63%, respectively, would accept an additional year of service obligation if accompanied by additional cash incentives.

Further, the GAO notes, longer obligations could have “unintended consequences.” For example, students might decide to separate and train in a civilian program after 1 or more tours as general medical officers to complete their active duty service obligation, decline further medical training and specialization via a military fellowship program, or separate from the military sooner than planned.

Potential Reductions in Health Care Force

The DoD, according to the report, also is considering reducing the overall number of active-duty physicians, including “targeted reductions” to certain specialties, raising concerns among participants in all 8 focus groups.

Given that the DoD spends millions of dollars annually to train medical and dental students and that almost half of the special pay budget is dedicated to retaining them once they’re fully trained, consistently collecting information to help inform investment decisions is “critical to ensuring the efficiency of these significant resources,” the GAO says. Collecting such information, the GAO says, and using it, would help inform its decision making. For instance, such information would help officials decide whether it would be more cost effective to focus on retaining medical personnel rather than training new staff.

Retaining “top talent,” the DoD says, is “essential to sustaining mission readiness that is adaptable and responsive.” The GAO report cites a 2012 study that found compensation for military physicians had “a large impact on the decision to remain in the military in the first unobligated year of service and just a small impact on retention in the years afterward.” 

DoD officials told the GAO that budget considerations and statutory limitations hinder their ability to change the rate of special and incentive pays. The GAO calls these “valid considerations” but suggests that collecting information on replacement costs, retention, and civilian wages would allow DoD departments to “provide greater stewardship of available funding by ensuring its efficient application.” It may be, the GAO says, that retaining fully trained physicians within the DoD is “highly economical.”. Most important, using such data to inform investment decisions will allow the DoD to “efficiently and effectively meet its mission of providing health care during times of war and peace.”

In response to the GAO findings, DoD officials have a group working on a plan to recruit and retain critical specialties, which will be released by June 2020. They also concurred with other GAO recommendations, saying changes will be made within 2 years.

Is the US Department of Defense (DoD) doing enough—or the right things—to attract and keep physicians and dentists? According to a new report by the Government Accountability Office (GAO), although the DoD is hitting the mark in some areas, there’s room for improvement in others.

It’s a crucial question. The GAO reported in 2018 that DoD officials cited “a number of challenges” that made it difficult to attract and retain physicians and dentists, such as national shortages and competition with the private sector. Indeed, military health system physicians and dentists make less than do their counterparts in the private sector, the GAO says. For 21 of 27 specialties studied in the new report, the maximum cash compensation was less than the civilian median within 4 officer pay grades (O-3 to O-6). Moreover, cash compensation even for the most senior military physicians and dentists was less than that of the civilian median at “key retention points,” such as after physicians and dentists fulfill their initial active-duty service.

The DoD provides “substantial” deferred and noncash benefits, the GAO notes, such as retirement pensions and tuition-free education, but adds that the value to service members is “difficult to determine.” The DoD also recruits with a package of incentives, including multi-year retention bonuses.

In general, the GAO found, the DoD applies several “effective human capital management” principles. For instance, it relies on clearly defined criteria on when to use incentives (such as rules-based pay plans). It also identifies and evaluates unique staffing situations. For example, to attract physicians and dentists in “critically short wartime specialties,” it offers a Critical Wartime Skills Accession Bonus.    

However, the report says, the DoD does not consistently collect information that could help inform its recruitment/retention decisions. At the time of the study, the DoD had not identified replacement costs for physicians or dentists as it does, for instance, with nuclear propulsion personnel. Nor did it gather current and historical retention information. Specifically, the GAO report says, Navy and Air Force officials said they don’t have readily available information to determine the percentage of those who accepted a retention bonus. Conversely, Army officials don’t have a framework in place that uses retention information to determine the effectiveness of retention bonuses (as do the Navy, Marine Corps, and Air Force).

Extending Service Obligations

The DoD is considering extending service obligations for students receiving DoD-funded assistance for physician or dentist education. Students in the DoD scholarship program have a 2-year minimum service obligation, with 6months of active-duty service obligations for each 6 months of benefits received. Medical students attending the Uniformed Services University of the Health Sciences (USUHS), have a 7-year active-duty service obligation.

The GAO held 8 focus groups with students and found 68% of USUHS students and 46% of scholarship students would be willing to accept 1 more year of obligation (although only 34% and 16%, respectively, would agree to 2). The participants expressed concern that longer service obligations would delay their eligibility for retention bonuses—resulting in a reduction of cash compensation over the course of a career. However, 80% and 63%, respectively, would accept an additional year of service obligation if accompanied by additional cash incentives.

Further, the GAO notes, longer obligations could have “unintended consequences.” For example, students might decide to separate and train in a civilian program after 1 or more tours as general medical officers to complete their active duty service obligation, decline further medical training and specialization via a military fellowship program, or separate from the military sooner than planned.

Potential Reductions in Health Care Force

The DoD, according to the report, also is considering reducing the overall number of active-duty physicians, including “targeted reductions” to certain specialties, raising concerns among participants in all 8 focus groups.

Given that the DoD spends millions of dollars annually to train medical and dental students and that almost half of the special pay budget is dedicated to retaining them once they’re fully trained, consistently collecting information to help inform investment decisions is “critical to ensuring the efficiency of these significant resources,” the GAO says. Collecting such information, the GAO says, and using it, would help inform its decision making. For instance, such information would help officials decide whether it would be more cost effective to focus on retaining medical personnel rather than training new staff.

Retaining “top talent,” the DoD says, is “essential to sustaining mission readiness that is adaptable and responsive.” The GAO report cites a 2012 study that found compensation for military physicians had “a large impact on the decision to remain in the military in the first unobligated year of service and just a small impact on retention in the years afterward.” 

DoD officials told the GAO that budget considerations and statutory limitations hinder their ability to change the rate of special and incentive pays. The GAO calls these “valid considerations” but suggests that collecting information on replacement costs, retention, and civilian wages would allow DoD departments to “provide greater stewardship of available funding by ensuring its efficient application.” It may be, the GAO says, that retaining fully trained physicians within the DoD is “highly economical.”. Most important, using such data to inform investment decisions will allow the DoD to “efficiently and effectively meet its mission of providing health care during times of war and peace.”

In response to the GAO findings, DoD officials have a group working on a plan to recruit and retain critical specialties, which will be released by June 2020. They also concurred with other GAO recommendations, saying changes will be made within 2 years.

Is the US Department of Defense (DoD) doing enough—or the right things—to attract and keep physicians and dentists? According to a new report by the Government Accountability Office (GAO), although the DoD is hitting the mark in some areas, there’s room for improvement in others.

It’s a crucial question. The GAO reported in 2018 that DoD officials cited “a number of challenges” that made it difficult to attract and retain physicians and dentists, such as national shortages and competition with the private sector. Indeed, military health system physicians and dentists make less than do their counterparts in the private sector, the GAO says. For 21 of 27 specialties studied in the new report, the maximum cash compensation was less than the civilian median within 4 officer pay grades (O-3 to O-6). Moreover, cash compensation even for the most senior military physicians and dentists was less than that of the civilian median at “key retention points,” such as after physicians and dentists fulfill their initial active-duty service.

The DoD provides “substantial” deferred and noncash benefits, the GAO notes, such as retirement pensions and tuition-free education, but adds that the value to service members is “difficult to determine.” The DoD also recruits with a package of incentives, including multi-year retention bonuses.

In general, the GAO found, the DoD applies several “effective human capital management” principles. For instance, it relies on clearly defined criteria on when to use incentives (such as rules-based pay plans). It also identifies and evaluates unique staffing situations. For example, to attract physicians and dentists in “critically short wartime specialties,” it offers a Critical Wartime Skills Accession Bonus.    

However, the report says, the DoD does not consistently collect information that could help inform its recruitment/retention decisions. At the time of the study, the DoD had not identified replacement costs for physicians or dentists as it does, for instance, with nuclear propulsion personnel. Nor did it gather current and historical retention information. Specifically, the GAO report says, Navy and Air Force officials said they don’t have readily available information to determine the percentage of those who accepted a retention bonus. Conversely, Army officials don’t have a framework in place that uses retention information to determine the effectiveness of retention bonuses (as do the Navy, Marine Corps, and Air Force).

Extending Service Obligations

The DoD is considering extending service obligations for students receiving DoD-funded assistance for physician or dentist education. Students in the DoD scholarship program have a 2-year minimum service obligation, with 6months of active-duty service obligations for each 6 months of benefits received. Medical students attending the Uniformed Services University of the Health Sciences (USUHS), have a 7-year active-duty service obligation.

The GAO held 8 focus groups with students and found 68% of USUHS students and 46% of scholarship students would be willing to accept 1 more year of obligation (although only 34% and 16%, respectively, would agree to 2). The participants expressed concern that longer service obligations would delay their eligibility for retention bonuses—resulting in a reduction of cash compensation over the course of a career. However, 80% and 63%, respectively, would accept an additional year of service obligation if accompanied by additional cash incentives.

Further, the GAO notes, longer obligations could have “unintended consequences.” For example, students might decide to separate and train in a civilian program after 1 or more tours as general medical officers to complete their active duty service obligation, decline further medical training and specialization via a military fellowship program, or separate from the military sooner than planned.

Potential Reductions in Health Care Force

The DoD, according to the report, also is considering reducing the overall number of active-duty physicians, including “targeted reductions” to certain specialties, raising concerns among participants in all 8 focus groups.

Given that the DoD spends millions of dollars annually to train medical and dental students and that almost half of the special pay budget is dedicated to retaining them once they’re fully trained, consistently collecting information to help inform investment decisions is “critical to ensuring the efficiency of these significant resources,” the GAO says. Collecting such information, the GAO says, and using it, would help inform its decision making. For instance, such information would help officials decide whether it would be more cost effective to focus on retaining medical personnel rather than training new staff.

Retaining “top talent,” the DoD says, is “essential to sustaining mission readiness that is adaptable and responsive.” The GAO report cites a 2012 study that found compensation for military physicians had “a large impact on the decision to remain in the military in the first unobligated year of service and just a small impact on retention in the years afterward.” 

DoD officials told the GAO that budget considerations and statutory limitations hinder their ability to change the rate of special and incentive pays. The GAO calls these “valid considerations” but suggests that collecting information on replacement costs, retention, and civilian wages would allow DoD departments to “provide greater stewardship of available funding by ensuring its efficient application.” It may be, the GAO says, that retaining fully trained physicians within the DoD is “highly economical.”. Most important, using such data to inform investment decisions will allow the DoD to “efficiently and effectively meet its mission of providing health care during times of war and peace.”

In response to the GAO findings, DoD officials have a group working on a plan to recruit and retain critical specialties, which will be released by June 2020. They also concurred with other GAO recommendations, saying changes will be made within 2 years.

Groceries, maybe a new shirt, and now some veterans can fit in some shopping at their next health care visit. In a pilot project, the US Department of Veterans Affairs (VA) is partnering with Walmart to offer veterans easy access to health care at 5 sites.

The VA-led ATLAS (Accessing telehealth through local area stations) program is part of the VA Anywhere to Anywhere telehealth initiative, which aims to provide care to veterans no matter where they live. Other telehealth pilot sites are in Wisconsin, Michigan, and Iowa. In addition to Walmart, ATLAS sites are located at American Legion posts and Veterans of Foreign Wars (VFW) posts.

The local VA facility associated with the ATLAS site determines which clinical services the site offers. The health care services do not require hands-on exams. Clinical services may include, for instance, primary care, mental health counseling, clinical pharmacy, nutrition services, and social work. On-site attendants provide information, help the veterans get started, troubleshoot technical issues, and clean the space between appointments. Walmart donated equipment and space, where veterans can meet with a VA provider in a private room via video technology.

Last year, nearly 500,000 veterans logged > 1.3 million VA video telehealth encounters. It is the “way of the future,” says VA Secretary Robert Wilkie. “Veterans need the expansion of choice, and this partnership is vital to affording them convenient access to VA health care services where they live.”

Daryl Risinger, Chief Growth Officer for Walmart US Health and Wellness, is a veteran of the Air Force, and has a son and son-in-law serving. He says, “I know firsthand how important support and access is for our military, especially when it comes to health care. …This is another way we are helping our communities live better.”

For a veteran to attend an appointment at an ATLAS site, the site must be associated with the VA Medical Center where the veteran is enrolled. Family members who receive care through the VA can also visit ATLAS sites for select appointments.

Groceries, maybe a new shirt, and now some veterans can fit in some shopping at their next health care visit. In a pilot project, the US Department of Veterans Affairs (VA) is partnering with Walmart to offer veterans easy access to health care at 5 sites.

The VA-led ATLAS (Accessing telehealth through local area stations) program is part of the VA Anywhere to Anywhere telehealth initiative, which aims to provide care to veterans no matter where they live. Other telehealth pilot sites are in Wisconsin, Michigan, and Iowa. In addition to Walmart, ATLAS sites are located at American Legion posts and Veterans of Foreign Wars (VFW) posts.

The local VA facility associated with the ATLAS site determines which clinical services the site offers. The health care services do not require hands-on exams. Clinical services may include, for instance, primary care, mental health counseling, clinical pharmacy, nutrition services, and social work. On-site attendants provide information, help the veterans get started, troubleshoot technical issues, and clean the space between appointments. Walmart donated equipment and space, where veterans can meet with a VA provider in a private room via video technology.

Last year, nearly 500,000 veterans logged > 1.3 million VA video telehealth encounters. It is the “way of the future,” says VA Secretary Robert Wilkie. “Veterans need the expansion of choice, and this partnership is vital to affording them convenient access to VA health care services where they live.”

Daryl Risinger, Chief Growth Officer for Walmart US Health and Wellness, is a veteran of the Air Force, and has a son and son-in-law serving. He says, “I know firsthand how important support and access is for our military, especially when it comes to health care. …This is another way we are helping our communities live better.”

For a veteran to attend an appointment at an ATLAS site, the site must be associated with the VA Medical Center where the veteran is enrolled. Family members who receive care through the VA can also visit ATLAS sites for select appointments.

Groceries, maybe a new shirt, and now some veterans can fit in some shopping at their next health care visit. In a pilot project, the US Department of Veterans Affairs (VA) is partnering with Walmart to offer veterans easy access to health care at 5 sites.

The VA-led ATLAS (Accessing telehealth through local area stations) program is part of the VA Anywhere to Anywhere telehealth initiative, which aims to provide care to veterans no matter where they live. Other telehealth pilot sites are in Wisconsin, Michigan, and Iowa. In addition to Walmart, ATLAS sites are located at American Legion posts and Veterans of Foreign Wars (VFW) posts.

The local VA facility associated with the ATLAS site determines which clinical services the site offers. The health care services do not require hands-on exams. Clinical services may include, for instance, primary care, mental health counseling, clinical pharmacy, nutrition services, and social work. On-site attendants provide information, help the veterans get started, troubleshoot technical issues, and clean the space between appointments. Walmart donated equipment and space, where veterans can meet with a VA provider in a private room via video technology.

Last year, nearly 500,000 veterans logged > 1.3 million VA video telehealth encounters. It is the “way of the future,” says VA Secretary Robert Wilkie. “Veterans need the expansion of choice, and this partnership is vital to affording them convenient access to VA health care services where they live.”

Daryl Risinger, Chief Growth Officer for Walmart US Health and Wellness, is a veteran of the Air Force, and has a son and son-in-law serving. He says, “I know firsthand how important support and access is for our military, especially when it comes to health care. …This is another way we are helping our communities live better.”

For a veteran to attend an appointment at an ATLAS site, the site must be associated with the VA Medical Center where the veteran is enrolled. Family members who receive care through the VA can also visit ATLAS sites for select appointments.

The opioid crisis has hit the American Indian and Alaska Native (AI/AN) communities particularly hard, and “[i]nfants born withdrawing from opioids represent one of the most heartbreaking aspects,” says US Department of Health and Human Services Secretary Alex Azar.

Intrauterine exposure to opioids can induce symptoms that may result in spontaneous abortion, placental injury, and reduced nutrients for the fetus. Moreover, as many as 55% to 94% of infants prenatally exposed to opioids develop neonatal opioid withdrawal syndrome (NOWS), which can vary in severity from mild to life-threatening.

AI/AN women face significant barriers to obtaining appropriate care for substance use disorders, which may delay early interventions for the newborn’s health, said Shaquita Bell, MD, FAAP, chair of the American Academy of Pediatrics (AAP) Committee on Native American Child Health. The Indian Health Service (IHS) and the AAP have recently released clinical recommendations on NOWS for IHS, tribal, and urban Indian organization health care facilities.

The recommendations describe supportive, culturally appropriate standards of care for screening, diagnosing, and treating pregnant mothers and infants affected by prenatal opioid exposure. Management of NOWS begins with identifying women at risk, says the multidisciplinary panel responsible for the recommendations. Among other things, the experts advise screening a pregnant woman at the initial presentation for risk of substance use disorder, as well as for prescription opioid use for treatment of pain, and other risk factors for NOWS.

The panel notes that early application of nonpharmacologic treatment and support can reduce the need for pharmacologic treatment and transfer. Patient education should be a “key component of every prenatal care visit,” the panel says, provided in a nonjudgmental, culturally competent way to increase engagement, involving the partner and other family members if possible. Discussion topics may include the physical effects of continued substance use on both the woman and her infant, but also may include social and legal consequences of continued use.

The recommendations are also a companion guide to clinical recommendations for improving care of AI/AN pregnant women and women of childbearing age with opioid use disorder, which were announced by IHS and the American College of Obstetricians and Gynecologists in March 2019.

The opioid crisis has hit the American Indian and Alaska Native (AI/AN) communities particularly hard, and “[i]nfants born withdrawing from opioids represent one of the most heartbreaking aspects,” says US Department of Health and Human Services Secretary Alex Azar.

Intrauterine exposure to opioids can induce symptoms that may result in spontaneous abortion, placental injury, and reduced nutrients for the fetus. Moreover, as many as 55% to 94% of infants prenatally exposed to opioids develop neonatal opioid withdrawal syndrome (NOWS), which can vary in severity from mild to life-threatening.

AI/AN women face significant barriers to obtaining appropriate care for substance use disorders, which may delay early interventions for the newborn’s health, said Shaquita Bell, MD, FAAP, chair of the American Academy of Pediatrics (AAP) Committee on Native American Child Health. The Indian Health Service (IHS) and the AAP have recently released clinical recommendations on NOWS for IHS, tribal, and urban Indian organization health care facilities.

The recommendations describe supportive, culturally appropriate standards of care for screening, diagnosing, and treating pregnant mothers and infants affected by prenatal opioid exposure. Management of NOWS begins with identifying women at risk, says the multidisciplinary panel responsible for the recommendations. Among other things, the experts advise screening a pregnant woman at the initial presentation for risk of substance use disorder, as well as for prescription opioid use for treatment of pain, and other risk factors for NOWS.

The panel notes that early application of nonpharmacologic treatment and support can reduce the need for pharmacologic treatment and transfer. Patient education should be a “key component of every prenatal care visit,” the panel says, provided in a nonjudgmental, culturally competent way to increase engagement, involving the partner and other family members if possible. Discussion topics may include the physical effects of continued substance use on both the woman and her infant, but also may include social and legal consequences of continued use.

The recommendations are also a companion guide to clinical recommendations for improving care of AI/AN pregnant women and women of childbearing age with opioid use disorder, which were announced by IHS and the American College of Obstetricians and Gynecologists in March 2019.

The opioid crisis has hit the American Indian and Alaska Native (AI/AN) communities particularly hard, and “[i]nfants born withdrawing from opioids represent one of the most heartbreaking aspects,” says US Department of Health and Human Services Secretary Alex Azar.

Intrauterine exposure to opioids can induce symptoms that may result in spontaneous abortion, placental injury, and reduced nutrients for the fetus. Moreover, as many as 55% to 94% of infants prenatally exposed to opioids develop neonatal opioid withdrawal syndrome (NOWS), which can vary in severity from mild to life-threatening.

AI/AN women face significant barriers to obtaining appropriate care for substance use disorders, which may delay early interventions for the newborn’s health, said Shaquita Bell, MD, FAAP, chair of the American Academy of Pediatrics (AAP) Committee on Native American Child Health. The Indian Health Service (IHS) and the AAP have recently released clinical recommendations on NOWS for IHS, tribal, and urban Indian organization health care facilities.

The recommendations describe supportive, culturally appropriate standards of care for screening, diagnosing, and treating pregnant mothers and infants affected by prenatal opioid exposure. Management of NOWS begins with identifying women at risk, says the multidisciplinary panel responsible for the recommendations. Among other things, the experts advise screening a pregnant woman at the initial presentation for risk of substance use disorder, as well as for prescription opioid use for treatment of pain, and other risk factors for NOWS.

The panel notes that early application of nonpharmacologic treatment and support can reduce the need for pharmacologic treatment and transfer. Patient education should be a “key component of every prenatal care visit,” the panel says, provided in a nonjudgmental, culturally competent way to increase engagement, involving the partner and other family members if possible. Discussion topics may include the physical effects of continued substance use on both the woman and her infant, but also may include social and legal consequences of continued use.

The recommendations are also a companion guide to clinical recommendations for improving care of AI/AN pregnant women and women of childbearing age with opioid use disorder, which were announced by IHS and the American College of Obstetricians and Gynecologists in March 2019.

A single subanesthetic dose of ketamine infusion can often relieve depressive symptoms within hours when conventional antidepressants have not worked. But off-label use of IV ketamine—especially given its history of abuse—has raised concerns about adverse effects (AEs).

However, a single low-dose infusion was “relatively free of side effects” for patients with treatment-resistant depression, according to researchers from the National Institute of Mental Health. They compiled data on AEs from 163 patients with major depressive disorder or bipolar disorder and 25 healthy controls from 5 placebo-controlled crossover clinical trials and 1 open-label study conducted at the National Institutes of Health (NIH) Clinical Center over 13 years.

The assessments included active and structured surveillance of emerging AEs in an inpatient setting and used both a rating scale and clinician interviews.

The most common effect was feeling “strange or loopy,” the researchers say. Most AEs peaked within an hour of administration and were gone within 2 hours. The researchers did not see any serious, drug-related AEs or increased ketamine cravings.

The researchers evaluated 120 possible AEs. Of the 44 that occurred in at least 5% of participants over all trials, 33 were significantly associated with treatment. At least half the participants reported the “spacey” feeling, visual distortions, difficulty speaking, and numbness. No AEs lasted beyond 4 hours.

The study did not address AEs associated with repeated infusions or long-term use, but during the approximately 3-month follow-up period, the researchers found no drug-related serious AEs, propensity for recreational use, or significant cognitive or memory deficits.

A single subanesthetic dose of ketamine infusion can often relieve depressive symptoms within hours when conventional antidepressants have not worked. But off-label use of IV ketamine—especially given its history of abuse—has raised concerns about adverse effects (AEs).

However, a single low-dose infusion was “relatively free of side effects” for patients with treatment-resistant depression, according to researchers from the National Institute of Mental Health. They compiled data on AEs from 163 patients with major depressive disorder or bipolar disorder and 25 healthy controls from 5 placebo-controlled crossover clinical trials and 1 open-label study conducted at the National Institutes of Health (NIH) Clinical Center over 13 years.

The assessments included active and structured surveillance of emerging AEs in an inpatient setting and used both a rating scale and clinician interviews.

The most common effect was feeling “strange or loopy,” the researchers say. Most AEs peaked within an hour of administration and were gone within 2 hours. The researchers did not see any serious, drug-related AEs or increased ketamine cravings.

The researchers evaluated 120 possible AEs. Of the 44 that occurred in at least 5% of participants over all trials, 33 were significantly associated with treatment. At least half the participants reported the “spacey” feeling, visual distortions, difficulty speaking, and numbness. No AEs lasted beyond 4 hours.

The study did not address AEs associated with repeated infusions or long-term use, but during the approximately 3-month follow-up period, the researchers found no drug-related serious AEs, propensity for recreational use, or significant cognitive or memory deficits.

A single subanesthetic dose of ketamine infusion can often relieve depressive symptoms within hours when conventional antidepressants have not worked. But off-label use of IV ketamine—especially given its history of abuse—has raised concerns about adverse effects (AEs).

However, a single low-dose infusion was “relatively free of side effects” for patients with treatment-resistant depression, according to researchers from the National Institute of Mental Health. They compiled data on AEs from 163 patients with major depressive disorder or bipolar disorder and 25 healthy controls from 5 placebo-controlled crossover clinical trials and 1 open-label study conducted at the National Institutes of Health (NIH) Clinical Center over 13 years.

The assessments included active and structured surveillance of emerging AEs in an inpatient setting and used both a rating scale and clinician interviews.

The most common effect was feeling “strange or loopy,” the researchers say. Most AEs peaked within an hour of administration and were gone within 2 hours. The researchers did not see any serious, drug-related AEs or increased ketamine cravings.

The researchers evaluated 120 possible AEs. Of the 44 that occurred in at least 5% of participants over all trials, 33 were significantly associated with treatment. At least half the participants reported the “spacey” feeling, visual distortions, difficulty speaking, and numbness. No AEs lasted beyond 4 hours.

The study did not address AEs associated with repeated infusions or long-term use, but during the approximately 3-month follow-up period, the researchers found no drug-related serious AEs, propensity for recreational use, or significant cognitive or memory deficits.

Adverse childhood experiences (ACEs), such as violence, abuse, and substance abuse in the household, have dramatic and lasting effects on adult health, according to a first-ever CDC analysis of data from 25 states. Toxic stress from ACEs can “derail optimal health and development by altering gene expression, brain connectivity and function, immune system function, and organ function,” as well as compromising health coping strategies, the researchers note.

In their study, ACEs were linked to at least 5 of the 10 leading causes of death. But they also found that preventing ACEs can have equally dramatic effects: for example, potentially reducing the number of cases of coronary artery disease (CAD) by 12.6%.

The researchers analyzed data from > 144,000 adults who responded to questions in the Behavior Risk Factor Surveillance System from 2015 through 2017. ACEs are common, the researchers say: 61% of adults had at least 1, and 1 in 6 adults experienced ≥ 4types of ACE. Women and several racial/ethnic minority groups had a greater risk. People who experienced ≥ 4types of ACE accounted for a “disproportionate share of the preventable fraction” of each of the 14 negative health and socioeconomic outcomes measured, including cancer, respiratory disease, diabetes, and suicide.

Extrapolating from the 25 states to national numbers, the researchers say preventing ACEs could result in 1.9 million fewer CADs, 2.5 million fewer overweight or obese adults, and 21 million fewer adults with depression.

The CDC has recommendations for rescuing potentially millions of adults from the lingering effects of childhood trauma: early intervention. The researchers cite, for instance, studies that have found preschool enrichment and early childhood home visitation programs reduce the rates of child abuse and neglect by 48% to 52%.  

Moreover, health care providers can “anticipate and recognize” current risk for ACEs in children and history of ACEs in adults. They can refer patients to effective services and support, and link adults to family-centered treatment that includes substance abuse treatment and parenting interventions. The CDC also recommends that employers can adopt and support family-friendly policies, such as paid family leave and flexible work schedules. And states and communities can, among other initiatives, improve access to high-quality child care by expanding eligibility, activities offered, and family involvement.

Adverse childhood experiences (ACEs), such as violence, abuse, and substance abuse in the household, have dramatic and lasting effects on adult health, according to a first-ever CDC analysis of data from 25 states. Toxic stress from ACEs can “derail optimal health and development by altering gene expression, brain connectivity and function, immune system function, and organ function,” as well as compromising health coping strategies, the researchers note.

In their study, ACEs were linked to at least 5 of the 10 leading causes of death. But they also found that preventing ACEs can have equally dramatic effects: for example, potentially reducing the number of cases of coronary artery disease (CAD) by 12.6%.

The researchers analyzed data from > 144,000 adults who responded to questions in the Behavior Risk Factor Surveillance System from 2015 through 2017. ACEs are common, the researchers say: 61% of adults had at least 1, and 1 in 6 adults experienced ≥ 4types of ACE. Women and several racial/ethnic minority groups had a greater risk. People who experienced ≥ 4types of ACE accounted for a “disproportionate share of the preventable fraction” of each of the 14 negative health and socioeconomic outcomes measured, including cancer, respiratory disease, diabetes, and suicide.

Extrapolating from the 25 states to national numbers, the researchers say preventing ACEs could result in 1.9 million fewer CADs, 2.5 million fewer overweight or obese adults, and 21 million fewer adults with depression.

The CDC has recommendations for rescuing potentially millions of adults from the lingering effects of childhood trauma: early intervention. The researchers cite, for instance, studies that have found preschool enrichment and early childhood home visitation programs reduce the rates of child abuse and neglect by 48% to 52%.  

Moreover, health care providers can “anticipate and recognize” current risk for ACEs in children and history of ACEs in adults. They can refer patients to effective services and support, and link adults to family-centered treatment that includes substance abuse treatment and parenting interventions. The CDC also recommends that employers can adopt and support family-friendly policies, such as paid family leave and flexible work schedules. And states and communities can, among other initiatives, improve access to high-quality child care by expanding eligibility, activities offered, and family involvement.

Adverse childhood experiences (ACEs), such as violence, abuse, and substance abuse in the household, have dramatic and lasting effects on adult health, according to a first-ever CDC analysis of data from 25 states. Toxic stress from ACEs can “derail optimal health and development by altering gene expression, brain connectivity and function, immune system function, and organ function,” as well as compromising health coping strategies, the researchers note.

In their study, ACEs were linked to at least 5 of the 10 leading causes of death. But they also found that preventing ACEs can have equally dramatic effects: for example, potentially reducing the number of cases of coronary artery disease (CAD) by 12.6%.

The researchers analyzed data from > 144,000 adults who responded to questions in the Behavior Risk Factor Surveillance System from 2015 through 2017. ACEs are common, the researchers say: 61% of adults had at least 1, and 1 in 6 adults experienced ≥ 4types of ACE. Women and several racial/ethnic minority groups had a greater risk. People who experienced ≥ 4types of ACE accounted for a “disproportionate share of the preventable fraction” of each of the 14 negative health and socioeconomic outcomes measured, including cancer, respiratory disease, diabetes, and suicide.

Extrapolating from the 25 states to national numbers, the researchers say preventing ACEs could result in 1.9 million fewer CADs, 2.5 million fewer overweight or obese adults, and 21 million fewer adults with depression.

The CDC has recommendations for rescuing potentially millions of adults from the lingering effects of childhood trauma: early intervention. The researchers cite, for instance, studies that have found preschool enrichment and early childhood home visitation programs reduce the rates of child abuse and neglect by 48% to 52%.  

Moreover, health care providers can “anticipate and recognize” current risk for ACEs in children and history of ACEs in adults. They can refer patients to effective services and support, and link adults to family-centered treatment that includes substance abuse treatment and parenting interventions. The CDC also recommends that employers can adopt and support family-friendly policies, such as paid family leave and flexible work schedules. And states and communities can, among other initiatives, improve access to high-quality child care by expanding eligibility, activities offered, and family involvement.

More than 6,000 veterans die by suicide every year—more than the total number of combat deaths in Iraq and Afghanistan combined.

In recently released Improving the Quality of Mental Health Care for Veterans: Lessons from Rand Research, RAND researchers say the overwhelming message from 10 years of research, including a comprehensive evaluation of the US Department of Veterans Affairs (VA) mental health system and a congressionally mandated analysis of VA health care vs other health care systems, is, We could do more to save the lives of veterans.

RAND research has found that the VA outperforms other health systems on most measures of health care, including mental health care. The report also acknowledges that the VA and US Department of Defense (DoD) have both invested heavily in public-awareness campaigns and efforts to better identify those at risk of suicide, but “the research shows it’s not enough.”

Improving the Quality of Mental Health Care for Veterans has 6 recommendations:

1. Increase the number of highly trained mental health providers within the VA and in private practice. The VA has continued to hire more providers, integrate mental health into primary care settings, and expand the use of telemental health. However, quality varies “considerably” across facilities, the report says, with best practices not universally delivered.

Moreover, fewer than half of all veterans get their care at the VA. Most use local hospitals and health clinics. RAND research has shown those community health providers are often not prepared to address the needs of veterans. Few community providers even ask their patients if they ever served, the researchers say. Recently, the report notes, the VA has taken steps to help private providers serve veterans more effectively, by providing toolkits, training programs, and other resources.

2. Reduce barriers to care by educating veterans about treatment and expanding access to high-quality treatment. The report notes that patients may believe that admitting a mental health problem is a “sign of weakness,” or that they may be skeptical about the effectiveness of treatment.

3. Adopt and enforce appropriate, consistent quality-of-care standards by creating incentives and disincentives that support best practices.

4. Improve monitoring and performance measurement for VA community care programs. According to the report, “Little is known about the timeliness or quality of care that veterans receive through these programs as mandated.”

5. Continue to develop and test new models of care, particularly as new interventions become available and show promise. The report lists examples of evidence-based practices that have proven effective, including narrative exposure therapy for PTSD, mindfulness-based therapies for depression, and behavioral couples therapy for alcohol use disorder.

6. Strengthen the evidence base for understanding the effectiveness of complementary and alternative therapies for mental health conditions.

The research also supports the concept that policies that change the environment and attitudes can reduce and prevent suicides. For instance, a RAND essay advocates policies that promote better sleep and address a “culture of stress.” Policies that promote safe gun storage, encourage health care providers to ask their patients about guns, and remove guns from those at highest risk could help: Nearly 70% of veterans who die by suicide use a firearm. And because sexual assault within the military is a major risk factor for suicide among female veterans, a zero-tolerance policy on sexual assault could make a difference for thousands of service members.

In 2011, RAND researchers published The War Within, a comprehensive look at suicide in the military. One of the driving forces behind the research was senior behavioral scientist Terri Tanielian, whose father, a veteran, committed suicide. Evidence-based treatment not only improves recovery rates but saves money, Tanielian says. In 2008, she and other researchers estimated the 2-year societal costs of postdeployment mental health problems among veterans who had served since the September 11, 2001, attacks at approximately $6.2 billion (in 2007 dollars). If all veterans received high-quality care for depression, posttraumatic stress disorder, and other conditions, those costs could be reduced by $1.2 billion, they found.

The RAND report emphasizes that suicide and mental health issues are a national problem, not just a VA problem. “We can’t think about addressing these issues in the veteran population without thinking about them for the larger American population,” Tanielian says. “We can’t keep pointing a finger at the DoD and the VA. We have to think about this as the national public health crisis that it is.”

More than 6,000 veterans die by suicide every year—more than the total number of combat deaths in Iraq and Afghanistan combined.

In recently released Improving the Quality of Mental Health Care for Veterans: Lessons from Rand Research, RAND researchers say the overwhelming message from 10 years of research, including a comprehensive evaluation of the US Department of Veterans Affairs (VA) mental health system and a congressionally mandated analysis of VA health care vs other health care systems, is, We could do more to save the lives of veterans.

RAND research has found that the VA outperforms other health systems on most measures of health care, including mental health care. The report also acknowledges that the VA and US Department of Defense (DoD) have both invested heavily in public-awareness campaigns and efforts to better identify those at risk of suicide, but “the research shows it’s not enough.”

Improving the Quality of Mental Health Care for Veterans has 6 recommendations:

1. Increase the number of highly trained mental health providers within the VA and in private practice. The VA has continued to hire more providers, integrate mental health into primary care settings, and expand the use of telemental health. However, quality varies “considerably” across facilities, the report says, with best practices not universally delivered.

Moreover, fewer than half of all veterans get their care at the VA. Most use local hospitals and health clinics. RAND research has shown those community health providers are often not prepared to address the needs of veterans. Few community providers even ask their patients if they ever served, the researchers say. Recently, the report notes, the VA has taken steps to help private providers serve veterans more effectively, by providing toolkits, training programs, and other resources.

2. Reduce barriers to care by educating veterans about treatment and expanding access to high-quality treatment. The report notes that patients may believe that admitting a mental health problem is a “sign of weakness,” or that they may be skeptical about the effectiveness of treatment.

3. Adopt and enforce appropriate, consistent quality-of-care standards by creating incentives and disincentives that support best practices.

4. Improve monitoring and performance measurement for VA community care programs. According to the report, “Little is known about the timeliness or quality of care that veterans receive through these programs as mandated.”

5. Continue to develop and test new models of care, particularly as new interventions become available and show promise. The report lists examples of evidence-based practices that have proven effective, including narrative exposure therapy for PTSD, mindfulness-based therapies for depression, and behavioral couples therapy for alcohol use disorder.

6. Strengthen the evidence base for understanding the effectiveness of complementary and alternative therapies for mental health conditions.

The research also supports the concept that policies that change the environment and attitudes can reduce and prevent suicides. For instance, a RAND essay advocates policies that promote better sleep and address a “culture of stress.” Policies that promote safe gun storage, encourage health care providers to ask their patients about guns, and remove guns from those at highest risk could help: Nearly 70% of veterans who die by suicide use a firearm. And because sexual assault within the military is a major risk factor for suicide among female veterans, a zero-tolerance policy on sexual assault could make a difference for thousands of service members.

In 2011, RAND researchers published The War Within, a comprehensive look at suicide in the military. One of the driving forces behind the research was senior behavioral scientist Terri Tanielian, whose father, a veteran, committed suicide. Evidence-based treatment not only improves recovery rates but saves money, Tanielian says. In 2008, she and other researchers estimated the 2-year societal costs of postdeployment mental health problems among veterans who had served since the September 11, 2001, attacks at approximately $6.2 billion (in 2007 dollars). If all veterans received high-quality care for depression, posttraumatic stress disorder, and other conditions, those costs could be reduced by $1.2 billion, they found.

The RAND report emphasizes that suicide and mental health issues are a national problem, not just a VA problem. “We can’t think about addressing these issues in the veteran population without thinking about them for the larger American population,” Tanielian says. “We can’t keep pointing a finger at the DoD and the VA. We have to think about this as the national public health crisis that it is.”

More than 6,000 veterans die by suicide every year—more than the total number of combat deaths in Iraq and Afghanistan combined.

In recently released Improving the Quality of Mental Health Care for Veterans: Lessons from Rand Research, RAND researchers say the overwhelming message from 10 years of research, including a comprehensive evaluation of the US Department of Veterans Affairs (VA) mental health system and a congressionally mandated analysis of VA health care vs other health care systems, is, We could do more to save the lives of veterans.

RAND research has found that the VA outperforms other health systems on most measures of health care, including mental health care. The report also acknowledges that the VA and US Department of Defense (DoD) have both invested heavily in public-awareness campaigns and efforts to better identify those at risk of suicide, but “the research shows it’s not enough.”

Improving the Quality of Mental Health Care for Veterans has 6 recommendations:

1. Increase the number of highly trained mental health providers within the VA and in private practice. The VA has continued to hire more providers, integrate mental health into primary care settings, and expand the use of telemental health. However, quality varies “considerably” across facilities, the report says, with best practices not universally delivered.

Moreover, fewer than half of all veterans get their care at the VA. Most use local hospitals and health clinics. RAND research has shown those community health providers are often not prepared to address the needs of veterans. Few community providers even ask their patients if they ever served, the researchers say. Recently, the report notes, the VA has taken steps to help private providers serve veterans more effectively, by providing toolkits, training programs, and other resources.

2. Reduce barriers to care by educating veterans about treatment and expanding access to high-quality treatment. The report notes that patients may believe that admitting a mental health problem is a “sign of weakness,” or that they may be skeptical about the effectiveness of treatment.

3. Adopt and enforce appropriate, consistent quality-of-care standards by creating incentives and disincentives that support best practices.

4. Improve monitoring and performance measurement for VA community care programs. According to the report, “Little is known about the timeliness or quality of care that veterans receive through these programs as mandated.”

5. Continue to develop and test new models of care, particularly as new interventions become available and show promise. The report lists examples of evidence-based practices that have proven effective, including narrative exposure therapy for PTSD, mindfulness-based therapies for depression, and behavioral couples therapy for alcohol use disorder.

6. Strengthen the evidence base for understanding the effectiveness of complementary and alternative therapies for mental health conditions.

The research also supports the concept that policies that change the environment and attitudes can reduce and prevent suicides. For instance, a RAND essay advocates policies that promote better sleep and address a “culture of stress.” Policies that promote safe gun storage, encourage health care providers to ask their patients about guns, and remove guns from those at highest risk could help: Nearly 70% of veterans who die by suicide use a firearm. And because sexual assault within the military is a major risk factor for suicide among female veterans, a zero-tolerance policy on sexual assault could make a difference for thousands of service members.

In 2011, RAND researchers published The War Within, a comprehensive look at suicide in the military. One of the driving forces behind the research was senior behavioral scientist Terri Tanielian, whose father, a veteran, committed suicide. Evidence-based treatment not only improves recovery rates but saves money, Tanielian says. In 2008, she and other researchers estimated the 2-year societal costs of postdeployment mental health problems among veterans who had served since the September 11, 2001, attacks at approximately $6.2 billion (in 2007 dollars). If all veterans received high-quality care for depression, posttraumatic stress disorder, and other conditions, those costs could be reduced by $1.2 billion, they found.

The RAND report emphasizes that suicide and mental health issues are a national problem, not just a VA problem. “We can’t think about addressing these issues in the veteran population without thinking about them for the larger American population,” Tanielian says. “We can’t keep pointing a finger at the DoD and the VA. We have to think about this as the national public health crisis that it is.”

Veterans have some of the highest rates of overweight and obesity in the country: 78%, compared with 35% of American adults overall. So bariatric surgery can be a boon to many veterans. But while it improves health for those with severe obesity, does it also translate into lower health care costs?

Researchers from the Durham VA Medical Center (VAMC) say no. In a study funded by VA Health Services Research and Development and the National Institute on Drug Abuse, they analyzed data on 2,498 veterans who underwent bariatric surgery between January 2000 and September 2011, and 7,456 patients (also severely obese) who did not have surgery. The researchers compared the 2 groups’ outpatient, inpatient, and pharmacy expenditures from 3 years before surgery to 10 years after surgery.

Mean total expenditures for the surgery cohort were $5,093 at 7 to 12 months before surgery, $1,400 higher than costs for the nonsurgery group. The numbers rose to $7,448 at 6 months after surgery—$3,000 higher than in the nonsurgery group. Postsurgical expenditures dropped to $6,692 at 5 years, then gradually increased to $8,495 at 10 years. Outpatient pharmacy expenditures were significantly lower among the surgery cohort throughout the follow-up, but the cost reductions were offset by higher inpatient and outpatient expenditures.

Total expenditures were higher in the surgery cohort than the nonsurgery cohort during the 3 years before and the first 2 years after surgery, but the numbers of the 2 groups converged 5 to 10 years after surgery.

The researchers offer some possible reasons that the surgery did not lower health care costs. For instance, despite better overall health, patients may still need to be treated for short-term complications of bariatric surgery, such as nausea, anemia, and vitamin deficiencies. The surgery patients also may have needed additional procedures, such as removal of excess skin. They might have become eligible for knee or hip replacement after having lost weight.

Finally, the researchers point out, many conditions linked to obesity, such as diabetes, do not necessarily go away when the patient loses weight.

The study authors noted that “few health care treatments are required to be cost saving or even cost-effective to be widely available, so requiring cost savings of bariatric surgery imposes an unfair standard.”

Veterans have some of the highest rates of overweight and obesity in the country: 78%, compared with 35% of American adults overall. So bariatric surgery can be a boon to many veterans. But while it improves health for those with severe obesity, does it also translate into lower health care costs?

Researchers from the Durham VA Medical Center (VAMC) say no. In a study funded by VA Health Services Research and Development and the National Institute on Drug Abuse, they analyzed data on 2,498 veterans who underwent bariatric surgery between January 2000 and September 2011, and 7,456 patients (also severely obese) who did not have surgery. The researchers compared the 2 groups’ outpatient, inpatient, and pharmacy expenditures from 3 years before surgery to 10 years after surgery.

Mean total expenditures for the surgery cohort were $5,093 at 7 to 12 months before surgery, $1,400 higher than costs for the nonsurgery group. The numbers rose to $7,448 at 6 months after surgery—$3,000 higher than in the nonsurgery group. Postsurgical expenditures dropped to $6,692 at 5 years, then gradually increased to $8,495 at 10 years. Outpatient pharmacy expenditures were significantly lower among the surgery cohort throughout the follow-up, but the cost reductions were offset by higher inpatient and outpatient expenditures.

Total expenditures were higher in the surgery cohort than the nonsurgery cohort during the 3 years before and the first 2 years after surgery, but the numbers of the 2 groups converged 5 to 10 years after surgery.

The researchers offer some possible reasons that the surgery did not lower health care costs. For instance, despite better overall health, patients may still need to be treated for short-term complications of bariatric surgery, such as nausea, anemia, and vitamin deficiencies. The surgery patients also may have needed additional procedures, such as removal of excess skin. They might have become eligible for knee or hip replacement after having lost weight.

Finally, the researchers point out, many conditions linked to obesity, such as diabetes, do not necessarily go away when the patient loses weight.

The study authors noted that “few health care treatments are required to be cost saving or even cost-effective to be widely available, so requiring cost savings of bariatric surgery imposes an unfair standard.”

Veterans have some of the highest rates of overweight and obesity in the country: 78%, compared with 35% of American adults overall. So bariatric surgery can be a boon to many veterans. But while it improves health for those with severe obesity, does it also translate into lower health care costs?

Researchers from the Durham VA Medical Center (VAMC) say no. In a study funded by VA Health Services Research and Development and the National Institute on Drug Abuse, they analyzed data on 2,498 veterans who underwent bariatric surgery between January 2000 and September 2011, and 7,456 patients (also severely obese) who did not have surgery. The researchers compared the 2 groups’ outpatient, inpatient, and pharmacy expenditures from 3 years before surgery to 10 years after surgery.

Mean total expenditures for the surgery cohort were $5,093 at 7 to 12 months before surgery, $1,400 higher than costs for the nonsurgery group. The numbers rose to $7,448 at 6 months after surgery—$3,000 higher than in the nonsurgery group. Postsurgical expenditures dropped to $6,692 at 5 years, then gradually increased to $8,495 at 10 years. Outpatient pharmacy expenditures were significantly lower among the surgery cohort throughout the follow-up, but the cost reductions were offset by higher inpatient and outpatient expenditures.

Total expenditures were higher in the surgery cohort than the nonsurgery cohort during the 3 years before and the first 2 years after surgery, but the numbers of the 2 groups converged 5 to 10 years after surgery.

The researchers offer some possible reasons that the surgery did not lower health care costs. For instance, despite better overall health, patients may still need to be treated for short-term complications of bariatric surgery, such as nausea, anemia, and vitamin deficiencies. The surgery patients also may have needed additional procedures, such as removal of excess skin. They might have become eligible for knee or hip replacement after having lost weight.

Finally, the researchers point out, many conditions linked to obesity, such as diabetes, do not necessarily go away when the patient loses weight.

The study authors noted that “few health care treatments are required to be cost saving or even cost-effective to be widely available, so requiring cost savings of bariatric surgery imposes an unfair standard.”

Blood oxygen levels drop during sleep, but how much and when that happens is mainly hereditary? Now researchers from Brigham and Women’s Hospital and Case Western Reserve University are getting closer to finding the genetic reasons for the fluctuations, which could help people with sleep apnea and other lung illnesses.

In their study, funded by the National Heart, Lung, and Blood Institute (NHLBI), the researchers analyzed whole genome sequence data from the NHLBI’s Trans-Omics for Precision Medicine (TOPMed) program. They also incorporated results for family-based linkage analysis, which maps genes with hereditary traits to their location in the genome.

The researchers identified 57 genetic variations of DLC1, a gene consistently associated with average arterial oxyhemoglobin saturation during sleep. The variants explain almost 1% of the variability in the oxygen levels in European Americans. That is high for complex genetic phenotypes, the researchers say. Of the 57 variants, 51 influence and regulate human lung fibroblast cells.

 “This study highlights the advantage of using family data in searching for rare variants,” says James Kiley, PhD, director of the Division of Lung Diseases at NHLBI. “It showed that, when guided by family linkage data, whole genome sequence analysis can identify rare variants that signal disease risks, even with a small sample. In this case, the initial discovery was done with fewer than 500 samples.”

Blood oxygen levels drop during sleep, but how much and when that happens is mainly hereditary? Now researchers from Brigham and Women’s Hospital and Case Western Reserve University are getting closer to finding the genetic reasons for the fluctuations, which could help people with sleep apnea and other lung illnesses.

In their study, funded by the National Heart, Lung, and Blood Institute (NHLBI), the researchers analyzed whole genome sequence data from the NHLBI’s Trans-Omics for Precision Medicine (TOPMed) program. They also incorporated results for family-based linkage analysis, which maps genes with hereditary traits to their location in the genome.

The researchers identified 57 genetic variations of DLC1, a gene consistently associated with average arterial oxyhemoglobin saturation during sleep. The variants explain almost 1% of the variability in the oxygen levels in European Americans. That is high for complex genetic phenotypes, the researchers say. Of the 57 variants, 51 influence and regulate human lung fibroblast cells.

 “This study highlights the advantage of using family data in searching for rare variants,” says James Kiley, PhD, director of the Division of Lung Diseases at NHLBI. “It showed that, when guided by family linkage data, whole genome sequence analysis can identify rare variants that signal disease risks, even with a small sample. In this case, the initial discovery was done with fewer than 500 samples.”

Blood oxygen levels drop during sleep, but how much and when that happens is mainly hereditary? Now researchers from Brigham and Women’s Hospital and Case Western Reserve University are getting closer to finding the genetic reasons for the fluctuations, which could help people with sleep apnea and other lung illnesses.

In their study, funded by the National Heart, Lung, and Blood Institute (NHLBI), the researchers analyzed whole genome sequence data from the NHLBI’s Trans-Omics for Precision Medicine (TOPMed) program. They also incorporated results for family-based linkage analysis, which maps genes with hereditary traits to their location in the genome.

The researchers identified 57 genetic variations of DLC1, a gene consistently associated with average arterial oxyhemoglobin saturation during sleep. The variants explain almost 1% of the variability in the oxygen levels in European Americans. That is high for complex genetic phenotypes, the researchers say. Of the 57 variants, 51 influence and regulate human lung fibroblast cells.

 “This study highlights the advantage of using family data in searching for rare variants,” says James Kiley, PhD, director of the Division of Lung Diseases at NHLBI. “It showed that, when guided by family linkage data, whole genome sequence analysis can identify rare variants that signal disease risks, even with a small sample. In this case, the initial discovery was done with fewer than 500 samples.”

Traumatic microbleeds (TMBs) may indicate vascular injury and predict worse outcomes after even minor brain injury, according to a study at the National Institute of Neurological Disorders and Stroke.

The study involved 439 adults with head injuries treated in the emergency department. The participants had magnetic resonance imaging (MRI) scans within 48 hours of the injury and again during 4 subsequent visits. They also completed behavioral and outcome questionnaires.

Microbleeds appear as small dark lesions on MRI scans but are usually too small to be seen on computer tomography (CT) scans. Sometimes they appear as dots (punctate), sometimes they are linear. In previous studies, researchers examined TMBs in the acute phase of traumatic brain injury (TBI) and stroke and found linear-appearing TMBs only in patients with TBI, suggesting that at least linear TMBs are consistent with trauma and might be the result of injured vessels. They conjectured that TMBs seen on MRI might be a form of traumatic vascular injury distinct from primary injury to the axons.

In this study, one-third of the patients had TMBs. More than half (58%) of the participants with severe head injury showed microbleeds, as did 27% of patients with mild injuries. In most patients with microbleeds, they appeared as linear streaks or dotted lesions. The study also revealed that the frontal lobes were the region most likely to show microbleeds.

The researchers controlled for variables known to predict poor outcome, such as trauma level and trauma-related injury on CT. Even so, microbleeds significantly predicted worse outcome. Patients with both punctate and linear TMBs were twice as likely to have disability (Glasgow Outcome Scale-Extended ≤6) on follow-up.

One participant’s family donated his brain for further analysis after he died. Imaging with a more powerful MRI scanner and a detailed histologic analysis allowed the researchers to better understand the pathology.

The researchers found that what appeared as a punctate TMB on MRI corresponded to iron-laden macrophages in the perivascular space surrounding a vascular tree that extended over centimeters. That was surprising, the researchers say. They expected to see iron within the parenchyma, but they also found iron inside macrophages outside of the parenchyma between the vessel and neuropil, tracking alongside vessels.

The researchers say that finding signified that the extent of injury was more extensive than indicated on MRI and had consequences to cellular function over a larger area of brain. In fact, they suggest, punctate and linear TMBs may not be distinct entities: The difference in shape may be “an issue of resolution.”

The researchers conclude that TMBs could be biomarkers for vascular injury. They also note that the leakage of blood from damaged blood vessels can trigger an inflammatory response. The damage to vessels, the disruption of normal pathways of blood flow, and the influx of inflammatory cells could result in secondary injury to the brain tissue due to ischemia.

Thus, TMBs may also be useful biomarkers for identifying which patients are candidates for treatments that reduce ischemic damage or improve microvascular cerebral blood flow.

Traumatic microbleeds (TMBs) may indicate vascular injury and predict worse outcomes after even minor brain injury, according to a study at the National Institute of Neurological Disorders and Stroke.

The study involved 439 adults with head injuries treated in the emergency department. The participants had magnetic resonance imaging (MRI) scans within 48 hours of the injury and again during 4 subsequent visits. They also completed behavioral and outcome questionnaires.

Microbleeds appear as small dark lesions on MRI scans but are usually too small to be seen on computer tomography (CT) scans. Sometimes they appear as dots (punctate), sometimes they are linear. In previous studies, researchers examined TMBs in the acute phase of traumatic brain injury (TBI) and stroke and found linear-appearing TMBs only in patients with TBI, suggesting that at least linear TMBs are consistent with trauma and might be the result of injured vessels. They conjectured that TMBs seen on MRI might be a form of traumatic vascular injury distinct from primary injury to the axons.

In this study, one-third of the patients had TMBs. More than half (58%) of the participants with severe head injury showed microbleeds, as did 27% of patients with mild injuries. In most patients with microbleeds, they appeared as linear streaks or dotted lesions. The study also revealed that the frontal lobes were the region most likely to show microbleeds.

The researchers controlled for variables known to predict poor outcome, such as trauma level and trauma-related injury on CT. Even so, microbleeds significantly predicted worse outcome. Patients with both punctate and linear TMBs were twice as likely to have disability (Glasgow Outcome Scale-Extended ≤6) on follow-up.

One participant’s family donated his brain for further analysis after he died. Imaging with a more powerful MRI scanner and a detailed histologic analysis allowed the researchers to better understand the pathology.

The researchers found that what appeared as a punctate TMB on MRI corresponded to iron-laden macrophages in the perivascular space surrounding a vascular tree that extended over centimeters. That was surprising, the researchers say. They expected to see iron within the parenchyma, but they also found iron inside macrophages outside of the parenchyma between the vessel and neuropil, tracking alongside vessels.

The researchers say that finding signified that the extent of injury was more extensive than indicated on MRI and had consequences to cellular function over a larger area of brain. In fact, they suggest, punctate and linear TMBs may not be distinct entities: The difference in shape may be “an issue of resolution.”

The researchers conclude that TMBs could be biomarkers for vascular injury. They also note that the leakage of blood from damaged blood vessels can trigger an inflammatory response. The damage to vessels, the disruption of normal pathways of blood flow, and the influx of inflammatory cells could result in secondary injury to the brain tissue due to ischemia.

Thus, TMBs may also be useful biomarkers for identifying which patients are candidates for treatments that reduce ischemic damage or improve microvascular cerebral blood flow.

Traumatic microbleeds (TMBs) may indicate vascular injury and predict worse outcomes after even minor brain injury, according to a study at the National Institute of Neurological Disorders and Stroke.

The study involved 439 adults with head injuries treated in the emergency department. The participants had magnetic resonance imaging (MRI) scans within 48 hours of the injury and again during 4 subsequent visits. They also completed behavioral and outcome questionnaires.

Microbleeds appear as small dark lesions on MRI scans but are usually too small to be seen on computer tomography (CT) scans. Sometimes they appear as dots (punctate), sometimes they are linear. In previous studies, researchers examined TMBs in the acute phase of traumatic brain injury (TBI) and stroke and found linear-appearing TMBs only in patients with TBI, suggesting that at least linear TMBs are consistent with trauma and might be the result of injured vessels. They conjectured that TMBs seen on MRI might be a form of traumatic vascular injury distinct from primary injury to the axons.

In this study, one-third of the patients had TMBs. More than half (58%) of the participants with severe head injury showed microbleeds, as did 27% of patients with mild injuries. In most patients with microbleeds, they appeared as linear streaks or dotted lesions. The study also revealed that the frontal lobes were the region most likely to show microbleeds.

The researchers controlled for variables known to predict poor outcome, such as trauma level and trauma-related injury on CT. Even so, microbleeds significantly predicted worse outcome. Patients with both punctate and linear TMBs were twice as likely to have disability (Glasgow Outcome Scale-Extended ≤6) on follow-up.

One participant’s family donated his brain for further analysis after he died. Imaging with a more powerful MRI scanner and a detailed histologic analysis allowed the researchers to better understand the pathology.

The researchers found that what appeared as a punctate TMB on MRI corresponded to iron-laden macrophages in the perivascular space surrounding a vascular tree that extended over centimeters. That was surprising, the researchers say. They expected to see iron within the parenchyma, but they also found iron inside macrophages outside of the parenchyma between the vessel and neuropil, tracking alongside vessels.

The researchers say that finding signified that the extent of injury was more extensive than indicated on MRI and had consequences to cellular function over a larger area of brain. In fact, they suggest, punctate and linear TMBs may not be distinct entities: The difference in shape may be “an issue of resolution.”

The researchers conclude that TMBs could be biomarkers for vascular injury. They also note that the leakage of blood from damaged blood vessels can trigger an inflammatory response. The damage to vessels, the disruption of normal pathways of blood flow, and the influx of inflammatory cells could result in secondary injury to the brain tissue due to ischemia.

Thus, TMBs may also be useful biomarkers for identifying which patients are candidates for treatments that reduce ischemic damage or improve microvascular cerebral blood flow.