The Providence VA Medical Center - Rhode Island Medical Society

The ProvidenceVA Medical CenterVolume 93 No. 1 January 2010

We're not LIKE A Good Neighbor,WE AREThe Good Neighbor Alliance5256Specializing in Employee Benefits since 1982Health Dental Life Disability Long Term CarePension Plans Workers' Compensation Section 125 PlansThe Good Neighbor Alliance CorporationThe Benefits SpecialistAffiliated Affiliated with withRHODE ISLAND MEDICAL SOCIETYrhode isl a ndmedical society401-828-7800 or 1-800-462-1910P.O. Box 1421 Coventry, RI 02816www.goodneighborall.com

UNDER THE JOINTEDITORIAL SPONSORSHIP OF:The Warren Alpert Medical School ofBrown UniversityEdward J. Wing, MD, Dean of Medicine& Biological ScienceRhode Island Department of HealthDavid R. Gifford, MD, MPH, DirectorQuality Partners of Rhode IslandRichard W. Besdine, MD, ChiefMedical OfficerRhode Island Medical SocietyVera A. DePalo, MD, PresidentEDITORIAL STAFFJoseph H. Friedman, MDEditor-in-ChiefJoan M. Retsinas, PhDManaging EditorStanley M. Aronson, MD, MPHEditor EmeritusEDITORIAL BOARDStanley M. Aronson, MD, MPHJohn J. Cronan, MDJames P. Crowley, MDEdward R. Feller, MDJohn P. Fulton, PhDPeter A. Hollmann, MDAnthony E. Mega, MDMarguerite A. Neill, MDFrank J. Schaberg, Jr., MDLawrence W. Vernaglia, JD, MPHNewell E. Warde, PhDOFFICERSVera A. DePalo, MDPresidentGary Bubly, MDPresident-ElectNitin S. Damle, MDVice PresidentAlyn L. Adrain, MDSecretaryJerald C. Fingerhut, MDTreasurerDiane R. Siedlecki, MDImmediate Past PresidentDISTRICT & COUNTY PRESIDENTSGeoffrey R. Hamilton, MDBristol County Medical SocietyRobert G. Dinwoodie, DOKent County Medical SocietyRafael E. Padilla, MDPawtucket Medical AssociationPatrick J. Sweeney, MD, MPH, PhDProvidence Medical AssociationNitin S. Damle, MDWashington County Medical SocietyCover: “The Cardinal in a Snowy Bush,” watercolor,by Kristin Morrill. The artist studied art atNortheastern University, Worcester Art Museumand with several local NE artists privately. She receivedtwo grants for her series of Historical MillWorkers paintings currently on display in Pawtucket,RI, at the Library and the BV Visitor Center andonline at http://kristinmorrill.net/Historical_Mill_Workers.aspx. Her website: www.kristinmorrill.net; her e-mail : kristym@comcast.netMedicine HealthVOLUME 93 NO. 1 January 2010R HODE I SLANDPUBLICATION OF THE RHODE ISLAND MEDICAL SOCIETYCOMMENTARIES2 Choosing a TreatmentJoseph H. Friedman, MD3 Racism and the Threat of InfluenzaStanley M. Aronson, MDCONTRIBUTIONSSPECIAL ISSUE: The Providence VA Medical CenterGuest Editor: Sharon Rounds, MD4 Overview of the Providence VA Medical CenterSharon Rounds, MD6 Innovative Approaches to Healthcare Delivery at the Providence VA MedicalCenterSharon Rounds, MD8 Electronic Medical Record and Quality of Patient Care in the VATanya Ali, MD11 Primary Care at the Providence VA Medical Center: Challenges, Opportunitiesand InnovationsThomas P. O’Toole, MD13 Mental Health Care at the Providence VA Medical Center: Providing IntegratedComprehensive Mental Health ServicesMichael G. Goldstein, MD16 Military Blast Injury in Iraq and Afghanistan: The Veterans HealthAdministration’s Polytrauma System of CareStephen T. Mernoff, MD, FAAN, and Stephen Correia, PhD22 Neurorehabilitation Research Laboratory at the Providence VAMCAlbert Lo, MD, PhDCOLUMNS25 THE CREATIVE CLINICIAN: Fooled by the Fragments: Masquerading MicroangiopathySamir Dalia, MD, Cannon Milani, MD, Jorge Castillo, MD, Anthony Mega, MD,Fred J. Schiffman, MD27 GERIATRICS FOR THE P RACTICING P HYSICIAN: Sudden Cardiac Death and ImplantableCardioverter Defibrillators (ICD) in the Older AdultOmar Hyder, MD, and Ohad Ziv, MD29 HEALTH BY NUMBERS: Intimate Partner Violence Before or During Pregnancy inRhode IslandHyun (Hanna) Kim, PhD, Rachel Cain, and Samara Viner-Brown, MS32 PHYSICIAN’S LEXICON: Synonyms of NothingStanley M. Aronson, MD32 Vital Statistics33 January Heritage34 2009 IndexMedicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the RhodeIsland Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicalspostage paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235Promenade St., Suite 500, Providence, RI 02908. Classified Information: Cheryl Turcotte/Rhode Island Medical Society, phone: (401) 331-3207, fax:(401) 751-8050, e-mail: cturcotte@rimed.org. Production/Layout Design: John Teehan, e-mail: jdteehan@sff.net.VOLUME 93 NO. 1 JANUARY 20101

Boston University School of Medicine. In addition, thePVAMC has educational programs in nursing, pharmacy, anddental care with affiliations with 56 educational institutions,including the University of Rhode Island, Rhode Island College,and others. In 2008 the PVAMC was the site of educationof 506 students, residents, and MD and PhD post-doctoralfellows in various disciplines.In 2008, the PVAMC was awarded a competitive VANursing Academy grant that established a nursing educationaffiliation between the Providence VAMC and Rhode IslandCollege School of Nursing (RICSON). The VA Nursing Academywas established in 2007 to address the nationwide shortageof nurses and to ensure that veterans continue to receivethe best services available. The PVAMC-RICSON NursingAcademy is a four-year program that has brought about bothfaculty and student expansion and innovative initiatives.The Providence VAMC has grown in research fundingand facilities. In 1997, the VA dedicated the Research Building(Building 35), providing 13,000 sq. ft. of newly constructedwet laboratory and clinical research space and investigator offices.Construction will soon begin on an 1860 sq. ft. additionto the Research Building. Animal care facilities at the ProvidenceVA Medical Center have a total space of 12,761 sq. ft.The Research Service of the PVAMC is accredited by bothAAALAC-I and AAHRPP.The PVAMC is the site of the Research EnhancementAward Program (REAP), led by Peter Friedmann, MD, Professorof Medicine. The REAP is funded by the VA HealthServices Research & Development program to train junior investigatorsand to foster research collaboration in health servicesand outcomes. The REAP provides an ideal clinical collaborativeresearch and training environment, with computinginfrastructure, methodology expertise, and biostatisticalsupport. Research training for junior investigators is facilitatedin bi-weekly conferences that provide interactive learning inresearch design, methods and data analysis. The REAP is locatedin Building 32, which houses clinical and health outcomesresearch in 2500 square feet.The PVAMC is also the site of the recently re-funded VA/Brown Center for Restorative and Regenerative Medicine, ledby Roy Aaron, MD, Professor of Orthopaedics. The goal ofthe Center is to create bio-hybrid limbs and other unique toolsto restore function. There is a particular need for this researchin that veterans wounded in the conflicts in Iraq and Afghanistanhave returned with devastating limb injuries. Because ofimprovements in body armor, soldiers are surviving after injuriesthat would have proven fatal in the past. The Center forRestorative and Regenerative Medicine is a collaborativemultidisciplinary research effort between the PVAMC, BrownUniversity, and the Massachusetts Institute of Technology. Researchprojects include: the development of powered lower legprosthesis a projected directed by Hugh Herr, PhD, at MIT;the first clinical trial of a robotic arm and hand, directed byLinda Resnik, PhD, PT, Associate Professor of CommunityHealth at Brown; and a clinical trial of the “Braingate” devicein patients with Amyotrophic Lateral Sclerosis, directed by JohnDonoghue, PhD, and Leigh Hochberg, MD, PhD, of theDepartments of Neuroscience and Bioengineering at Brown.The VA is building a 23,500 sq. ft. new, state-of-the-art researchspace for this VA/Brown Center, an investment of $6million by the VA to the Brown University research enterprise.The new facility will be dedicated in January 2010.Another area of research excellence is the VA and NIHfundedVascular Research Laboratory (www.brown.edu/Research/Vascular_Research_Laboratory/),consisting of investigatorsfrom Pulmonary/Critical Care and Cardiology sectionsof the Brown Department of Medicine. Alcohol and Addictionresearch is led by Robert Swift, PhD, MD, Professor ofPsychiatry and Human Behavior and Associate Chief of Stafffor Research at the VA, and two VA Career Scientists, PeterMonti, PhD, Professor of Community Health and DamarisRohsenow, PhD, Professor of Community Health. MartinWeinstock, PhD, MD, Professor and Chief of Dermatology atthe VA, leads VA and NIH-funded multi-center clinical trialsin skin cancer epidemiology and treatment. Dr. Weinstockalso leads the VISN1 Teledermatology Program, described inanother article in this series. Albert Lo, PhD, MD, AssistantProfessor of Neurology, leads VA-funded multi-center trials inthe use of robotics in rehabilitation of patients with strokes andin multiple sclerosis. His work is described in another articlein this series. Tracie Shea, PhD, and William Unger, Ph. havea research program in Post-traumatic Stress Disorder (PTSD),which afflicts a high percentage of veterans returning fromIraq and Afghanistan.Thus, the Providence VA Medical Center provides aunique set of services for veteran patients and a practice environmentthat focuses on quality of care, with resources for educationand research.Sharon Rounds, MD, is Chief, Medical Service, ProvidenceVA Medical Center, and Professor of Medicine and of Pathologyand Laboratory Medicine, The Warren Alpert Medical School ofBrown University.Disclosure of Financial InterestsThe author has no financial interests to disclose.CORRESPONDENCESharon Rounds, MDProvidence VA Medical Center830 Chalkstone AveProvidence, RI 02908Phone: (401) 457-3020e -mail: Sharon_Rounds@brown.eduVOLUME 93 NO. 1 JANUARY 20105

6Innovative Approaches to Healthcare Delivery at theProvidence VA Medical CenterThe major goal of the VA system is costeffective,high quality healthcare. BecauseVA physicians are salaried, there isno entrepreneurial incentive to bill forfee-for-service. Thus, VA healthcare providersare more likely to use physicianextenders or other means of expandingoutreach and have therefore developedinnovative methods of delivering care toselected populations of patients. Examplesof innovative modalities of careare described below.MEDICINE & HEALTH/RHODE ISLANDSharon Rounds, MDENHANCING PATIENT ADHERENCETO PRESCRIBED THERAPYObstructive sleep apnea (OSA) isestimated to be present in 9-14% ofmales and 2-7% of females in the US. 1OSA is associated with hypertension,coronary artery disease, and stroke, 2 aswell as motor vehicle accidents resultingfrom excessive daytime somnolence. 3Accumulating evidence indicates thattreatment of OSA with continuous positiveairway pressure (CPAP) decreasesthe prevalence of cardiovascular complications.2 However, although CPAPtherapy is effective in reversing sleep apnea,there is a high rate of non-compliance.An estimated 29-83% of patientswith OSA are non-adherent with CPAPtherapy, defined as use of CPAP at least4 hours per night. 4 Thus, it is importantto develop methods of enhancing compliancewith CPAP treatment for OSA.The VA provides CPAP therapy forveterans with proven OSA of at leastmoderate severity after evaluation andprescription of CPAP by a pulmonaryphysician. The VA requires that patientsbe re-evaluated periodically for need forCPAP, in addition to home visits by theCPAP vendor. We developed a novelgroup—CPAP Clinic—managed by apulmonary nurse practitioner and a respiratorytherapist. Veterans for whomCPAP is provided by the VA are requiredto attend this clinic every 12-18 months.About 10 patients attend each groupclinic session. Their equipment ischecked for proper function and prescriptionsfor supplies are provided ateach session. Compliance with CPAP isassessed by review of records of machineuse, and patient symptoms and complicationsof CPAP therapy are assessed andtreated. In addition, at each clinic session,a group educational session is held,with nurse practitioner and respiratorytherapist plus compliant patients providingencouragement of CPAP use.In a retrospective review, we assessedcompliance with CPAP therapy betweenpatients who attended CPAP clinic, comparedwith patients who did not attendthe clinic. We found that compliancewith therapy, as defined by 5 hours ofmachine use per night, improved in 29%of patients attending CPAP clinic. 5 Thesuccess of CPAP clinic is dependent uponuse of physician extenders (nurse practitionerand respiratory therapist) for patientassessment and education and uponthe encouragement provided to noncompliantpatients by compliant patientsalso attending the group clinics.MULTIPLE CARDIOVASCULAR RISKFACTOR INTERVENTIONControl of modifiable cardiac riskfactors for the prevention and treatmentof coronary artery disease (CAD) in patientswith diabetes mellitus decreases therisk of cardiovascular events. However,many patients do not achieve target goalsfor low density lipoprotein (LDL) cholesterol,systolic blood pressure, glycemiccontrol, and tobacco cessation, despiteintensive efforts. Control of multiplerisk factors is expensive, requiring multiplefollow-up physician visits in the traditionalpractice setting.The Cardiology Section and thePharmacy Department at the ProvidenceVA Medical Center, in conjunction withthe School of Pharmacy at the Universityof Rhode Island, have implemented novelpharmacist-led, multidisciplinary clinics(Cardiovascular Risk Reduction Clinic,CRRC) with interventions to control hyperlipidemia,hypertension, hyperglycemia,and tobacco use. The clinics arecoordinated by a clinical pharmacist,working in close collaboration with aphysician cardiologist. Because clinicalpharmacists have prescribing privilegesin the VA system within their scope ofpractice, they are able to implementmedication changes, in addition to providingeducation and advice on lifestylemodifications. Furthermore, the VAdrug formulary is limited and controlled,according to results of clinical studies.Finally, treatment of cardiovascular riskcan be expressed in algorithms that arestrongly supported by clinical trials. Thus,cardiovascular risk reduction is wellsuited for a pharmacist-led clinic.In retrospective reviews, all cardiovascularrisk factors were significantlyimproved after attendance at CRRC programs6 with sustained improvements. 7The VA is funding a prospective studyto assess the effectiveness of the pharmacist-ledmodel CRRC clinic, underthe leadership of Wen-Chih Wu, MD,VA staff cardiologist and Assistant Professorof Medicine at Brown, and TraceyTaveira, PharmD, Associate Professor ofClinical Pharmacy at the University ofRhode Island.Because of the success of the CRRC,pharmacist-led clinics in conjunctionwith cardiology have also been establishedat the Providence VAMC for congestiveheart failure, another conditionfor which strong evidence from clinicaltrials supports algorithms for clinicalmanagement.TELEDERMATOLOGYWorkforce surveys have documenteda national shortage of dermatologists. 8 Thisproblem is exacerbated in rural areas withlong travel distances to dermatology providers.The practice of medical dermatologyis well suited for telemedicine, sinceskin lesions are easily documented andtransmitted. The availability of an electronicmedical record with robust securityfor personal health information, suchas the VistA system used by the VA, is criticalfor successful teledermatology.

The Dermatology Section of theProvidence VA Medical Center has beenproviding teledermatology services to VAfacilities in rural Maine since 1997, underthe leadership of Dr. MartinWeinstock, MD, PhD, Chief of thePVAMC Dermatology Section. Thisteledermatology practice was the first inthe VA system nationally. A “store-andforward”approach is used with clinicalhistory, physical examination, and digitalphotos of affected skin taken by a nursepractitioner or physician assistant inMaine, who forwards the skin photos andclinical information to the physician dermatologistin Providence.Epiluminescence microscopic images arealso taken, as indicated. These data arereviewed by the dermatologist in Providencewho provides an impression andplan that are transmitted electronically andimplemented in Maine by the nurse practitioneror physician assistant. When necessary,in person consultation with a dermatologistcan also be implemented. This“store-and-forward” approach is very economical,s compared with face-to-face dermatologyconsultation or real-timeteledermatology consultation. A reviewof patient satisfaction with the PVAMCteledermatology services revealed thatmore than half of patients were satisfiedwith the service and most indicated thatthey would not have otherwise have haddermatology evaluation due to inability totravel to the nearest VA dermatology clinic.Overall, 74% of providers rated the programas excellent or good and would recommendthe teledermatology program fortheir patients. 9Telemedicine approaches are economicaland useful for many dermatologicalproblems. The experience at theProvidence VAMC has been an examplefor the VA system nationally, and implementationof teledermatology for otherunderserved areas is now underway. Indeed,telemedicine has been implementedby the VA for other conditions,such as “Telebuddy” home monitoringfor patients with hypertension, congestiveheart failure, and chronic obstructivepulmonary disease.These examples of innovative approachesto difficult clinical problemswere pioneered and implemented at theProvidence VAMC. All have been assessedfor effectiveness, with on-goingpatient satisfaction and clinical effectivenesssurveys.ACKNOWLEDGEMENTS:This work is the result of work supportedby resources and the use of facilitiesat the Providence VA Medical Centerand by the NHLBI, RO1 64936.REFERENCES1. Young T, Peppard PE, Gottlieb DJ. Epidemiologyof obstructive sleep apnea. Am J Respir CritCare Med 2002;165: 1217-39.2. Lattimore JD, Celermajer DS, Wilcox I. Obstructivesleep apnea and cardiovascular disease. J AmColl Cardiol 2003;41: 1429-37.3. Pack AI, Pien GW. How much do crashes relatedto obstructive sleep apnea cost? Sleep 2004;27:369-70.4. Weaver TE, Grunstein RR. Adherence to continuouspositive airway pressure therapy. Proc AmThorac Soc 2008;5: 173-8.5. Likar LL, Panciera TM, et al. Group educationsessions and compliance with nasal CPAP therapy.Chest 1997;111: 1273-7.6. Taveira TH, Wu WC, et al. Pharmacist-led cardiacrisk reduction model. Prev Cardiol 2006;9:202-8.7. Pirraglia PA, Taveira TH, et al. Maintenance ofcardiovascular risk goals in veterans with diabetesafter discharge from a cardiovascular risk reductionclinic. Prev Cardiol 2009;12: 3-8.8. Kimball AB, Resneck JS, Jr. The US dermatologyworkforce. J Am Acad Dermatol 2008;59: 741-5.9. Weinstock MA, Nguyen FQ, Risica PM. Patientand referring provider satisfaction withteledermatology. J Am Acad Dermatol 2002; 47:68-72.Sharon Rounds, MD, is Chief, MedicalService, Providence VA Medical Center,and Professor of Medicine and of Pathologyand Laboratory Medicine, The WarrenAlpert Medical School of Brown University.Financial DisclosureThe author has no financial intereststo disclose.CORRESPONDENCESharon Rounds, MDProvidence VA Medical Center830 Chalkstone AveProvidence, RI 02908e-mail: Sharon.Rounds@va.govVOLUME 93 NO. 1 JANUARY 20107

Electronic Medical Record and Quality ofPatient Care In the VAI was working at the Providence VAMedical Center emergency room when Iwas asked to see a new, confused, diabeticpatient, who was visiting her family inProvidence. The nurse informed me thather blood sugar was low. We took measuresto correct her blood sugar immediately.The patient was not clear regardingher medications. Her primary care physicianwas at a VA hospital in California.Logging into the VA Computerized PatientRecord System (CPRS), I gainedaccess to the patient’s recent outpatientoffice visit notes, and obtained the mostcurrent medication list. It became clearthat the patient was not taking her diabeticmedications as prescribed and thatshe was hypoglycemic because of overmedication.Via the electronic medicalrecord, VA physicians can ascertain notonly the patient’s latest data, but also a completemedical record going back as far asthe mid -1980s, including records of careperformed in any other Veterans HealthAdministration (VHA ) hospital or clinic.More than $ 1.2 trillion spent onhealth care each year is estimated to bewasted—about half the $2.2 trillionspent in the United States on health careeach year, according to the most recentdata from Price Waterhouse CooperHealth Research Institute. 1 Much of thewaste is a result of disorganization andlack of accurate information. This resultsin orders for unneeded tests and ineffectiveprocedures and in simple human error.Advanced health information technologycan reduce these consequencessubstantially in the following ways: 21. Improved communication2. More readily accessible knowledge3. Assistance with calculations4. Performance of checks in realtime5. Assistance with monitoring6. Decision support7. Requirement for key pieces ofinformation (dose, e.g.)Tanya Ali, MDBased on a well-specified definitionof electronic health records, only 17% ofUS physicians used either a minimallyfunctional or a comprehensive electronicrecords system in 2009. 3 Twenty fourfunctionalities have been identified as theessential components of comprehensiveelectronic records system. 4In 1995 the VA launched a major reengineeringof its health care system thatincluded better use of information technology,measurement and reporting of performance,integration of services, and realignedpayment policies. Health Informationtechnology benefited from significant investments6 and the CPRS was implementednationally throughout the VHA in 1999. 7,8In any VA hospital clinicians cannavigate the electronic medical recordsby logging into CPRS. Via a graphicaluser interface, physicians can access completepatient records from inpatient visits,subspecialty consults, primary carevisits, emergency room visits, laboratorydata, radiology reports, medication history,surgical notes and discharge summaries.All physicians’ work on any patientutilizes the same medical record andall entries are legible. This facilitates communicationamong care providers, makesthe data collection process efficient, savestime, and eliminates difficulty decipheringillegible handwriting.The Clinical Decision Support(CDS) component of CPRS providesclinical data, clinical guidelines, clinicalreminders, situation-specific advice, andmakes relevant information available inTable 1. Electronic Functionalities of ComprehensiveElectronic Records System 3Electronic FunctionalityClinical documentation• Demographic characteristics of patients• Physician’s notes• Nursing assessments• Problem lists• Medication lists• Discharge summaries• Advanced directivesTest and imaging results• Laboratory reports• Radiologic reports• Radiologic images• Diagnostic – test results• Diagnostic – test images• Consultant reportsComputerized provider-order entry• Laboratory tests• Radiologic tests• Medications• Consultation requests• Nursing ordersDecision support• Clinical guidelines• Clinical reminders• Drug-allergy alerts• Drug-drug interaction alerts• Drug-laboratory interaction alerts• Drug-dose support (renal dose guidance)8MEDICINE & HEALTH/RHODE ISLAND

eal time to facilitate clinical decisionmaking. Availability of these componentsmakes information collection a smoothprocess, provides decision support automaticallyas part of workflow and providesactionable recommendations. 9CDS reminds the clinician to evaluate fordifferent JCAHO-required indicatorssuch as pain scale, signs of abuse, safetyin the living place, counseling for smokingcessation, assessment for pressure ulcers,medicine reconciliation, and verificationof advance directives. The sameCDS system reminds doctors to prescribeappropriate care for patients when theyleave the hospital, such as prescriptionof beta blockers after heart attacks, ACEinhibitors for congestive heart failure, leftventricular function assessment byechocardiogram for heart failure, anticoagulationin patients with atrial fibrillation,and daily weight measurement inpatients with congestive heart failure.All patient care orders are enteredinto CPRS through a ComputerizedPhysician Order Entry (CPOE) system.All inpatient orders (for diet, activity, intravenousfluid, medication, lab, radiology,consultations, etc) and outpatientorders are entered through this system.The CPRS has an active clinical decisionsupport system focused on drugs,laboratory testing and radiology procedures.For example, when a physicianenters a new medication order in CPRS,the system immediately alerts the physicianto any previous allergic reaction tothe same medication and to any relevantdrug-drug interactions. CPRS checks forduplicate therapy, provides basic drugdosing guidance, and makes formularydata available. It also checks dosing forrenal insufficiency and geriatric patients,medication-related lab testing (e.g. PT,PTT before intravenous heparin initiation),and drug-pregnancy and drug-diseasecontraindications. The laboratorygenerates view alerts to the provider onany abnormal testing results through theCPRS. For example, orders for CT scanwith contrast generate alerts to the providerif the patient is on metformin, ifserum creatinine is abnormal, or if a recentserum creatinine is not available inorder to caution the provider regardingpotential contrast-related complications.The radiologist can generate a computerizedalert to primary care providers (inpatientand outpatient) whenever an abnormalradiology image is reviewed.Computerized Clinical Reminders(CCR) are just-in-time reminders at thepoint of care that reflect evidence – basedclinical practice guidelines and reducereliance on memory. This system keepstrack of when veterans are due for a flushot, pneumococcal vaccine, diabetic eyeexam, diabetic foot exam, lipid profile,screening colonoscopy, breast cancerscreen, or other screening and generatesa computerized reminder to the providerat the time of the patient visit.The electronicmedical record hasstrongly supportedperformanceimprovementthroughoutthe VHA.When the quality of care in the VeteransHealth Administration (VHA)health care system was assessed from1994 (before re-engineering) through2000, it was found that quality of careimproved dramatically in all domainsstudied. These improvements were evidentfrom 1997 through fiscal year2000. 5 Compared with Medicare fee –for –service programs, the VA performedsignificantly better on all eleven similarhealth quality indicators for the periodfrom 1997 through 1999. In 2000 theVA out-performed Medicare on 12 of 13indicators. 5 The VA also out-performedother health systems in the communityon standardized measures of health carequality. Performance in the VHA outpacedthat of a national sample for bothchronic care and preventive care. In particular,the VHA sample received significantlybetter care for depression, diabetes,hyperlipidemia and hypertension. 10The electronic medical record hasstrongly supported performance improvementthroughout the VHA. TheVHA instituted a performance measurementinitiative nationally in 1996. As apart of this initiative, evidence - basedclinical performance measures were identifiedand performance on these measureswas ascertained via an External Peer ReviewProgram (EPRP). In EPRP, a non–VHA contractor abstracts records of asample of VHA patients from each VHAfacility, derived from electronic healthrecords. 11 These measures are incorporatedinto an annual performance contract,and senior managers are held accountableto meet or to exceed specificperformance targets. 12 This VHA performancemeasurement initiative hasbeen enhanced by the comprehensiveelectronic medical record system that facilitatedthe use of electronic decisionsupport such as clinical reminders. 13 Theuse of these reminders is at the discretionof the local facilities. The search forstrategies contributing to high clinicalperformance measures throughout theVHA showed that the second most commonlycited strategies across all performancecategories were clinical reminders(41.4%). 13 The computerized clinicalreminders 7,14- 22 and computer basedstanding orders 18, 23, 24 are proven interventionsto enhance preventive care (e.g.immunizations, cancer screening).The significant improvement in thehealth care provided by VHA wasachieved by transformation into a culturebased on accountability for continuousimprovement of performance. 6 The VA’ssuperior quality relative to that of Medicarefor the period from 1997 through2000 probably has more to do with thequality—improvement initiatives thatwere instituted in the mid-1990s thanwith structural differences. 5In conclusion, the re-engineering ofthe VHA has resulted in dramatic improvementsin the quality of care providedto veterans. In fact, the Institute of Medicinerecently recommended many of theprinciples adopted by the VA in its qualityimprovement projects, including emphasison the use of information technologyand performance measurement andreporting. 25REFERENCES1. http://money.cnn.com/2009/08/10/news/economy/healthcare_money_wasters/index.htm2. www.hsrd.research.va.gov/for_researchers/.../valenta-031808.ppt3. Jha AK, DesRoches C, et al. NEJM 2009;360:1628-38.4. Blumenthal D, DesRoches C, et al. Health informationTechnology in the United States: The InformationBase for Progress. Princeton, NJ: RobertWood Johnson Foundation 2006.VOLUME 93 NO. 1 JANUARY 20109

5. Jha AK, Perlin JB, et al.. NEJM 2003; 348:2218-27.6. Francis J, Perlin JB, et al. J Continuing Educat inthe Health Profession 2006; 26:63-71.7. Glassman P, Volpp B, et al. J In Technol Healthc2003; 1:251-65.8. Fletcher RD, Dayhoff RE, et al. Cancer 2001;91:1603-6.9. Kawamoto K, et al. BMJ 2005 doi:10.1136/bmj.38398.500764.8F (published 14 March2005).10. Asch SM, McGlynn EA, et al. Ann Intern Med2004; 141:938-45.11. Forsythe JH, Perlin JB, Brehm J. Data Qualityand medical record abstraction in the VeteransHealth Administration’s External Peer ReviewProgram. In: Pierce EM, Katz-Hass R, eds. Proceedingsof the Sixth International Conferenceon Information Quality. Cambridge, MA: MassachusettsInstitute of Technology; 2001:362-369.12. Perlin JB, Kolodner RM, Rosewell RH. Am JManag Care 2004; 10(pt 2):828-36.13. Craig TJ, Perlin JB, et al. Amer J Med Quality 2007;22: 438-44.14. Davis DA, Thomson MA, et al. JAMA 1995;274:700-5.15. Buntix F, Winkens R, et al. Fam Pract 1993;10:219-28.16. Hunt DL, Haynes RB, et al. JAMA 1998; 280:1339-46.17. Zielstorff RD. J Am Inform Assoc 1998; 5:227-36.18. Sullivan F, Mitchell E. BMJ 1995; 311:848-52.19. Dexter PR, Perkins S, et al. NEJM 2001; 345:965-70.20. Yano EM, Fink A, et al. Arch Intern Med 1995;155:1146-56.21. Garg A. Adhikari NK, et al. JAMA 2005;293:1223-38.22. Mandelblatt J, Kantesky PA. J Fam Pract 1995;40:162-71.23. Dexter PR, Perkins SM, et al. JAMA2004:292:2366-73.24. Rhew DC, Glassman PA, Goetz MB. J Gen InternMed 1999; 14:351-6.25. Committee on Quality of health care in America.Crossing the Quality Chasm: A New Health Systemfor the 21st century. Washington, DC: NationalAcademy Press, 2001.Tanya Ali, MD, is a Staff Hospitalistat the Providence VA Medical Center, andClinical Assistant Professor of Medicine atThe Warren Alpert Medical School ofBrown University.CORRESPONDENCETanya Ali, MDProvidence VA Medical Center830 Chalkstone AveProvidence, RI 02908Phone: (401) 457-3020e –mail: tanya.ali@va.gov10MEDICINE & HEALTH/RHODE ISLAND

Primary Care at the Providence VA Medical Center:Challenges, Opportunities and InnovationsThomas P. O’Toole, MDports, optimizing organization of care, tailoringdelivery systems to chronic diseasecare, and utilizing clinical information systemsfor population health. 5,6At the Providence VA, about 18,000patients receive care at the ProvidenceMedical Center campus; the remaining12,000 patients receive their care in oneof three Community-Based OutpatientClinics (CBOCs) located in Middletown,RI, New Bedford, MA and Hyannis, MA.In 2006, the Providence VA Primary CareService underwent a further reorganizationto better align itself with VA objectivesand to prepare for anticipated challengesfacing our veterans. Three initiativesstemming from this reorganization aredescribed in further detail.VA-based care isorganized aroundthe Patient-CenteredMedical Home(PCMH) Model.THE VA PRIMARY CARE MEDICALHOMECore to the primary care reorganizationwas the need to strengthen the medicalhome model as a treatment entity. Thisrequired re-organizing the existing “Firm”system into smaller clinical units of 3,500to 4,500 patients each and re-assigningclinical staff to increase the number of“hands-on” providers involved in day-todaypatient care. Each patient is assignedto a primary care provider and a medicalteam based on specific needs and preferences.Each general medicine clinic teamconsists of 4-5 primary care providers, anRN, 2 nursing assistants and a shared socialworker and LPN. In addition, intensivemetabolic disease management and cardiacrisk reduction clinics are available for shortterm intensive management of patients withdifficult-to-control diabetes and hyperlipidemia,telehealth services are available forhigh-risk patients, and an integrated primarycare-mental health team can assist inAlmost one out of ten Rhode Island residentsis a US veteran. About 30,000 of them gettheir care at the VA. Their needs reflectboth the aging demographic of World WarII and Korean War veterans now in their80s and younger men and women returningfrom the Iraq and Afghanistan wars.The veteran population also tends to besicker, with more medical conditions, overallpoorer health, and to use more medicalresources than the US general population. 1From a primary care perspective, caringfor today’s veteran requires a focus inthree core areas: (1) chronic disease managementincluding early detection, reducingthe risk of disease progression and preventing/treatingacute exacerbations; (2)the interface between public health andclinical medicine which encompasses everythingfrom universal screening for posttraumatic stress disorder, depression andsubstance abuse to implementing a firstlineresponse to the H1N1 pandemic andpromoting weight reduction and smokingcessation; and (3) the capacity to addresshealth disparities and the needs ofvulnerable populations disproportionatelyrepresented in veteran populations.To address these areas, primary carewithin the VA began a major transformationabout 15 years ago in its organization. 23VA-based care is organized around the Patient-CenteredMedical Home (PCMH)Model. Every veteran is assigned a primarycare provider and clinical team. Comprehensivecare is coordinated within an integratedmedical system model that promotescontinuity along with population and patient-baseddisease management and healthpromotion. 4 A comprehensive electronicmedical record system allows for timelycommunication across services as well ascare planning, population tracking, andclinical feedback. It also allows the providerto have access to records of all careacross all VA facilities nationwide. Togetherthe medical home model and electronicmedical record provide the capacity andtools needed to apply the Chronic CareModel within a primary care setting: promotingpatient self-management, engagingcommunity resources, use of decision suptheon-site management of patients presentingwith depression or anxiety disorders.Monthly clinical reports drawn from theelectronic medical record are provided toeach clinician, RN and team that includesaggregated chronic disease managementmeasures (most recent blood pressures, LDLand hemoglobin A1C) and a listing of alloutlier patients in that team. These data areused in bi-weekly team meetings to bothpromote effective care planning and serveas the benchmark for team-based qualityimprovement initiatives. Since implementingthis care structure in 2006, we haveseen a significant improvement in chronicdisease management performance and theproportion of patients at target for bloodpressure, lipid and diabetes control, exceedingboth national VA targets and communitystandards.PROMOTING PATIENT SELF-CAREA significant component of the ChronicCare Model is the promotion of patient selfcareand self-empowerment. Patients whoare able to assume more proactive roles intheir care tend to feel better and have bettercare outcomes. 7 To help achieve this goal,we established several self-care initiativeswithin primary care that can be accessed independentof a PCP referral and are intendedto promote enhanced chronic diseaseself-management or disease preventiongoals. Structured as either group or individualeducation and/or medication managementsessions, they include: (1) MOVE,a program led by the PVAMC dietician serviceto assist patients trying to lose weight;(2) Smoking Cessation Program, co-led by aprimary care provider and clinical pharmacistand structured as a walk-in group sessionwith follow-up one-on-one counselingand medication prescribing; (3) DiabetesSelf-Management groups led by a diabetesnurse educator; (4) Economic Hardship Programled by the primary care clinical socialworkers to assist patients having difficultiesfollowing through on prescribed medicalcare due to financial hardship; and (5) aCaregiver Support Group led by the SpecialPopulations social worker to assist familiesof loved ones suffering from Alzheimer’sVOLUME 93 NO. 1 JANUARY 201011

12Disease. Taken together, these efforts are intendedto complement the efforts of theclinic team, improving compliance and patientsatisfaction.MEDICINE & HEALTH/RHODE ISLANDpointments needed on fixed clinic days toaccommodate the difficulties many homelesspersons have keeping appointments setwithin narrowly defined times. The SMIclinic is co-located within the outpatientmental health unit and runs concurrentlywith scheduled mental health appointmentsto create a more seamless transition frommental to physical health service delivery. (2)All the clinics also have case managementincorporated into their care models with theuse of patient registries to minimize loss tofollow-up. (3) Care within the clinics is tailoredto issues relevant to that population.For example, the initial assessment at thehomeless clinic specifically queries patientson food security, current sheltering needsand benefits status. There is also amultidisciplinary team on-site during clinicdays that includes primary care, a VA housingcoordinator, a VA benefits representative,and a mental health practitioner. TheGeriatrics Clinic has specific assessments andsupports for caregivers of those veterans sufferingfrom Alzheimer’s Disease and othercognitive impairments. (4) Lastly, each clinicteam is trained in care nuances and prioritiesrelevant to that population. For thehomeless clinic, the emphasis is on harm reduction;for women’s health, on integratedPTSD and MST related care needs, etc.To date, over 800 patients are enrolledin these “special-populations enhanced medicalhomes” with significant clinical outcomesto date. In all four clinics primary care contactsper patient have increased significantlyand the rate of potentially preventable, ambulatorysensitive admissions (e.g., congestiveheart failure, COPD) among patients transferredto these clinics has declined by 12%.Chronic disease management has also significantlyimproved; less than 40% of thepatients in the SMI and homeless cohortswere at lipid target (LDL 80 years old, many of whomare cognitively impaired, frail, and at highrisk for hospitalization and institutionalization.11 Together, these four groups havesubstantially more co-morbidity, use emergencydepartments and inpatient medicalservices at much higher rates and have muchworse health outcomes.As part of the reorganization of theProvidence VAMC Primary Care Service, wetailored clinical programs based on theMedical Home model to better engage eachof these “high risk populations” in treatmentand to optimize clinical and social outcomes.The Homeless Oriented Primary Care Clinicwas established in November, 2006 followedby the Geriatrics Primary Care Clinic in July,2007. A clinic for female veterans sufferingfrom PTSD or military sexual trauma wasalso started in 2007. The Serious MentallyIll (SMI) clinic, co-located with mentalhealth, was established in the Fall of 2007for patients with serious persistent mental illnesseswho were unable to successfully accessand/or navigate the general medicineprimary care clinics. The clinics are definedby four consistent features: (1) Access to careis modeled after the needs of that population.For example, the homeless clinic operatesas an open-access model with no apansand those new veterans returning homefrom Iraq and Afghanistan, and the needto provide care in a patient-centered, evidence-basedand cost-efficient manner.Health care delivery in the United States isat a watershed moment as policy leadersgrapple with burgeoning costs, disparateaccess and inadequate outcomes. The VAsystem serves as a model for what can beaccomplished and should be referenced inthe ongoing health care debate.REFERENCES1. Agha Z, Lofgren RP, et al. Are patients at VeteransAffairs Medical Centers sicker? Arch Intern Med2000;160:3252-7.2. Longman P. Best Care Anywhere: Why VA healthcare is better than yours. PolipointPress, Sausalito,CA. 20073. Asch SM, McGlynn EA, , et al. Comparison ofquality of care for patients in the Veterans HealthAdministration and patients in a national sample.Ann Intern Med 2004;141:938-45.4. www.acponline.org/running_practice/pcmh/demonstrations/jointprinc_05_17.pdf5. Bodenheimer T, Wagner EH, Grumbach K. Improvingprimary care for patients with chronic illness.JAMA 2002; 288:1775-96. Coleman K, Austin BT, et al. Evidence on theChronic Care Model in the New Millennium.Health Affairs 2009; 28:75-85.7. Lorig KR, Ritter P, et al. Chronic disease self-managementprogram. Med Care 2001; 39:1217-23.8. O’Toole TP, Conde-Martel A, et al. Health care forhomeless veterans. J Gen Intern Med 2003 18:929-339. Kilbourne AM, McCarthy JF, , et al. Access to andsatisfaction with care comparing patients with andwithout serious mental illness. Int J Psychiatry Med2006;36:383-99.10. Frayne SM, Yu W, et al. Gender and use of care:planning for tomorrow’s Veterans HealthAdminstration. J Women’s Health (Larchmt)2007;16:1188-99.11. Selim AJ, Berlowitz DR, et al. The health status ofelderly veteran enrollees in the Veterans Health Administration.J Am Geriatr Soc 2004;52:1271-6.Thomas P. O’Toole, MD, is Chief, PrimaryCare Service, Providence VA MedicalCenter, and Associate Professor of Medicine,The Warren Alpert Medical Schoolof Brown University.Disclosure of Financial InterestsThe author has no financial intereststo disclose.CORRESPONDENCEThomas P. O’Toole, MDProvidence VA Medical Center830 Chalkstone Ave.Providence, RI 02908e-mail: Thomas.O’Toole@va.gov

Mental Health Care at the Providence VA Medical Center:Providing Integrated Comprehensive Mental Health ServicesMichael G. Goldstein, MDThough mental health care has alwaysbeen a core element of the Veterans Affairs(VA) health care system, in recentyears mental health care has receivedgreatly increased attention, support andresources from the Veterans Health Administration(VHA). TheVHA’s 2004Comprehensive Mental Health StrategicPlan (MHSP) 1 included over 200initiatives designed to enhance mentalhealth care and integrate mental healthcare with other VHA healthcare services,particularly in Primary Care. The MHSPled to the funding of the VA’s MentalHealth Enhancement Initiative, whichallocated funds to create a number ofnew mental health services and the expansionof several others at PVAMC.The VHA Handbook, Uniform MentalHealth Services in VA Medical Centersand Clinics, issued in June 2008 and updatedin September 2008, 2 establishesminimum clinical requirements for VHAmental health services and serves as a blueprintfor the implementation of the MHSPat all VA Medical Centers. The UniformMental Health Services initiative seeks tocreate “a system providing ready access tocomprehensive, evidence-based mentalhealth care.” The handbook outlines thoseservices that must be provided at each VAMedical Center (VAMC), as well as thegeneral principles that must guide thedelivery of all mental health care.These principles include: 1) mentalhealth care is an essential component ofoverall health care: 2) mental health caremust be integrated or coordinated withother health care, especially primary care;3) care must be patient-centered, recovery-focusedand strength-based and mustemphasize the importance of engaging patientsin decision-making, treatment planningand self-management; 4) cliniciansmust be culturally competent, includinghaving an understanding of military andveterans’ culture; 5) care should be evidence-basedand consistent with currentresearch and practice guidelines; 6) familyinvolvement in care and treatment decisionsshould be offered when desiredby the veteran; and 7) program and servicesshould be linked to programs andresources in the community to enhancethe veteran’s access to these resources andto allow him or her to become a more engagedand supported member of community-basedsocial networks.In this paper, we will provide severalexamples of these new services.THE GROWTH OF MENTAL HEALTHSERVICES AT THE PVAMCOf the 30,000 veterans enrolled at thePVAMC, more than 8,000 received mentalhealth care in the fiscal year 2008-2009.We are on track to record over 90,000 outpatientencounters in 2008-9 within a widevariety of outpatient mental health treatmentprograms. The majority of these veterans aretreated at the Providence VA MedicalCenter’s main campus, while a rapidly growingnumber of veterans receive care at our 3Community-Based Outpatient Clinics(CBOCs) in Middletown, RI, and in NewBedford and Hyannis, MA. Veterans requiringsupervised living receive clinical and caremanagement services within VA-approvedcommunity-based residential care facilitiesthroughout Rhode Island and southeasternMassachusetts. Figures 1 and 2 show substantialgrowth of our patient population andthe number of outpatient mental healthencounters at PVAMC over the last 7 years.Since 2003, we have experienced a 68%increase in the number of veterans servedand a 58% increase in outpatient encounters.PVAMC supports 115 full time equivalentpositions across MHBSS programs, adramatic increase over the past 7 years. Ourstaff includes social workers, psychologists,psychiatrists, nurses, pharmacists, administrative/clericalstaff and addiction and vocationalcounselors. We also provide trainingopportunities for trainees from virtually allthese disciplines and we enjoy academic affiliationswith the Warren Alpert MedicalSchool of Brown University, the Universityof Rhode Island, and Rhode Island College.These increases in patients and staffingare largely a result of significant expansionand enhancement of mental health programsand services at PVAMC, spurred by theVHA’s Comprehensive Mental Health StrategicPlan and Mental Health EnhancementInitiatives. As noted, the VHA is deeply committedto putting mental health care on apar with other health care services. AtPVAMC, we are grateful for having receivedour fair share of enhancement funds fromthe VHA. Enhancement Initiatives have ledto the launching of a number of new servicesat PVAMC over the last several years,including: the Opiate Treatment Program;an Intensive Outpatient Substance AbuseTreatment Program; a Mental Health IntensiveCase Management (MHICM) programfor patients with serious and persistentmental illness, based on the evidence-basedAssertive Community Treatment model 3 ; aReturning Veterans Mental Health program;an Integrated Mental Health-Primary CareFigure 1. Unique MHBSS Patients Served at Providence VA Medical Center, 2003-2009VOLUME 93 NO. 1 JANUARY 201013

14Figure 2. Outpatient MHBSS Clinic Encounters at Providence VA Medical Center, 2003-2009program 4 ; and an innovative Serious MentallyIll (SMI) medical clinic for patients withcombined chronic medical and psychiatricconditions, conducted in collaboration withprimary care, described by Dr. O’Toole inthis issue. In addition, enhancement fundinghas been used to: increase access to servicesin our 3 Community-Based OutpatientClinics; meet the treatment needs of patientswith co-morbid PTSD and Substance Abusedisorders; expand care management servicesthroughout outpatient programs; offer suicideprevention education, resources andtools throughout the PVAMC; and developnew programs to address homeless veterans.In concert with these new or enhancedmental health services, the PVAMC continuesto provide more “traditional” mentalhealth services, including: a 17 bed InpatientPsychiatry Unit (soon to be 21 beds ona newly renovated unit); an Interim Care(Emergency Care/Triage) service; generaland specialty outpatient mental programs(including specific programs in Post TraumaticStress Disorders, Substance AbuseDisorders, Neuropsychology); and vocationaland rehabilitative mental health services.MENTAL HEALTH SERVICES FORHOMELESS VETERANSThe VHA Uniform Mental HealthServices Handbook ambitiously requires that“all veterans who are homeless, or at risk forhomelessness, must be offered shelterthrough collaborative relationships with providersin the community. Facility staff mustensure that homeless veterans have a referralfor emergency services and shelter or temporaryhousing.” 2 To meet this mandate,MEDICINE & HEALTH/RHODE ISLANDMHBSS staff at PVAMC administer a rangeof programs, including: outreach and linkageswith local shelters and community agenciesthat offer emergency shelter and provisionsto homeless veterans; participation inthe homeless primary care clinics developedby Dr. O’Toole and described in this issue; aGrant and Per Diem transitional housingprogram that includes 24/7 on call supportand case management; and a Departmentof Housing and Urban Development(HUD)-VA Supported Housing (VASH)Program. The HUD-VASH Program isnoteworthy. Through a partnership agreement,HUD provides permanent rental assistancevouchers to homeless veterans referredby MHBSS social workers. MHBSSsocial workers also provide case managementand other clinical services to veterans in thisprogram. A case worker is provided for every35 veterans who receive HUD-VASHvouchers. In the last year, PVAMC staffdistributed 35 HUD-VASH vouchers tolocal veterans and their families; in the comingyear we expect to provide another 100vouchers. During this same period, 159patients were placed in the Grant Per Diemtransitional housing program.MEETING THE MENTAL HEALTHNEEDS OF RETURNING VETERANSTo date, over 1.6 million veterans haveserved in Operation Enduring Freedom(OEF) in Afghanistan and Operation IraqiFreedom (OIF) in Iraq. 5 According to onestudy, of the OEF/OIF veterans entering VAhealth care from 2002-2008, approximately37% received mental health diagnoses, including22% with Post Traumatic Stress Disorder,17% with depression and approximately10% with alcohol use or other druguse disorders. 5 Over the last 2 years, PVAMCmental health professionals have participatedin approximately 100 Returning Veteransoutreach events, reaching over 2400 veteransand almost 1200 family members, militaryleaders and civilians. Currently, over540 OEF/OIF veterans are enrolled in ourReturning Veterans mental health clinic.Meeting the mental health needs of thesereturning veterans requires close coordinationamong multiple health care serviceswithin the VA, including primary care, neurology,newly developed Traumatic BrainInjury and Polytrauma services, as well as surgical,specialty medical and rehabilitative services.MHBSS staff also coordinate care withlocal military and national guard health careproviders as well as with counselors at VetCenters in Warwick, RI and Hyannis, MA.Vet Centers (administered by the Departmentof Veterans Affairs, but not part of theVHA) offer outreach, individual, group,marital and family counseling to veterans andtheir families.RECOVERY-FOCUSED CAREAn emphasis on recovery-focused care isconsistent with recent efforts, within and outsidethe VA, to shift the focus of mental healthcare from traditional clinician-centered goals(e.g., symptom management, medication taking,following through with treatment) tobroader, patient and family-centered goals thatinclude increased social functioning and integrationwithin the patient’s community. 6,7 Accordingto the National Consensus Statementon Mental Health Recovery (http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/ ), “Mental health recoveryis a journey of healing and transformationenabling a person with a mental healthproblem to live a meaningful life in a communityof the person’s choice while striving toachieve ... full potential.” Within the VA, cliniciansare encouraged to promote 14 fundamentalcomponents of recovery-focusedcare: 1) self-direction; 2) individualized andperson-centered; 3) empowerment; 4) holistic;5) non-linear; 6) strengths-based; 7) peersupport; 8) respect, 9) responsibility; 10)hope; 11) privacy; 12) security; 13) honor;and 14) support for VA patient rights.In 2007, each VA medical center, includingPVAMC, appointed a Local RecoveryCoordinator (LRC), who is responsiblefor promoting the integration of recoveryprinciples into all mental health services pro-

vided at PVAMC and providing training andconsultation to facility leadership, staff, veterans,and family members. At PVAMC, ourLRC conducted or supported multiple trainingsessions for MHBSS staff in recoveryfocusedprinciples and strategies. Of note isthe close alignment between the recoveryorientedmodel of mental health care andthe patient-centered, empowerment, patientactivation and self-management models thathave been associated with enhanced outcomesof care when adopted within primarycare settings. 8,9 Dr. O’Toole, Chief of PrimaryCare at the PVAMC, discusses the integrationof these patient-centered modelsinto primary care in this issue.The growth and expansion of thePVAMC’s Veterans Resource and RecoveryCenter (VRRC) provides veterans with programsand services designed to enhance theirsocial, behavioral and vocational skills. Vocationalprograms include Compensated WorkTherapy (CWT), Transitional Work Experience(TWE), Supported Employment(SE) and Incentive Work Therapy (IWT).These occupational rehabilitation, maintenanceand therapeutic programs are designedto: 1) assist the veteran to develop skillsneeded to return to competitive work; 2) facilitatethe veteran’s transition into theworkforce at-large; and (3) assist the veteranto engage in other activities that enhance selfesteem,self-worth and gainful activity. OtherVRRC programs linked to the occupationalprograms include Job Club, Computer Lab,Horticultural Program, the Vet-to-Vet PeerSupport Group Program, and the WRAPself-management support skills groups. ThePVAMC VRRC has enrolled scores of veteransinto its rehabilitative and recovery-focusedprograms. Each year the VRRC programsplace approximately 30 veterans intopermanent jobs in the community.MH-PC INTEGRATIONThe VHA’ s Uniform Mental HealthServices Handbook stipulates that all VAMedical Centers have integrated mentalhealth services co-located within primary careclinics. These programs must utilize a blendedmodel that includes collaborative care and caremanagement programs. To meet this mandate,the PVAMC has co-developed an integratedMental Health-Primary Care (MH-PC) program staffed by psychologists, socialworkers, psychiatric clinical nurse specialistsand a consulting psychiatrist to work alongsideprimary care colleagues to meet the mentalhealth needs of patients in primary careclinical settings. Primary care providers routinelyemploy mental health diagnostic screeningprotocols for substance abuse (includingtobacco), depression and PTSD. Embeddedmental health staff are available within the primarycare setting to accept “warm hand-offs”and provide follow-up mental health assessments,psychopharmacologic consultations,depression care management, brief on-sitetreatment of mental health conditions, smokingcessation interventions, and referral to moreintensive mental health services when indicated.Programmatic efforts to enhance patientself-management of chronic medical conditions,manage chronic pain, address adherenceto medical treatment and reduce riskyhealth behaviors (e.g., sedentary behavior,obesity) are being co-developed by primarycare and mental health staff at the PVAMC.In his article, Dr. O’Toole describes severalefforts at PVAMC to tailor services to meetthe combined mental health and primary careneeds of 4 especially vulnerable populations.…of the OEF/OIF[Afghanistan andIraq] veteransentering VA healthcare from 2002-2008, approximately37% receivedmental healthdiagnoses…CONCLUSIONThe Mental Health and Behavioral SciencesService (MHBSS) at the ProvidenceVA Medical Center (PVAMC) provides anarray of services, resources and programs tomeet the mental health, psychosocial and behavioralhealth needs of veterans in RhodeIsland and Southeastern Massachusetts. Recovery-focused,veteran-centered, evidencebasedmental health care is offered in a varietyof settings including an acute inpatient unit,general and specialty outpatient mental healthunits, innovative integrated Mental Health-Primary Care Programs, residential programsfor homeless and seriously mentally ill veterans,special programs for veterans returningfrom current conflicts in Afghanistan andIraq, and a Veterans Resource and RecoveryCenter, which offers vocational, rehabilitativeand self-management services. Through linksand partnerships with community and militaryservice organizations, the PVAMC alsoprovides educational and preventive servicesto veterans and their families. We are planningthe expansion of services in geriatric mentalhealth care, outpatient detoxification, mentalhealth care for women veterans, peer-peerinterventions, family involvement in care, andprimary care-based interventions to enhancechronic illness self-management and healthrisk behavior change. The VA’s approach toproviding integrated and comprehensivemental health care serves as a model for a publiclyfunded public health care system.REFERENCES1. Department of Veterans Affairs, VHA Mental HealthStrategic Plan Workgroup/Mental Health StrategicHealth Care Group, and Office of the AssistantDeputy Under Secretary for Health, A ComprehensiveVHA Strategic Plan for Mental Health Services-Revised. 2004.2. Department of Veterans Affairs, VHA Handbook1160.01, Uniform Mental Health Services in VA MedicalCenters and Clinics, D.o.V. Affairs, Editor. 2008.3. Mueser K, et al. Models of community care for severemental illness. Schizophrenia Bull 1998; 24: 37-74.4. Butler M, et al. Integration of Mental Health/SubstanceAbuse and Primary Care: Evidence Report/TechnologyAssessment No. 173 2008, Prepared by the MinnesotaEvidence-based Practice Center under Contract No.290-02-0009.: Rockville, MD.5. Seal KH, et al. Trends and risk factors for mental healthdiagnoses among Iraq and Afghanistan veterans usingDepartment of Veterans Affairs health care, 2002-2008. Am J Public Health 2009; 99:1651-8.6. Farkas M, et al. Implementing recovery oriented evidencebased programs.Community Mental Health J 2005; 41:141-58.7. Ralph RO, Corrigan PW, eds. Recovery in Mental Illness.Broadening Our Understanding of Wellness. 2005,American Psychological Association: Washington, DC.8. Bodenheimer T, et al. Patient self-management ofchronic disease in primary care. JAMA 2002; 288:2469-75.9. Stewart M, et al. The impact of patient-centered careon outcomes. J Fam Pract 2000; 49:805-7.Michael G. Goldstein, MD, is Chief,Mental Health and Behavioral SciencesService, Providence VA Medical Center,and Professor of Psychiatry and HumanBehavior, the Warren Alpert MedicalSchool at Brown University.Disclosure of Financial InterestsThe author has no financial intereststo disclose.CORRESPONDENCEMichael G. Goldstein, MDProvidence VA Medical Center830 Chalkstone Ave.Providence, RI 02908Phone: (401) 273-7100 x3156e-mail: Michael.goldstein2@va.govVOLUME 93 NO. 1 JANUARY 201015

16Military Blast Injury In Iraq and Afghanistan:The Veterans Health Administration’sPolytrauma System of CareStephen T. Mernoff, MD, FAAN, and Stephen Correia, PhDThe proportion of veterans cared for bythe Veterans Health Administration(VHA) is rapidly shifting to those derivingfrom the Gulf War, which began in1990 and the Global War on Terror,which began in 2001. 1 The conflicts inAfghanistan (Operation Enduring Freedom,OEF) and Iraq (Operation IraqiFreedom, OIF), have produced1,016,213 veterans; and 454,121 ofthem have received care through theVHA as of the second quarter of 2009. 2As of July 31, 2009, 3980 US servicemembers have been killed and almost35,000 have been wounded in actionin OEF/OIF. 3 Explosive blasts haveaccounted for about 60% of these injuries.4,5 Other mechanisms of injury includeprojectiles (bullets, shrapnel), motorvehicle collisions, falls, and non-combat-relatedassaults. Service membersare surviving combat injuries at muchhigher rates than in past conflicts 5 anda high percentage of these individualshave traumatic brain injury (TBI),which has led to TBI’s label as the “signatureinjury” of OEF/OIF. 6 Estimatedrates of TBI in OEF/OIF reported inthe media vary widely with some beingalarmingly high. However, empiricalsupport for these estimates is limited dueto the small sample size, reliance on selfreportdata, use of data derived from asingle center, and restrictive inclusioncriteria. 5 Epidemiological data for injuriesin these conflicts continues to developbut a rigorous scientific study ofthe prevalence of TBI has not beendone. 5MEDICINE & HEALTH/RHODE ISLANDBLASTS, TBI, AND PTSD IN THEMILITARY POPULATIONBlasts are by far the most commoncause of wounded-in-action injuries anddeath in OEF/OIF. 5,6 The majority ofblasts are from improvised explosive devices.The most commonly involved organsystems include skin and muscle, skeletal,pulmonary, gastrointestinal, cardiovascular,vestibular, and neurological includingbrain, spinal cord, and peripheralnerves.The mechanisms by which blastscause TBI are unclear but likely arise froma combination of primary and secondaryeffects. The primary effect derives fromthe blast pressure wave. Evidence thatthese pressure waves can cause brain injuryderives from animal studies. 7,8 Secondaryeffects contributing to blast-relatedTBI include impact from projectileslaunched by the blast or from the victimstriking his or her head against theground or other stationary objects as aresult of the blast.The definition of mild TBI (mTBI)adopted by the VHA and Departmentof Defense (DOD) is based on the 1993American Congress of RehabilitationMedicine criteria:Mild traumatic brain injury isa traumatically-induced structuralinjury or physiologicaldisruption of brain functionresulting in one of the following:brief alteration in consciousness(dazed, disoriented,or confused), or loss of consciousness(LOC) of 30 minutesor less, or 24 hours or lessof posttraumatic amnesia(PTA, i.e., a loss of memory forthe period surrounding theevent that may occur with orwithout LOC).It is unknown whether the natureor prognosis of blast-related mTBI differsfrom other causes of mTBI. Recentdata suggest that the cognitive profiles ofpatients with blast-related vs. impact-relatedmTBI are similar. 9 Blast-relatedmTBI may have a stronger associationwith PTSD than other causes of mTBI. 5Recent studies have demonstrated a highrate of comorbidity with post traumaticstress disorder (PTSD). 10-12 As of thefirst quarter of 2009 approximately102,000 of OEF/OIF veterans havebeen diagnosed with PTSD. 2Postconcussive and PTSD symptomsoverlap considerably but not completely.13 Shared symptoms include depression/anxiety,insomnia, appetitechanges, irritability/anger, concentrationdifficulty, fatigue, hyperarousal, andavoidance. Symptoms more uniquely associatedwith persistent postconcussivesyndrome include headache, heightenedsensitivity to light and sound, dizzinessand disequilibrium, and memory impairment.Symptoms that are more uniqueto PTSD include re-experiencing,shame, and guilt. Nonetheless, accuratelyparsing the extent to which anindividual’s symptoms are attributed toPTSD vs. TBI is difficult, especially whenrelying on retrospective self-report of atemporally remote event. Many believethat it is more parsimonious and clinicallyuseful to conceptualize these symptomsas a single syndrome rather than two distinctentities. One term that has beenproposed is Combat-Related Brain Injuryand Stress Syndrome (David X. Cifu,personal communication, October2007). One of the authors (S.M.) hasused the term “Deployment-RelatedCognitive Impairment” to refer to thefrequent cognitive complaints of inattentionand forgetfulness. This term alignswell with previous findings of deployment-relatedneuropsychological deficitsin army personnel deployed in the Iraqwar. 14POLYTRAUMA SYSTEM OF CAREThe rate of survival of combat injuriesin OEF/OIF, including TBI, is approximately90% 15 —considerably higher thanin previous conflicts. The high survival rateis due mainly to improvements in helmetand body armor and to improved deliveryof medical care including battlefield andin-theater hospital innovations. 5 This hasled to a high number of veterans with re-

habilitative needs. In response, the VHAestablished the Polytrauma Sytem of Carein 2004 with a mission “To ensure that theneeds of injured service members and Veteransare met.” 16 The VHA definespolytrauma as follows:“…two or more injuries sustainedin the same incident thataffect multiple body parts or organsystems and result in physical,cognitive, psychological, orpsychosocial impairments andfunctional disabilities. TBI frequentlyoccurs as part of thepolytrauma spectrum in combinationwith other disabling conditions,such as amputations,burns, pain, fractures, auditoryand visual impairments, PTSD,and other mental health conditions.When present, injury tothe brain is often the impairmentthat dictates the course of rehabilitationdue to the nature ofthe cognitive, emotional, and behavioraldeficits related toTBI.” 16The system is a hierarchy of facilitieswith particular roles:Polytrauma Rehabilitation Centers(PRC) provide acute high-intensityrehabilitative and medical care forthe seriously injured. There are fourPRCs, located at VA Medical Centersin Tampa, FL; Richmond, VA;Minneapolis, MN; and Palo Alto,CA. A fifth center is under constructionat San Antonio, TX.Polytrauma Network Sites (PNS) providepost-acute inpatient and outpatientinterdisciplinary rehabilitativecare of moderate intensity formedically stable patients. Each ofVHA’s 22 Veterans Integrated ServiceNetworks (VISNs) has onePNS. The PNS for the New Englandregion (VISN-1) is the BostonVA Health Care System.Polytrauma Support Clinic Teams(PSCT) are interdisciplinary teamsthat manage medically stable outpatientswith an interdisciplinarytreatment plan. Patients are monitoredfor progress and the teamidentifies unresolved problems andimplements solutions. Eighty onePSCTs have been established nationally.Polytrauma Points of Contact (PPOC)are staff members at all remainingVA facilities who assist veterans inaccessing the Polytrauma system.Patients can be referred up or downthe hierarchy in accordance with theirmedical needs and the services providedat the various facilities.POLYTRAUMA SYSTEM: SCREENINGFOR TBIVHA Directive 2007-13 establishedscreening of all service members returningfrom deployment in OEF/OIF todetermine if they had possibly sustaineda deployment-related traumatic braininjury that had not already been diagnosed.In response, the VA PolytraumaProgram developed a standard, two-tierscreening process implemented nationally.The data collected is entered into theVA’s electronic medical record system andis tracked nationally.The initial screen, called the “TBIClinical Reminder,” is required for allOEF/OIF veterans who enter the VAhealth care system. The Reminder consistsof a set of yes-no questions organizedinto four sections that determine whetheror not the veteran experienced the following:exposure to a deployment-relatedevent with risk for TBI; acute alterationof consciousness; postconcussive symptomsduring the immediate post-acutephase; persistence of such symptoms currently.A positive screen is defined as anaffirmative response to all four sections;a negative response to any section resultsin a negative screen. The reliability andvalidity of the screen have not been established,and is under research investigation.Veterans who screen positive are referredfor a “Comprehensive Second-Level Evaluation” which consists of a standard,more detailed assessment of TBI.It is intended to determine more accuratelythe likelihood that a veteran sustaineda TBI and to estimate the severityof the injury. It also assesses symptoms,elicits clinicians’ opinions about the likelihoodthat the symptoms reflect the effectsof TBI and/or other factors (e.g., psychiatricdisorder), and establishes a treatmentplan. At most VA facilities, the“Second-Level Evaluation” is performedby a “TBI specialist,” typically a physiatristor neurologist, who leads thepolytrauma team at that facility.Except in relatively rare cases inwhich documentation is available, theinitial screen and the Second-Level Evaluationtypically rely on patients’ recall oftheir injuries. This is an important limitationto the system because retrospectiveself-report of an event or events thatoccurred many months or years earliermay be unreliable. Moreover, the intenseemotional reaction to the chaotic eventof a blast may well acutely and transientlyalter cognitive function which couldmasquerade as TBI or enhance its effectsand it can be very difficult teasing thesefactors apart. At the PVAMC, we haveadopted a fairly parsimonious clinicalguideline for determining the presenceof absence of TBI: a patient who can relatea continuous narrative before/during/afteran event seems unlikely to havesuffered a physiologic disruption of brainfunction. We have found this guidelineto be quite helpful in ambiguous casesbut its reliability and validity have notbeen determined.DIAGNOSIS OF TBI IN THEPOLYTRAUMA SYSTEMNational Experience (data roundedoff to nearest 1000):The TBI Clinical Reminder wasimplemented in April 2007. ThroughMay 31, 2009, 316,000 veterans havecompleted the Clinical Reminder;63,000 (20%) screened “positive” forpossible TBI. Of these, 41,000 completedthe Comprehensive Second-Level Evaluationwhich confirmed the mTBI diagnosisin 20,000 (49%). This estimate doesnot include an additional 9440 veteranswho self-reported having been previouslydiagnosed with TBI during their deployment.There is considerable variabilityacross VA Medical Centers in the rateat which mTBI is diagnosed by this process.Potential reasons include variabilityin the combat roles of military unitsbased in different geographical regionsof the U.S. (some combat roles carryVOLUME 93 NO. 1 JANUARY 201017

18greater risk for TBI than others), variabilityin TBI experience of cliniciansperforming the evaluations, and the institutionallearning curve given the factthat the process was introduced relativelyrecently.Providence VAMC Experience:Through May 31, 2009, thePVAMC has screened 1672 veteranswith the Clinical Reminder; of these, 262(15.7%) have screened “positive.” Ofthese positive screens, 184 have completedthe Comprehensive Second-LevelEvaluation, which confirmed the mTBIdiagnosis in 120 (65%).Our Polytrauma Team functions asa PSCT (official designation by VHA ispending). The team is led by a neurologistspecializing in neurorehabilitation/TBI and includes a social worker/casemanager, neuropsychologist, primarycare physician, and a psychologist specializingin PTSD, as well as a physicaltherapist, occupational therapist, speechtherapist, ENT nurse practitioner, andhearing and vision specialists. Other disciplinesare consulted as needed. Theteam meets weekly to review veteransnew to the Polytrauma Team and to provideperiodic review of established patients.A weekly Polytrauma intake clinic(neurologist, neuropsychologist, socialworker/case manager) screens newly referredveterans to identify ongoing problemsand develop a treatment plan. Inaddition, the neurologist and case managerhave a weekly Polytrauma/TBI follow-upclinic in which veterans with ongoingmedical and psychosocial problemsare seen as needed. The majority of patientsseen by our team likely sustainedmTBI during their OEF/OIF deploymentwithout concomitant severe somaticinjuries.MEDICINE & HEALTH/RHODE ISLANDSYMPTOM MANAGEMENTThe most common complaints ofpatients in the Polytrauma Clinic includepain (mostly headaches and back pain),dizziness, hearing loss/tinnitus, sleep difficulty,anxiety and symptoms of PTSD,and cognitive complaints such as forgetfulnessand diminished concentration.As there is no “specific” treatmentfor cognitive complaints in mTBI, emphasisis placed on identifying and treatingmodifiable factors such as PTSD,depression, substance abuse, sleep deprivation,pain, and other factors such asloss of employment and marital distress,that might be contributing to veterans’symptoms and which, if adequatelytreated or addressed, could have a positiveimpact on their quality of life. ThePolytrauma Team makes referrals to specialistsand VA programs as needed andpromotes veterans’ compliance with treatmentplans. The most common referralsare to the PVAMC Mental Health andBehavioral Science Service, particularlyto the PTSD Clinic, the Returning VeteransProgram, the Substance AbuseTreatment Program, and to the NeuropsychologyClinic. Referrals to PhysicalTherapy and Speech and Language Pathologyservices (the latter for cognitiveretraining) are also common. ThePolytrauma Team emphasizes educatingpatients and their families about the expectedtrajectory of recovery from mTBIand the possible treatable factors. Suchinterventions have been shown to reducethe likelihood of patients with mTBI developingpersistent postconcussion syndrome.17,18As of the firstquarter of 2009approximately102,000 of OEF/OIF veterans havebeen diagnosedwith PTSD.MILD TBI: CONTROVERSIESHoge et al 19 raise several concernsabout the DOD/VA process for diagnosisand management of mTBI. First,they postulate that the screening processrisks incorrect attribution of nonspecificsymptoms to mTBI. Second,they suggest that disability may be overlyattributed to mTBI, and they raise thepossibility that “post-deployment screeningis…likely to promote negative expectationsfor recovery.” They also assertthat misattribution of symptoms tomTBI potentially places veterans at riskof negative consequences, includingmedication adverse effects, failure toadequately address concurrent conditions(e.g., depression, PTSD, substanceabuse, etc.), and inappropriate use ofrehabilitation procedures. They suggestdevelopment of improved definitionsand diagnostic criteria and processes.The VHA’s standardized team approachaims to minimize over-diagnosisand misattribution errors via thoroughSecond-Level Evaluations that assess forco-existing conditions that may be contributingto symptoms and addressingthem appropriately. Many believe thatthe benefit derived from the thoroughnessof this process in identifying andaddressing previously untreated symptomsoutweighs the risk of over- diagnosis,and that when managed by trainedphysicians and ancillary providers, therisk of negative consequences is minimal,if present at all. Finally, the data to designimproved diagnostic criteria are notyet available.CONCLUSIONSVeterans of conflicts occurring overthe last nineteen years often have complex,multisystem injuries, and a largenumber are being diagnosed with mildTBI with significant comorbidities includingPTSD and somatic injuries,particularly auditory/vestibular injuries.The Polytrauma System of Care is designedto standardize the diagnosis andmanagement of these conditions nationwide.Although making the diagnosis ofmTBI requires ongoing assessment, ourexperience at PVAMC has been that thePolytrauma Team has been effective inbringing veterans with multiple injuriesand/or medical conditions into thehealth care system, helping them accessthe care they need, and monitoring theirprogress.ACKNOWLEDGMENTSThe authors thank David Chandler,PhD, Deputy Chief Consultant, RehabilitationServices, VHA, for his helpfulcomments on this manuscript. This materialis based upon work supported bythe Office of Research and DevleopmentRehabilitation R&D Service, Departmentof Veterans Affairs. The contentsof this manuscript do not represent theviews of the Department of Veterans Affairsor the United States.

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REFERENCES1. National Center for Veterans Analysis and Statistics.2007. http://www1.va.gov/vetdata/docs/2l.xls2. Bidelspach D. Personal communication (July 29,2009). (VHA Office of Public Health and EnvironmentalHazards, Veterans Affairs PolytraumaProgram Office).3. US Department of Defense. 2009www.defenselink.mil/news/casualty.pdf.4. Gawande A. Casualties of war—military care forthe wounded from Iraq and Afghanistan. NEJM2004; 351:2471-5.5. Ling G, Bandak F, et al. Explosive blastneurotrauma. J Neurotrauma 2009; 26: 815-25.6. Warden D. Military TBI during the Iraq and Afghanistanwars. J Head Trauma Rehab 2006;21:398-402.7. Cernak I, Wang Z, et al. Ultrastructural and functionalcharacteristics of blast injury-inducedneurotrauma. J Trauma 2001;50:695-706.8. Cernak I, Wang Z, et al. Cognitive deficits followingblast injury-induced neurotrauma. BrainInj 2001;15:593-612.9. Belanger HG, Kretzmer T, et al. Cognitive sequelaeof blast-related versus other mechanisms of braintrauma. J Int Neuropsychol Soc 2009;15:1-8.10. Hoge CW, et al. Mild traumatic brain injury inUS Soldiers returning from Iraq. NEJM 2008;358:453-463.11. Schneiderman AI, Braver ER, Kang HK. Understandingsequelae of injury mechanisms and mildtraumatic brain injury incurred during the conflictsin Iraq and Afghanistan. Amer J Epidemiol2008; 167:1446-52.12. Vanderploeg RD, Belanger HG, Curtiss G. Mildtraumatic brain injury and posttraumatic stress disorderand their associations with health symptoms.Arch Phys Med Rehabil 2009; 90: 1084-93.13. Stein MB, McAllister TW. Exploring the convergenceof posttraumatic stress disorder and mildtraumatic brain injury. Amer J Psychiatry2009;166:768-76.14. Vasterling JJ, et al. Neuropsychological outcomesof army personnel following deployment to theIraq war. JAMA 2006;296:519-29.15. Goldberg M. Testimony before the Committeeon Veterans’ Affairs, U.S. House of Representatives,.(Congressional Budget Office, 2007).16. Department of Veteran Affairs, Veterans HealthAdministration, Directives 2009-028.17. Miller LJ, Mittenberg W. Brief cognitive behavioralinterventions in mild traumatic brain injury.Applied Neuropsychol 1998; 5: 172-83.18. Mittenberg W, Canyock EM, et al. Treatment ofpost-concussion syndrome following mild headinjury. J Clin Experimental Neuropsychol2001;23:829-36.19. Hoge CW, Goldberg HM, Castro CA. Care ofwar veterans with mild traumatic brain injury—flawed perspectives. NEJM 2009;360:1588-91.Stephen T. Mernoff, MD, FAAN, isChief, Neurology Section, and Leader,Polytrauma Team, Providence VA MedicalCenter, and Assistant Professor of Neurology(Clinical), The Warren Alpert MedicalSchool of Brown University.Stephen Correia, PhD, is NeuropsychologySection Chief, Providence VAMedical Center, and Assistant Professor ofPsychiatry and Human Behavior, The WarrenAlpert Medical School of Brown University.Disclosure of Financial InterestsThe authors have no financial intereststo disclose.CORRESPONDENCEStephen T. Mernoff, MDProvidence VA Medical Center830 Chalkstone AveProvidence, RI 02908e-mail: Stephen.Mernoff@va.govVOLUME 93 NO. 1 JANUARY 201021

Neurorehabilitation Research Laboratoryat the Providence VAMCAlthough there has been tremendousprogress in treating neurological injuriesand disorders, there remains ample opportunityto improve recovery and to restorefunction in chronic and progressiveconditions, particularly during the acuteand subacute phases. As our understandingof neuroplasticity has advanced alongwith technology, attention has focused onnovel methods to augment more traditionalprocedures to reverse impairmentand regain function.The field of rehabilitative therapy hasrecently seen an explosion in the developmentof robotic technology for rehabilitation.A MEDLINE search for therapeuticrobotics yields only 15 results prior to1990, but as of September 16, 2009,there were 2095 results. The consequenttechnological and methodological advances1-3 have been particularly exciting.These devices provide high-volume, repetitive,reproducible, safe therapy andalso allow for reliable, instrumented outcomesof motor performance. One of thebest examples of such devices with a largequantity of pilot human data is the MIT-Manus 3 (InMotion Technologies, Inc.,Watertown, MA), which includes modulesfor shoulder, elbow and hand. Otherupper-extremity robotics include theARM Guide, the MIME, the InMotionShoulder-Elbow Robot, and the Bi-Manu-Track. 1,3 There also exist computeraidednon-robotic therapy orthotics suchas the T-WREX 4 , which allows upper-extremitymovement with 5 degrees of freedomand passively eliminates the force ofgravity via a system of elastics and metallinkages. For the lower extremities, thereexist gait training devices such as theLokomat (Hocoma, Zurich, Switzerland),a body weight-supported treadmill withrobotic orthotics which guide the legsthrough an idealized gait cycle. TheLokomat has been used in research interventionsfor neurological disorders suchas spinal cord injury, 5 stroke, 6 and multiplesclerosis. 7,8 As with the upper extremity,there also exist more focused devicesAlbert Lo, MD, PhDfor the lower extremity, such as the MITAnklebot 9 (InMotion Technologies, Inc.,Watertown, MA), which focuses on trainingankle plantar- and dorsiflexion as wellas in- and eversion. The data from randomizedcontrolled trials of robotics willyield further improvements in methodologyand understanding, allowing rehabilitationcenters to provide more efficientand efficacious care. One can imagine aneventual “robotic gym” 1,2 incorporatinghighly specialized robots capable of addressingevery form and degree of physicaland cognitive disability, all run in concertwith talented therapists.Despite the enthusiasm for robot-assistedtherapy, there is not yet full understandingof how, when, and in which patientpopulations these devices should beused. In order to gain the full potentialof this new technology, careful clinical researchis necessary to establish safe, effectiveprotocols and optimal doses, as wellas to eventually understand how these roboticdevices should be combined withconventional pharmacological and rehabilitativemethods. While robots are anew resource for clinicians to delivertherapy and to measure changes in motorperformance, they will likely neverreplace human interaction, but ratherenhance interactions with therapists.The Neurorehabilitation ResearchLaboratory at the Providence VA MedicalCenter, established in the summer of2007, has been conducting severalprojects examining the efficacy of robotictechnology in improving motor functionin individuals with stroke, multiple sclerosis(MS) and Parkinson’s disease. Additionally,our interests have expandedbroadly to other projects dealing moreinclusively with other aspects of neurologicalinjury, repair, and disability, suchas an epidemiological study on MS andanother study to develop and improvemethods for diagnosis and tracking ofcognitive function for mild traumaticbrain injury. A summary of our currentresearch is provided below.ROBOTIC ASSISTED UPPER-LIMBNEUROREHABILITATION IN STROKEPATIENTSA phase II/III multi-center clinicaltrial funded by the Department of VeteransAffairs is now testing the most advancedMIT-Manus system (includingseparate shoulder, elbow, wrist and handmodules) in chronic stroke patients withupper extremity impairment. The studywas initiated in November of 2006, andenrollment has closed with a total of 127participants at the VA Medical Centersin Baltimore MD, Gainesville FL, SeattleWA, and West Haven CT. This is the firstmulticenter randomized-controlled trialto test a robot-assisted rehabilitation devicefor stroke. The baseline characteristicsfor the study were just published; 10final results are expected to be releasedin early 2010.GAIT & MOBILITY IN MULTIPLESCLEROSIS USING ROBOT-ASSISTEDBODY WEIGHT SUPPORTEDTREADMILL TRAININGImpairment in walking is an importantsource of disability and cause for concernfor people with MS. Even at theearliest stages of disease, MS patients haveobservable gait problems which, in themajority of patients, will progressivelyworsen. 11 Body weight-supported treadmilltraining has been identified as apromising gait-specific intervention forMS, 12 and robotic assistance might proveto be a technological enhancement. Theinclusion of robotic assistance, such as onthe Lokomat, has the added advantageof delivering consistent, guided movementto the legs throughout the gaitcycle.Thirteen MS subjects have completeda randomized, cross-over trial comparingbody weight-supported treadmilltraining with and without robotic assistanceon the Lokomat. 8 In that study,participants improved gait velocity andendurance by over 30%. Approximately20 people have participated in our vari-22MEDICINE & HEALTH/RHODE ISLAND

ous research protocols using theLokomat. Additional studies will continueto refine the optimal dose, treatment regimen,and most relevant outcomes; identifythe patients most likely to respond;and explore the characteristics and neurologicalmechanisms of motor recovery.Dr. Elizabeth Triche from the Departmentof Community Health at BrownUniversity has collaborated on thisproject and is closely involved in many ofthe others presented.ROBOT-ASSISTED TRAINING ANDFOOT DROP IN MULTIPLE SCLEROSISOur clinical and research experiencehas suggested that approximately30% of MS patients experience footdrop. Although gait rehabilitation usingthe Lokomat can improve ambulationin MS patients, people with foot dropstill have difficulty translating task-repetitivegait training to normative gaitpatterns over ground. One of the keylimitations of the Lokomat is a lack ofrobotic assistance for the ankle joint.The MIT Anklebot has the potential toaddress that limitation through focusedankle training, but it does not train theknee or hip.The results of a case-series with 2 MSsubjects with foot drop have been published.1 Additional subjects with MS andfoot drop are being recruited to testwhether Anklebot therapy alone or acombination with Lokomat results in bettermobility. The project is currently enrollingpatients. Collaborators includeDr. Hermano Igo Krebs (MIT) and Dr.Jacob Berger (PVAMC, Department ofNeurology; Brown University).ROBOT-ASSISTED GAIT TRAININGAND FREEZING OF GAIT INPARKINSON’S DISEASEParkinson’s disease, the most commonmovement disorder in neurology,can present with a wide range of motormanifestations, such as bradykinesia,tremor and postural abnormalities.Freezing of gait (FOG) is one of the mostdisturbing symptoms, but there are noeffective treatments for FOG. Studieshave shown that uncoordinated, asymmetricalgait and reduced step length arerelated to FOG, 13 but no group has previouslystudied the effect of robot-assistedgait training on FOG.In collaboration with Drs. JosephFriedman and Victoria Chang, 4 participantshave been examined in a pilotstudy. Pilot data have suggested a reductionin episodes of freezing as well as animprovement in quality of life inParkinson’s disease as a result of robot-assistedgait training. A larger study isplanned.RHODE ISLAND MULTIPLESCLEROSIS STUDY (RIMSS)The Rhode Island Multiple SclerosisStudy (RIMSS) is a communitybasedepidemiological study of MS inRhode Island. This project, in collaborationwith Dr. Stephen Buka, BrownUniversity Professor of CommunityHealth (Epidemiology), is being conductedas a part of the Brown UniversityBioBank initiative. An initial groupof neurologists (Drs. Elaine Jones,Stephen Mernoff, William Stone, MerylGoldhaber, Mason Gasper, and SyedRizvi) has generously contributed in apilot collection of data as well as in gaugingpotential patient participation. TheRhode Island Neurological Society andthe Rhode Island Chapter of the NationalMultiple Sclerosis Society have alsoextended enthusiastic support for thisproject.Much of MS epidemiology andclinical course has been derived fromcohort studies collected outside of theUnited States or from short-term pharmaceuticalclinical trials: 14,15 thesesources may have inherent biases thatlimit their usefulness to typical patientsin the United States. The RIMSS studyproposes to establish a prospective population-basedcohort study of MS, collectingrich epidemiologic and clinical datacritical to both scientific understandingand accurate treatment. Overall goalsinclude enumerating and providing accuratedata on incident and prevalentcases of MS, as well as collecting demographicand diagnostic data from medicalrecords. Study data will describe thedistribution of physical and cognitivedisability, symptomatic areas, magneticimaging changes, disease subtypes, durationof disease, quality of life, and treatmentwith disease modifying agents. Thesecond phase is a longitudinal examinationwhich will follow a group of recentlydiagnosed patients with genetic,neuroimaging, clinical and patient-relatedoutcomes. The scope of thismultidisciplinary study provides an opportunityto build a unique MS cohortbased in Rhode Island to capture criticalinformation and thus better understandthe clinical and epidemiologicalcharacteristics of MS in the UnitedStates.NEW RAPID ASSESSMENT OF MILDTRAUMATIC BRAIN INJURYAs Mernoff and Correia report inthis issue, there are no rapid, reliable,valid, and easily administered tests togauge attention and executive cognitivecapabilities following mild traumaticbrain injury (mTBI). Multiple investigatorsat Brown University and the ProvidenceVAMC (Drs. Stephen Correia,Leigh Hochberg, Albert Lo, StephenMernoff, Michael Worden) are currentlydeveloping an easily administered computerizedassessment of attention, cognitionand motor reaction.The aforementioned projects haveattracted the interest of neurology residents,fellows, graduate students, and undergraduates,all of whom sense the excitementand importance of applying thebest technology and methodology towardrestoring function in individuals with severedisability from neurological disorders.In addition to the physicians andscientists with whom we collaborate atBrown and the Providence VAMC, ourlaboratory includes postdoctoral fellowTara Patterson, PhD, as well as full timeresearch assistants and program coordinatorsMilena Gianfrancesco, DouglasBenedicto, and Elizabeth Jackvony,MPH.Neurorehabilitation research is responsiveto the health needs of veterans.The Providence VAMC has supportedthis unique research, and theNeurorehabilitation Research Laboratorylooks forward to completion of the Centerfor Restorative and RegenerativeMedicine which will soon be the new sitefor this research.AcknowledgmentsThis work is supported by the Officeof Research and Development RehabilitationR&D Service, Departmentof Veterans Affairs.VOLUME 93 NO. 1 JANUARY 201023

REFERENCES1. Krebs H, et al. A paradigm shift for rehabilitationrobotics. IEEE-EMBS Magazine 2008;27: 61-70.2. Krebs HI, Hogan N. Therapeutic robotics. Proc.IEEE 2006; 94: 1727-38.3. Kwakkel O, Kollen BJ, Krebs HI. Effects of robot-assistedtherapy on upper limb recovery afterstroke. Neurorehabil Neural Repair 2008;22:111-21.4. Housman SJ, Scott KM, Reinkensmeyer DJ. Arandomized controlled trial of gravity-supported,computer-enhanced arm exercise for individualswith severe hemiparesis. Neurorehabil Neural Repair2009;23: 505-14.5. Winchester P, et al. Changes in supraspinal activationpatterns following robotic locomotortherapy in motor-incomplete spinal cord injury.Neurorehabil Neural Repair 2005; 19:313-24.6. Hidler J, et al. Multicenter randomized clinicaltrial evaluating the effectiveness of the Lokomatin subacute stroke. Neurorehabil Neural Repair2009;23:5-13.7. Beer S, et al. Robot-assisted gait training in multiplesclerosis. Mult Scler 2008;14:231-6.8. Lo AC, Triche EW. Improving gait in multiplesclerosis using robot-assisted, body weight supportedtreadmill training. Neurorehabil NeuralRepair 2008;22:661-71.9. Roy A, et al. Robot-aided neurorehabilitation.IEEE Trans Robotics 20009; 25:569-82.10. Lo AC, et al. Multicenter Randomized Trial ofRobot-Assisted Rehabilitation for Chronic Stroke:Methods and Entry Characteristics for VA RO-BOTICS. Neurorehabil Neural Repair 23, 775-783 (2009).11. Weinshenker BG, et al. The natural history ofmultiple sclerosis. Brain 1989;112 ( Pt 1): 133-46.12. van den Berg M, et al. Treadmill training for individualswith multiple sclerosis. J Neurol NeurosurgPsychiatry 2006;77: 531-3.13. Chee R, Murphy A, et al. Gait freezing inParkinson’s disease and the stride length sequenceeffect interaction. Brain 2009;132: 2151-60.14. Broman T, Andersen O, Bergmann L. Clinicalstudies on multiple sclerosis. Acta Neurol Scand1981;63:6-33.15. Weinshenker BG, et al. The natural history ofmultiple sclerosis. Brain 1991;114 ( Pt 2): 1045-56.Albert Lo, MD, PhD, is Staff Neurologist,Providence VA Medical Center,and Assistant Professor of Neurology at TheWarren Alpert Medical School of BrownUniversity.Disclosure of Financial InterestsThe author has no financial intereststo disclose.CORRESPONDENCEAlbert Lo, MD, PhDProvidence VA Medical Center830 Chalkstone Ave.Providence, RI 02908e-mail: Albert_Lo@brown.edu24MEDICINE & HEALTH/RHODE ISLAND

The Creative ClinicanFooled By the Fragments:Masquerading MicroangiopathySamir Dalia, MD, Cannon Milani, MD, Jorge Castillo, MD, Anthony Mega, MD, Fred J. Schiffman, MDA 65-year-old woman presented to a hospital withconfusion, shortness of breath, and ecchymoticskin lesions. She was afebrile. Her hemoglobinwas 3·6 g/dL (normal [nl] 11-15 g/dL),platelet count was 62 x 10 3 /mm 3 (nl 150-450x 10 3 /mm 3 ), white blood cell count was 5·9 x10 3 /mm 3 (nl 3.5-11 x 10 3 /mm 3 ), mean corpuscularvolume (MCV) was 114 fL (nl 80-99 fL),creatinine was 1·9 mg/dL (nl 0·4-1·3 mg/dL),and serum lactate dehydrogenase (LDH) was2,200 IU/L (nl 50-175 IU/L). Based on herconfusion, anemia, thrombocytopenia, and elevatedserum creatinine and LDH, a diagnosisof thrombotic thrombocytopenic purpura(TTP) was made.The patient received four units of packedred blood cells and was transferred to our hospitalfor urgent plasma exchange (PEX). Uponarrival, her history was unremarkable whilephysical examination was notable for tangentialspeech, conjunctival pallor, slight macroglossia,and ecchymotic areas on her extremities.Cardiopulmonary exam was normal andthere was no lymphadenopathy or hepatosplenomegaly.The patient’s peripheral blood smearshowed 1% to 5% schistocytes per high-powerfield that further suggested a microangiopathicprocess. However, macroovalocytes,hypersegmented neutrophils, polychromasia,and occasional teardrop cells were observed.(Figure 1). The patient received 2 units offresh frozen plasma (FFP) to correct hercoagulopathy and to partially replenish herpresumptively low ADAMTS13 while a serumcobalamin level and anti-IF antibody werechecked. The patient was empirically given adose of intramuscular cyanocobalamin.The patient’s serum cobalamin level returnedat 51 pg/ml (nl 211-911 pg/ml) andher anti-IF antibody was positive. After fourteendays of intramuscular cobalamin her peripheralblood smear showed resolution ofmegaloblastic changes and her mental statusand ecchymotic areas improved.The hematologic aberrations seen in cobalamin deficiency can includepancytopenia, the presence of hypersegmented neutrophils andmacroovalocytes on peripheral blood smear, and elevated serum levels ofLDH and bilirubin. 1 As seen in the present case, severe cobalamin deficiencycan also present with a clinical and hematological picture similarto a microangiopathic hemolytic process. In addition, neuropsychiatricmanifestations of cobalamin deficiency are marked by paresthesias, ataxia,urinary and fecal incontinence, impotence, optic atrophy, memory loss,dementia, and various psychiatric disorders including depression, hallucinations,and personality changes. 1Schistocyte formation in cobalamin deficiency may result from increasedmembrane rigidity with reduced deformability and subsequentlysis as RBCs pass through the reticuloendothelial system 2 . The anemiaof cobalamin deficiency is thought to result from a combination of lackof production and increased destruction of RBCs while thrombocytopeniais caused by a lack of production of platelets.We believe that in cases of apparent TTP with high MCV or otherdata suggestive of cobalamin deficiency, serum cobalamin levels shouldalways be checked. If a suspicion for cobalamin deficiency arises in theevaluation of TTP, empiric treatment with infusion of FFP can be useduntil more definitive testing is performed. PEX may be associated withserious side effects. In a nine-year cohort study of 206 consecutive patientstreated for TTP, 5 of the 206 (2%) died of complications of PEXtreatment. Fifty-three patients (26%) had major complications attributedto PEX treatment, including systemic infection, venous thrombosis, andhypotension requiring blood pressure support 3 . With review of a pe-Figure 1. Peripheral blood smear of our patient with hallmarks of cobalamindeficiency. There is marked anisopoikilocytosis. Ovalocyte (1), macroovalocyte(2,3), hypersegmented neutrophil with 5 lobes (4), schistocyte (5) andteardrop cell (6).VOLUME 93 NO. 1 JANUARY 201025

ipheral blood smear and rapid confirmatory laboratory testing,PEX may be avoided in patients presenting with severecobalamin deficiency mimicking TTP.Clinicians should be aware of unusual clinical presentationsof cobalamin deficiency masquerading as a seriousmicroangiopathic hemolysis. The prompt recognition, diagnosis,and treatment of cobalamin deficiency is vital becausetherapy is safe, inexpensive, and corrects hematologic abnormalitieswhile bringing about a complete or partial correctionof the neuropsychiatric abnormalities in the majority of patients.REFERENCES1. Stabler SP, Allen RH, et al. Clinical spectrum and diagnosis of cobalamindeficiency. Blood 1990;76:871-81.2. Andres E, Affenberger S, et al. Current hematological findings in cobalamindeficiency. Clin Lab Haematol 2006;28:50-6.3. Howard MA, Williams LA, et al. Complications of plasma exchange in patientstreated for clinically suspected thrombotic thrombocytopenic purpurahemolyticuremic syndrome. Transfusion 2006;46:154-6.Samir Dalia, MD, is a resident in internal medicine.Cannon Milani, MD, is a Fellow in Hematology/Oncology.Jorge Castillo MD, is Assistant Professor of Medicine, Departmentof Hematology/Oncology.Anthony Mega,MD, is Associate Professor of Medicine (Clinical),Department of Hematology/Oncology.Fred J Schiffman, MD, is Professor of Medicine, Departmentof Hematology/Oncology.All are at the The Warren Alpert Medical School of BrownUniversity.Disclosure of Financial InterestsThe authors have no financial interests to disclose.CORRESPONDENCESamir Dalia, MDThe Miriam Hospital164 Summit AveProvidence, RI 02906Phone: (401) 444-4000e-mail:sdalia@lifespan.orgDecember 2009Dear Colleague,This past summer marked a historic victory for antitobaccoadvocates. On June 22, 2009, President Obamasigned into law the new Family Smoking Prevention andTobacco Control Act giving the U.S. Food and Drug Administration(FDA) the authority to regulate tobaccoproducts and stop the harmful practice of marketing tobaccoto children. This law will help significantly reducethe number of children who start to use tobacco, the numberof adults who continue to use tobacco, and the numberof people who die as a result.While this is all good news, it is evident that the FamilySmoking Prevention and Tobacco Control Act cannot byitself put an end to tobacco use. Its intent is to complement,not replace, the successful work that we have beendoing over the years to educate our children about the importanceof being tobacco-free. Interestingly enough, inlate August, major tobacco manufacturers filed suit to overturnportions of the new law, specifically the restrictions onadvertising, marketing and labeling of tobacco products.Since there is more that can be done, the Rhode IslandMedical Society would welcome your support of ourTar Wars Rhode Island Program, the national tobaccofreeeducational program developed by the AmericanAcademy of Family Physicians. We are looking for physicianpresenters to volunteer to talk with students aboutthe dangers of tobacco use. The program involves teachingan hour-long lesson to the students (RIMS providesyou all materials); and then returning to the school to judgea half-hour poster contest. The Tar Wars flyer providesfurther details about the Tar Wars program as well as detailsabout the Family Smoking Prevention and TobaccoControl Act. You can also go to www.tarwars.org for moreinformation.If you are interested, please contact Catherine Nortonat 528-3286 or cnorton@rimed.org. We anticipate schoolpresentations to be scheduled during the months of January,February, and March 2010. We also have availablefor your use, “How to Present Tar Wars Guidelines.”Thank you for your support!Sincerely,Arthur A. Frazzano, MDPast PresidentChair, Tar Wars Rhode IslandTar Wars, a national tobacco-free educational program developedby the American Academy of Family Physicians, iscoordinated locally by the Rhode Island Medical Society, theRhode Island Academy of Family Physicians, and the RhodeIsland Chapter of the American Academy of Pediatrics.26MEDICINE & HEALTH/RHODE ISLAND

THE WARREN ALPERT MEDICAL SCHOOLOF BROWN UNIVERSITYDivision of GeriatricsDepartment of MedicineGERIATRICS FOR THEPRACTICING PHYSICIANSudden Cardiac Death and Implantable CardioverterDefibrillations (ICD) and the Older AdultSudden cardiac arrest (SCA) usually results from a hemodynamicallyunstable heart rhythm-ventricular fibrillation or ventriculartachycardia. Failure or absence of resuscitation results insudden cardiac death (SCD). There are 450,000 cases of SCDannually in the United States. Rate of survival following SCAhas not changed over the past three decades. 1 Survival afterhospital discharge, however, has improved, partly due to thedevelopment of implantable cardioverter defibrillators (ICDs).In 2005, the Centers for Medicaid and Medicare Services estimatedthat 500,000 Medicare beneficiaries were candidates forICD placement. 2 ICD prescription in elderly patients entailsparticular considerations, given common co-morbidities andhigher rates of non-cardiac mortality. ICD implantation shouldnot be regarded as routine in elders; each case should be consideredindividually. Geriatricians and other primary care physiciansplay a key role in the judicious selection of candidates forthis potentially life-saving therapy.RISK OF SCD IN ELDERLYThe prevalence of coronary artery disease (CAD) increaseswith age, along with risk of SCD. The proportion of CADdeaths attributed to SCD, however, decreases with age. In theFramingham study, 62% in men aged 45-54 years old whodied of CAD experienced SCD. 3 This percentage fell to 58%in men aged 55-64 years and to 42% in men aged 65-74 years.Congestive heart failure is responsible for a higher proportionof deaths in the elderly population. Advanced age, however, isassociated with a poor outcome following cardiac arrest. In areview of 5,882 cases of out-of-hospital cardiac arrest, octogenariansexperienced a hospital discharge rate of 9%, comparedto 19% in a younger group. 4 In a second series of 12,000patients treated by emergency medical service personnel forSCA, every one-year increase in age was associated with a significantlylower likelihood of survival. 1Omar Hyder, MD, and Ohad Ziv, MDQuality Partners of RIEDITED BY ANA TUYA FULTON, MDINDICATIONS FOR ICD PRESCRIPTIONOver the past two decades, studies identified ICDs as an effectiveprevention strategy of SCD. In survivors of SCA, ICDs arethe secondary prevention strategy of choice. 5,6 Patients at highriskalso benefit from prophylactic ICD implantation. TheMADIT II and MUSTT studies demonstrated a survival benefitin patients with reduced ejection fraction (

tomatic heart failure were excluded from the landmark trials, andare not considered for routine ICD placement if mean expectedsurvival is less than 6 months. Elderly patients with renal diseaseare a population that may derive diminished mortality benefit fromICD 13 although chronic renal failure was not an exclusion criterionin major trials. There are no age restrictions on ICD implantation,although octogenarians are underrepresented in trials despitethe fact they constitute 28% of possible ICD recipients. 14 Asa result, patients with multiple co-morbidities must be consideredfor ICD placement on an individual basis. Furthermore, for theelderly patient, as with all patients, ICD implantation requires carefulassessment of the individual’s estimated risk of cardiac arrestbased on the patient’s risk profile. 15PROCEDURAL COMPLICATIONSPeri-operative risks of ICD implantation include, but arenot limited to infection, system malfunction requiring a repeatprocedure, pneumothorax, tamponade and, rarely, death. Alimited number of studies have investigated age differences incomplication rates. Available data suggest that safety of ICDimplantation in the elderly patient is comparable to a youngerpopulation. One observational study from a decade ago reportsa similar rate of peri-operative death of 2% and 3% in patientsyounger and older than 65 years, respectively. 16 Exclusion ofolder generation devices implanted via a thoracotomy reducesperi-operative death to less than 1% in both groups. A morerecent study corroborates these findings; peri-operative mortalitywas less than 1% in patients younger and older than 70 years .8Based on these data, placement of this generation of ICDs isconsidered safe in patients of all ages.QUALITY OF LIFE AND END-OF-LIFE ISSUESStudies investigating quality of life have found either nochange or an improvement following ICD implantation. 17,18,19Numerous ICD shocks, history of anxiety disorders and preexistingpoor functional status are associated with poor quality of lifefollowing implantation. Advanced age is not identified as an independentpredictor of compromised quality of life in the abovestudies. As a result, a careful review of a patient’s co-morbiditiesand preexisting functional status must be considered prior to ICDimplantation. Patients must be counseled about the potential forpainful ICD discharges. Despite the discomfort associated withdischarges, a high rate of acceptance of ICD therapy is reportedin device recipients. Patients should also be informed that ICDtherapy is not a permanent prevention strategy, and devices canbe explanted or simply deactivated at the patient’s discretion.Furthermore, patients and families should be informed that ICDsreduce risk of SCD, but do not prevent death from other causes.Management of ICD at the end of life requires specific counselingto the patient and family. Frequency of shocks may increaseas a result of multiple terminal tachy-arrhythmias. Thiscan be a source of severe discomfort to both patient and family.If the patient or proxy is amenable, ICDs should be deactivatedwhen at the end of life. Unfortunately, this practice is not routinelyperformed. Interviews conducted with family membersof deceased ICD recipients revealed that counseling regardingdeactivation of devices did not occur in 75% of cases. 20CONCLUSIONSOlder patients are at higher risk of SCA, and have low survivalrates following an episode. ICDs are the strategy of choice inthe primary and secondary prevention of SCD. ICD placementin patients with multiple co-morbidities should be evaluated judiciously,as these individuals are underrepresented in major trialsthat define accepted guidelines. Complication rates in older patientsare similar to younger cohorts. The data also suggest eitherno impact or an improved quality of life among ICD recipients,regardless of age. In the elderly population, device implantationshould not be considered routine. Decisions should be made on acase by case basis, taking into consideration the patient’s wishes,co-morbidities and estimated risk of cardiac arrest.REFERENCES1. Rea TD, Eisenberg MS, et al. Circulation 2003;107:2780-5.2. Ruskin JN, et al. J Cardiovasc Electrophysiol 2002;13:38 - 43.3. Kuller LH. Prog Cardiovasc Dis 1980;23:1-12.4. Kim C, Becker L, et al. Arch Intern Med 2000;160:3439-43.5. The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators.NEJM 1997;337:1576–83.6. Sheldon R, et al, for the CIDS Investigators. Circulation 2000;101:1660–4.7. Buxton AE, Lee KL, et al. NEJM 1999;341:1882-90.8. Huang DT, Sesselberg HW, et al. Circulation 2003;1088(Suppl 17):1790.9. Bardy GH, Lee KL, et al. NEJM 2005;352:225-37.10. Moss AJ, Zareba W, et al. NEJM 2002;346:877-83.11. Quan KJ, Lee, JH, et al. Ann Thorac Surg 1997;64:1713–7.12. Duray G, Richter S, et al. J Interventional Cardiac Electrophysiol 2005; 14:169–73.13. Koplan B, Epstein L, et al. Am Heart J 2006; 152:714-914. McClellan MB, Tunis SR. NEJM 2005;352:222–4.15. Buxton AE, Lee KL, et al. J Am Coll Cardiol 2007;50:1150-7.16. Trappe HJ, Pfitzner P, et al. Heart 1997;78:364–70.17. Irvine J, Dorian P, et al. Am Heart J 2002;144:282–9.18. Kamphuis HC, de Leeuw JR, et al. Europace 2003;5:381–9.19. Schron EB, Exner DV, et al. Circulation 2002;105:589–94.20. Goldstein NE, Lampert R, et al. Ann Intern Med 2004;141:835–8.Omar Hyder, MD, is House Staff Officer in Internal Medicine,Rhode Island Hospital.Ohad Ziv, MD, is Clinical Instructor in Internal Medicine,The Warren Alpert Medical School of Brown University.Disclosure of Financial InterestsThe authors have no financial interests to disclose.CORRESPONDENCEOmar Hyder, MDPhone: (401) 533-2070e-mail: ohyder@lifespan.org9SOW-RI-GERIATRICS-012010THE ANALYSES UPON WHICH THIS PUBLICATION IS BASED were performedunder Contract Number 500-02-RI02, funded by theCenters for Medicare & Medicaid Services, an agency of theU.S. Department of Health and Human Services. The contentof this publication does not necessarily reflect the views or policiesof the Department of Health and Human Services, nor doesmention of trade names, commercial products, or organizationsimply endorsement by the U.S. Government. The author assumesfull responsibility for the accuracy and completeness ofthe ideas presented.28MEDICINE & HEALTH/RHODE ISLAND

RHODE ISLAND DEPARTMENT OF HEALTH • DAVID GIFFORD, MD, MPH, DIRECTOR OF HEALTHEDITED BY SAMARA VINER-BROWN, MSIntimate Partner Violence Before or DuringPregnancy In Rhode IslandHyun (Hanna) Kim, PhD, Rachel Cain, and Samara Viner-Brown, MSIntimate partner violence (IPV) can be any form of physical,psychological, economic, verbal, or sexual abuse by currentand former spouses and dating partners. 1 Each year in theUnited States, IPV affects approximately 1.5 million women,including as many as 324,000 pregnant women. 1 IPV duringpregnancy can lead to unintended pregnancy, smoking, depression,premature delivery, vaginal bleeding, miscarriage, andserious physical injury or even death of the mother and fetus.1,2 The American College of Obstetricians and Gynecologists(ACOG), the American Medical Association (AMA),and the American Academy of Family Physicians (AAFP)recommend routine screening of all women for IPV.This report describes 1) the prevalence of IPV before orduring pregnancy in Rhode Island and 2) the associations ofIPV with maternal health and well-being.METHODSData from the 2004-2007 RhodeIsland Pregnancy Risk Assessment MonitoringSystem (PRAMS) were analyzedto assess IPV before or during pregnancy.PRAMS, a surveillance project of the Centersfor Disease Control and Prevention(CDC) and state health departments, collectsstate-specific, population-based dataon maternal behaviors and experiencesbefore, during, and after delivery of a liveinfant. 3 During 2004-2007, a total of5,662 women completed the survey, withan average 73.8% weighted response rate.(Response rates were weighted to accountfor the sample design and unequal probabilitiesof selection of the survey.)Four survey questions focused onphysical abuse by partner/ex-partner orhusband/ex-husband: two concerned theyear prior to pregnancy and two themonths of pregnancy. Physical abuse includespushing, hitting, slapping, kicking,choking, or other forms of physical hurting.Maternal health and well-being wereassessed by the presence or absence ofhealth risk behaviors (delayed or no prenatalcare, smoking during and after pregnancy,unintended pregnancy, no currentbreastfeeding, alcohol use during pregnancy)and pregnancy complications(vaginal bleeding, urinary tract infection,severe nausea, vomiting or dehydration,preterm or early labor, premature rupture of membranes(PROM), diagnosed depression during pregnancy). PRAMSdata were weighted and analyzed to estimate the prevalence ofIPV, 95% confidence intervals (CI), p-values, and adjustedodds ratios (aOR). Data analyses were performed usingSUDAAN software, which accounts for the complex sampledesign of the survey. All unknown and missing responses wereexcluded from the analysis.RESULTSPrevalence of IPVOverall, 5.5% of RI women reported physical IPV beforeand/or during the most recent pregnancy: 4.2% for beforepregnancy and 3.2% for during pregnancy. (Figure 1) IPVwas significantly higher among teenagers (14.3%), HispanicsVOLUME 93 NO. 1 JANUARY 201029

(8.0%), American Indians (13.0%),Blacks (7.5%), and those who were unmarried(11.2%), had household incomes

DISCUSSIONEach year, about 12,500 women in Rhode Island deliverlive-born infants. Based on our estimates, about 690 RI womenwould experience IPV before or during pregnancy each year.This number may be low: it excludes women whose pregnanciesdid not result in live births. The data consider only physicalabuse as a measure of IPV, not sexual, psychological or verbalabuse. Finally, women tend to underreport IPV.Women who experienced IPV before or during pregnancywere more likely to have pregnancy complications and to engagein unhealthy behaviors.Although the ACOG and CDC recommend that allhealth care providers screen all patients for violence at regularintervals, many health care providers do not. 1 A survey conductedin Alaska indicates that only 17% of prenatal care providersroutinely screened for IPV at the first prenatal visit, andonly 5% at follow-up visits. 4 In Rhode Island, according to thePRAMS data, 55% of new mothers reported their health careproviders talked about IPV during their prenatal care visits.If a patient screens positively for IPV, physicians are recommendedto validate the patient’s experience and concerns,conduct safety assessment/develop a safety plan, offer informationabout/provide referrals to local agencies, document findingsin the medical record, and schedule a follow-up appointment.1,5REFERENCES1. ACOG and CDC Work Group on the Prevention of Violence During Pregnancy.Intimate partner violence during pregnancy: A guide for clinicians. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm2. Silverman JG, Decker MR, et al. Intimate partner violence victimization priorto and during pregnancy among women residing in 26 US states. Am J ObstetGynecol 2006;195:140-8.3. Centers for Disease Control and Prevention (CDC), Pregnancy Risk AssessmentMonitoring System (PRAMS). http://www.cdc.gov/prams4. Chamberlain L, Perham-Hester KA. Physicians’ screening practices for femalepartner abuse during prenatal visits. Mater Child Health J 2000; 4:141-8.5. Aneja S, Gottlieb A, Feller E. Physician intervention for intimate partner violence.Med & Health/RI 2009;92: 307-9.Hyun (Hanna) Kim, PhD, is Senior Public Health Epidemiologistin the Center for Health Data and Analysis, Rhode IslandDepartment of Health, and Clinical Assistant Professor inthe Department of Community Health, The Warren Alpert MedicalSchool of Brown University.Samara Viner-Brown, MS, is Chief of the Center for HealthData and Analysis, Rhode Island Department of Health.Rachel Cain is the PRAMS Program Coordinator in theCenter for Health Data and Analysis, Rhode Island Departmentof Health.Disclosure of Financial InterestsThe authors have no financial interests to disclose.R HODE Medicine I SLANDHealthClassified AdvertisementsTo place an advertisement,please contact:Cheryl TurcotteRhode Island Medical SocietyPhone: (401) 331-3207Fax: (401) 751-8050e-mail: cturcotte@rimed.orgVOLUME 93 NO. 1 JANUARY 201031

Poets, philosophers—even physicists—have vainly sought to define the characterand dimensions of nothingness. And physicians,too busy to explore the epistemologyof nothingness, have been satisfied merelyto gather their own assemblage of wordsdefining pathologic nothingnesses, spaces,when encountered within the human body.Thus, we confront the word, lacuna, adiminutive of the Latin, lacus, meaning a pondor a hollow, as in English words such as lakeand lagoon. Small spaces, lacunae, are commonlyencountered in arterially-compromisedbrain tissue and are then described in phrasessuch as lacunar encephalopathy. A very smalllacuna is called a lacunule (representing a Latindiminutive of a diminutive.) The word, lacuna,however, is not related to the Greekname, Lacoon, the Trojan prophet who hadpredicted the perils lurking within the Horsebuilt by the Greeks besieging Troy. It was hewho said: ”Beware of Greeks bearing gifts.”Physician’s LexiconSynonyms of NothingA vacuole, an empty space, generally ofpathologic origin, is a diminutive of theLatin, vacuum, and is the source of such Englishwords as vacuous, vacuity, vacant andvacuum.The word, void, also meaning an emptiness,is descended through late (vulgar) Latinand is derived ultimately from vacare, meaningto be empty, as in English words such asvacation and evacuation. Cognate Englishwords of void include devoid and avoid.The adjective, spongiform, is a Greekterm describing abnormal tissue filled withsmall cavities and thus resembling the marineinvertebrates (Porifera), the sponges. Aspongioblastoma is an archaic term for anaggressive astrocytoma.The word cavity descends from theLatin, cavus, meaning a hollow, and givesrise to cognate words such as concavity andcavitation. The word, empty, is of Old Englishorigin, emtig, meaning idle or vacant.The letter, ‘p’, called by semanticists ‘an excrescentletter’ was added belatedly as seenalso in words such as glimpse or sempstress(now usually spelled seamstress.)The medical profession thus has accessto a handful of words (lacuna, vacuole, void,cavity, empty-space) offering almost identicalmeanings. Some distinctions, necessarily,are drawn. Thus, if the abnormal spaceis very small, barely visible and in great numbers,the word spongiform might be employed.If of medium dimension, perhapsthe word lacuna might be used. And if quitelarge, as encountered in tuberculous pneumonitis,the lesion might then be describedas a cavity. Usage, over the centuries, hassharpened the intent of erstwhile synonymsso that the sentence, “The hotel room isempty” is no longer equivalent to, “Thehotel room is vacant.”– STANLEY M. ARONSON, MDRHODE ISLAND DEPARTMENT OF HEALTHDAVID GIFFORD, MD, MPHDIRECTOR OF HEALTHVITAL STATISTICSEDITED BY COLLEEN FONTANA, STATE REGISTRARRhode Island MonthlyVital Statistics ReportProvisional OccurrenceData from theDivision of Vital RecordsUnderlyingCause of DeathDiseases of the HeartMalignant NeoplasmsCerebrovascular DiseasesInjuries (Accidents/Suicide/Homicde)COPDJanuary2009Number (a)198155333756Reporting Period12 Months Ending with January 2009Number (a) Rates (b) YPLL (c)2,606 248.0 3,055.02,283 217.3 6,600.0417 39.7 650.0553 52.6 8,576.5486 46.3 432.032Vital EventsLive BirthsDeathsInfant DeathsNeonatal DeathsMarriagesDivorcesInduced TerminationsSpontaneous Fetal DeathsUnder 20 weeks gestation20+ weeks gestationMEDICINE & HEALTH/RHODE ISLANDJuly2009Reporting Period12 Months Ending withJuly 2009Number Number Rates1,066 12,412 11.6*768 9,486 8.9*(0) (88) 7.1#(0) (69) 5.6#679 6,433 6.0*234 2,835 2.7*367 4,345 350.1#56 824 66.4#(51) (724) 58.3#(5) (100) 8.1#(a) Cause of death statistics were derived fromthe underlying cause of death reported byphysicians on death certificates.(b) Rates per 100,000 estimated population of1,050,788 (US Census: July 1, 2007)(c) Years of Potential Life Lost (YPLL)Notes: Estimated total population for Rhode Island hasbeen updated in this month’s rates.Totals represent vital events which occurred in Rhode Islandfor the reporting periods listed above. Monthly provisionaltotals should be analyzed with caution because the numbersmay be small and subject to seasonal variation.* Rates per 1,000 estimated population# Rates per 1,000 live births

The Official Organ of the Rhode Island Medical SocietyIssued Monthly under the direction of the Publications CommitteeVOLUME 1 PER YEAR $2.00NUMBER 1 PROVIDENCE, R.I., JANUARY, 1917 SINGLE COPY, 25 CENTSNINETY YEARS AGO, JANUARY 1920Murray S. Danforth, MD, in “Advances in the Surgery ofthe Extremities during the War,” recounted: “My firstrecollection…is of seeing a patient lying in bed with a weight atthe foot of the bed for treatment on the lower fragment of thefractured femur, and with a long board splint and coaptationsplints for maintaining the fragments in position. With thatmethod a result in a simple fracture was rated as good, when theshortening was not more than an inch or even an inch and ahalf. This meant a limp and subsequent back strain with a notinconsiderable disability.” Post-war, therapists emphasized “notforcible manipulation” … but “more reliance on hot and coldshowers, whirlpool baths, massage, exercise…” Prewar the mortalityfrom a fracture of the femur was 83%; post-war, it hadfallen to 15%. In a comment to Dr. Danforth’s paper, a Societymember urged members to be cautious about applying lessonsfrom the complicated injuries of war to civilian fractures.Elizabeth M. Gardiner, MD, in “Child Welfare – Yesterdayand To-Day,” traced the Children’s Federal Bureau to the1909 White House Conference on Children’s Welfare, convenedby President Theodore Roosevelt. “It used to be saidthat once a child is born, the parents and the state must acceptresponsibility for its well-being. We now go a step further. Thevery fact that state after state…is creating new departments forchild welfare…is evidence enough that the state recognizes itsobligation to afford to every mother the necessary educationand health facilities to insure a safely born child.” The Warhad demonstrated the sorry state of children’s health: manywould-be soldiers were disqualified for health: “…a greaterproportion of them represented preventable childhood diseaseswhich we neglected to prevent.”Bennett L. Richardson, MD, in “Erythema Multiformefollowing Diphtheria Antitoxin,” described the case of a fouryear-old boy, sick with diphtheria, admitted to Providence CityHospital. His brother was admitted a week later, with the samesymptoms. On admission, the four year-old was given 2,000units of antitoxin intramuscularly; two weeks later, he had afever of 100.5 and was itching.An Editorial, “The Encore,” described the Society’s decisionto renew publication of the Journal: “Now that the smokeof battle is cleared away and everyone is back home again, tryingto pick up the loose ends of a practice, the need of aJournal…has become more and more evident.”FIFTY YEARS AGO, JANUARY 1960C. Miller Fisher, MD, Assistant Professor of Neurology,Harvard Medical School, spoke on “Present Trends in the Treatmentof Cerebral Vascular Disease” at the NeuropsychiatricRounds at Rhode Island Hospital. The Journal reprinted his talk.Orland F. Smith, MD, and Richard S. Rosen, MD, in“Colovesical Fistula: A Complication of Diverticulitis,” notedthat 20 years ago the surgical mortality for large bowel proceduresat the Mayo Clinic was 14.7%. The authors reported ontwo recent cases, treated successfully.Warren W. Francis, MD, in “Spontaneous Rupture andHerniae,” described two patients – a 68 year-old man and a 2year-old girl —where treatment called for “immediate surgicalrepair.”Raymond N. MacAndrew, MD, in “The Other AppendicealConditions,” discussed the carcinoid, the mucocele, andadenocarcinoma.An Editorial supported “A New Brown University MedicalSchool.” The Providence Journal had been lukewarm to the proposal.TWENTY-FIVE YEARS AGO, JANUARY 1985An Editorial, “Deinstitutionalization in Rhode Island,”cited an article in the International Herald Tribune that calledde-institutionalization “a quick fix that backfired.” That articlehad cited decreased funding, leading to an increased numberof people in slum housing. The Journal editor called RhodeIsland “a shining example of a successful experience,” creditingDr. Joseph Bevilaqua, former director of the state Departmentof Mental Health Rehabilitation and Hospitals, and hissuccessor, Tom Romeo.Charles E. Kaufman, MD, and Elliot M. Perlman, MD, in“Orbital Causes of Red Eye,” noted: “Differential diagnosis is essentialto initiate appropriate and possibly life-saving therapy.”In the “Clinico-pathological Conference: Case Report,”Maurice M. Albala, MD, George F. Meissner, MD, Tom J.Wachtel, MD, and Mark Fagan, MD, editors, presented the caseof a 60 year-old woman with a history of hypertension and alcoholabuse “admitted for abdominal pain.” This woman, who smokeda pack a day, had been in good health until a week before admission.She was initially given 2 units of packed red blood cells. Onthe second hospital day “endoscopy revealed mild distal esophagitisand mild to moderate gastritis. No bleeding was seen.” She wasgiven antacids and cimetidine. On the 4th hospital days, after abarium enema, she passed bright red blood clots. On the 9 th hospitalday, she went into cardiac arrest and died. The anatomicdiagnosis: “Aortoduodenal fistila with massive gastrointestinal hemorrhages/p right renal artery.” After 14 years, the patient showeda weakening of the suture line from an aortorenal bypass graft.VOLUME 93 NO. 1 JANUARY 201033

2009 Index34AUTHOR INDEXAdams Jr, Charles A. 164, 166, 172, 181Adams, Laura L. 268, 273Ahn, Sun H. 388, 394, 398Aidlen, Jeremy T. 170Alexander, Nicole E. 247Ali, Saman 369Alverson, Brian 247Amaio, Anthony 157Andreozzi, Mark 372Aneja, Sonia 307Ankoma, Angela 63Aronson, Stanley M. 3, 37, 43, 67, 71,115, 119, 159, 163, 184,195, 216, 227, 259, 263,289, 291, 317, 323, 347,351, 379, 387, 417Bagdasaryan, Robert 158, 249, 372Baird, Janette 196Bancroft, Barbara 135Batra, Kerri L. 353Beckwith, Curt G. 231, 247Beland, Michael D. 407Belhumeur, Randi 63Bishop, Kenneth D. 61Bond, Dale 58Borkan, Jeffrey 300Bright, Renee 82Butera, James N. 315Caffrey, Ainsling 373Cain, Rachel 345Caldwell, Marjorie J. 219Cambio, Joseph C. 212Carpenter, Charles C.J. 228, 237Carroll, David 282Chan, Florence 416Chang, Margret 310Chapin, Kimberle 231Cheuck, Lanna 327Coldiron, John S. 382Conklin, Patrick 394Conway, Nazli 356Cornell, Margaret 273Cornwall, Alexandra H. 231Craussman, Robert S. 111, 155Cryan, Bruce 217Cu-Uvin, Susan 229, 237Cullinen, Kathleen M. 219Damle, N.S. 113Davidson, H. Edward 182DePalo, Vera 264, 273Dexter, Clarisse 29DiMase, Joseph D. 285Dixon, Lauren 155Doberstein, Curtis E. 388Dollase, Richard 300Donnelly, Edward F. 185Dosa, David 377Dubel, Gregory J. 394, 398Dubrow, Robert 231Ducharme, Robert 231Elsamra, Sammy 188Epstein-Lubow, Gary 106MEDICINE & HEALTH/RHODE ISLANDEsposti, Silvia Degli 148Feldmann, Edward 300, 412Feller, Edward R. 72, 78, 120, 121,307, 310Fitzgibbons, Peter G. 250Fox, Wendy Baltzer 10Firth, Jacqueline A. 229Flanigan, Timothy P. 237, 244Frazzano, Arthur 256Freedman, Linn Foster 287Friedman, Joseph H. 2, 42, 70, 118,162, 194, 226, 262, 290,314, 322, 350, 386, 415Fulton, Ana Tuya 214, 343Garneau, Deborah 109, 253Gillani, Fizza S. 237Gjelsvik, Annie 32, 380Glicksman, Arvin S. 65Glinick, Stephen 415Gokee-LaRose, Jessica 50Goldman, Dona 380Gopalakrishnan, Geetha 229Gottlieb, Amy S. 307Grabert, Stacey 73, 82Grand, David J. 103Gravenstein, Stefan 182Gregg, Shea C. 172Gruppuso, Philip A. 292, 300Haas, Richard A. 388, 412Haleblian, George E. 339, 342Hamolsky, Milton W. 190Hampton, Brittany Star 5Han, Lisa F. 182Harrington, David T. 172, 179Harris, Adam 78Hart, Chantelle N. 48Hasan, Usama 212Heffernan, Daithi S. 166Hershkowitz, Melvin 154Hesser, Jana 420Ho, Christine M. 315Hussain, Altaf 212Iannotti, Harry 187Jayaraman, Mahesh V. 388, 412Jelalian, Elissa 48Jiang, Yongwen 420Julian, Linda 155Kapoor, Mahim 152Kawatu, David 131, 135Kerr, Stephen 63Kim, Hyun (Hanna) 109, 345Klipfel, Adam 89Kogut, Stephen 373Kojic, Erna Milunka 228, 229Kozloff, Matthew S. 181Lally, Edward V. 369Lam, Manuel Y. 121Lasser, Michael S. 327Latif, Syed 418Lawson, Eliza 63Leahey, Tricia M. 45, 58LeLeiko, Neal 82, 131, 135Lewis, Carol 297Lidofsky, Sheldon 125, 128Longabaugh, Richard 196Lonks, John R. 121Marquez, Becky 45Mayer, Kenneth 231McCarthy-Barnet, Kate 109McClory, Jill 363McClure, Cameron J. 204McIntyre, Bruce 111, 155McNicoll, Lynn 152, 250, 264, 273,282, 418McTaggart, Ryan A. 412Mehta, Akanksha 331Mello, Michael J. 196, 200, 204Merson, Michael H. 231Meyer, Andrea 65Miranda, Gustavo Gabino 211Montague, Brian T. 244Monteiro, Karine 32Morrissey, Paul 422Moy, Marilyn 380Murphy, Timothy P. 394Myers, Deborah L. 4, 22Nayak, Ramakrishna 158, 249Neale, Robin 247Nimmagadda, Jayashree 310Nirenberg, Ted D. 196Paine, Virginia 345Palenchar, Eileen 292Pappola, Linda 282Pareek, Gyan 324, 325, 327, 336Patel, Sutchin R. 435, 342Pearlman, Robert 222Pezzullo, Lynn 373Pinkos, Beth 131Pinkston, Megan 244Poch, Mihael 339Popick, Rachel 256Potter, Susan 279Pressman, Amanda 285Pricolo, Victor E. 100Rakatansky, Herbert 288Ranney, Megan L. 196, 200Rardin, Charles R. 12Raymond, Patricia 345Renzulli II, Joseph F. 188, 327Retsinas, Joan 38, 68, 116, 160, 192,224, 260, 290, 318,348, 385, 424Rhee, Kyung 48Rich, Josiah D. 237, 244Risica, Patricia Markham 63, 420Roach, Rachel 29Rocha, Jean Marie 273Rodriguez, Irma 231Rommel, John 200Rosas, Donovan 416Rotjanapan, Porpon 27, 377Ryder, Beth 58Sachs, Larissa 353Saha, Sumona 148

Said, Nuha 363Salerno, Mary E. 155Sands, Bruce E. 73, 82Sax, Harry C. 265Schirmang, Todd C. 398Schwartz, Stuart 356Shah, Samir A. 72, 78, 82, 120, 121Shapiro, Jason M. 135Sigman, Mark 331Sikkema, Kathleen J. 231Simon, Peter 318Smith, Jeanette 125, 128Soares, Gregory M. 394.398Sturrock, Paul 89Summerhill, Eleanor M. 279Sung, Vivian W. 16Tashima, Karen 416Taylor, Kathleen 420Taylor, Lynn E. 234Than, Peter 422Thomas, J. Graham 53Tinajero, Alvaro 253Trachtenberg, Robert 256Troncales, Anna Ocasiones 279Trotta, Janet 131Turini III, George A. 336Vallejo, Maria-Luisa 318Vance, Awais Z. 388Velasquez, Lavinia 231Verhoek-Oftedahl, Wendy 200Viner-Brown, Samara 345Vithiananthan, Siva 58Viticonte, Janice 292Wakeman, Sarah E. 244Wang, Chia Ching 229Warde, Newell E. 270Wheat, Anna 34Wing, Rena R. 44, 45, 53Wolf, Farrah J. 407Yates, Jennifer 187Zachary, Dalila 416Zaller, Nickolas D. 237, 244Zeller, Kimberly 237Zimmermann, Bernard 352, 352, 359Zink, Brian 204Zou, Jiachen 318TITLE INDEXAcronyms: What’s in a Name? 42Acute Deep Verin Thrombosis (DVT):Evolving Treatment Strategies andEndovascular Therapy 394Abbreviations:AP Advances in PharmacologyCC Creative ClinicianGPP Geriatrics for the PracticingPhysicianHBN Health by NumbersIM Images in MedicineJD Judicial DiagnosisPHB Public Health BriefingPL Physician’s LexiconPOV Point of ViewAcute Herpetic Infections Resulting inAcute Urinary Retention in YoungWomen [CC] 188Adult Behavioral Weight Loss Treatment 50Advances in Imaging in Crohn’s Disease 103Advances in Pharmacology [AP] 27, 373Advancing Boundaries in the Care ofthe Trauma Patient 166Ailment for the Royally Nourished 351America’s Multi-tiered Healthcare System:Is Organ Transplantation Fair? [POV] 422Analysis of Intentional and UnintentionalInjuries Caused by Firearms andCutting/Piercing Instruments amongProvidence Youth, Nov 2004-Dec2007 200Anticoagulation in the Octogenarianwith Atrial Fibrillation [GPP] 152Approach to the Treatment ofHyperuricemia 359Asymptomatic Versus SymptomaticUrinary Tract Infections in Long-Term Care Facility Residents [GPP] 377Bariatric Surgery for Severe Obesity:The Role of Patient Behavior 58Barriers to Healthcare Access in theSoutheast Asian Community ofRhode Island 310Behold, the Ambiguous Root [PL] 159Best Medical Schools 322Biased Articles 70Bone Disease in the InflammatoryBowel Disease Population 125Brief Inspection of the Navel 71Burn Injuries and Burn Care 179Cancer Screening Over 65 [GPP] 61Care of the Trauma Patient: A Disciplinein Flux 164Changes in Demographics and RiskFactors among Persons Living with HIVin an Academic Medical Center from2003-2007 237Community-Based Programs for ChronicInebriates as an Alternative to theEmergency Department 204Couched Words of Psychoanalysis [PL] 290Creative Clinician [CC] 188, 212, 416Diabetes Prevention and Control: ProgressTowards Healthy People 2010 Goals[HBN] 380Diagnosis and Management of AcuteGout 356Doctors and Torture [POV] 288Dovenning 386Effect of Zoledronic Acid on Bone PainSecondary to Metastatic BoneDisease [AP] 27Elements of Medicine: Faith, Hope andCredence 119Epidemiology of Inflammatory BowelDisease and Overview of Pathogenesis 73Epochs, Eras, and Eons [PL] 317Evaluating the Effectiveness of MotivationalCounseling and Hospital EmergencyDepartment Observation for Court-Mandated Young Drivers 196Evaluation of Rhode Island’s PediatricPractice Enhancement Project [HBN] 253Even the Gods are Sometimes Forgetful 195Evolution of Rhode Island TraumaSystem: Where Do We Stand? 172FTC Red Flags Rule: Requirements ofHealthcare Providers forCompliance [JD] 287Fall Prevention Interventions in AcuteCare Settings: The Rhode IslandExperience [GPP] 282Family Caregiver Health: What to DoWhen the Spouse or Child NeedsHelp [GPP] 106Family Values in the White House 323Fibroblastic Polyp / Perineurioma ofthe Colon [IIM] 249Frantic Assemblage of Words [PL] 115Fruitful Words of Obstetrics [PL] 184Geographic Access to Care in Rhode IslandThrough the Use of GIS [PHB] 256Geriatrics for the Practicing Physician[GPP] 29, 61, 106,152, 182, 214,250, 282, 315,343, 377, 418Glucocorticoid-Induced Osteoporosis inInflammatory Bowel Disease 128Gold Standards 194Gout in Women 363Granular Cell Tumor of Ileocecal Valve[IM] 158Graveyard of Words [PL] 417HIV among Marginalized Populations inRhode Island 244HIV/Viral Hepatitis Coinfection: TheImmunology Center Experience 234He Leadeth Me Beside the Still Waters 227Health by Numbers [HBN] 32, 63, 109,185, 217, 253,318, 345, 380,420Heritage 38, 68, 116, 160,192, 224, 260, 290,320, 348, 385, 424History of Robotics in Urology 325I’ve Got a Little List…I’ve Got a LittleList 3Identifying Acute HIV Infection in RhodeIsland 231Ignoble Fate of the Peppered Moth 291Ileal Pouch-anal Anastomosis for UlcerativeColitis – The Rhode IslandExperience 100Images in Medicine 158, 187, 211,249, 314, 342,372, 415Impermanency of Definitions [PL] 259Implementation of the CDC’s RevisedRecommendations for HIV Testing inMedical Settings: A Rhode IslandUpdate and Call for Action 247Improving Patient Safety with the Use ofSurgical Checklists 265Incidental Finding on Plain FilmPrompting the Diagnosis ofCastleman’s Disease [IM] 187Inflammatory Bowel Disease in Pediatrics 135Inflammatory Bowel Disease Potpourri:A Vignette-Based Discussion 121Inflammatory Bowel Diseases (Part I) 72Interstitial Cystitis 22VOLUME 93 NO. 1 JANUARY 201035

36Intracranial Aneurysms: Perspectives on theDisease and Endovascular Therapy 388Intracranial Atherosclerotic Disease:Epidemiology, Imaging andTreatment 412Intranasal Mucosal Malignant Melanoma[IM] 372Introduction: Beyond Our Doors: EmergencyPhysicians and Public Health 196Introduction: HIV 228Introduction: Hyperuricemia and Gout 352Introduction: Inflammatory BowelDiseases (Part II) 120Introduction: Obesity 44Introduction: Spotlight on Quality inRhode Island 264Introduction: The Role of MinimallyInvasive Urology in the NewMillenium 324Introduction: What is InterventionalRadiology? 388Judicial Diagnosis [JD] 287Knowledge and Behaviors Related toColorectal Cancer Prevention amongNon-Hispanic Black Women inRhode Island [PHB] 219Knee Lichenification in Parkin’s Disease:“Parkinson Knees” [IM] 415Letter to the Editor 154Lexicographer Burdened with Life 163Maintenance of Long-Term Weight Loss 53Medical Implications of Hyperuricemia 353Medical Student Education in RefugeeHealth and the Concept of aMedical Home 297Medical Therapy of IBD in 2009 78Medical Words in Extremis [PL] 37Medication and Non-Adherence in theOlder Adult [GPP] 418Medication Trials in an Imperfect World:Gout and Parkinson’s Disease 350Military Physicians Join Reach Out andRead at Naval Health Clinic NewEngland [POV] 157Minimally Invasive Approaches to PelvicReconstructive Surgery 12Minimally Invasive Stone Surgery:Percutaneous Ureteroscopic andExtracorporeal Approaches to Renaland Ureteral Calculi 339Motorcycle Injuries in Rhode Island[HBN] 185Multifocal Tumors of the Testis [CC] 212My Reality and Yours [POV] 222Neurology Requirements at Brown 290No Man is an Island 263Non-motor Movements Disorders:Internal Tremor 262Nutrition in Inflammatory Bowel Disease 131OSCCAR: Ocean State Crohn’s andColitis Area Registry 82Onward and Upward with Prefixes [PL] 67Optimal Hip Fracture Management inHigh-Risk Frail Older Adults [GPP] 250Overweight and Obesity in Rhode Island:Developing Programs to Combat theObesity Epidemic 45MEDICINE & HEALTH/RHODE ISLANDPain and Prejudice: The Use of ChronicNarcotic Therapy in MedicalPractice [PHB] 111Palliative Care – Evolution of a Vision[PHB] 34Patterns of Obesity among Men andWomen in Rhode Island in 2007[HBN] 420Pause for Reflection and Acknowledgement[GPP] 343Pediatric Trauma Surgery: UnderstandingWhen NOT to Operate 170Pelvic Organ Prolapse 5Penile Rehabilitation after RadicalProstatectomy 331Performance Improvement in InternalMedicine Residency Education:Memorial Hospital of Rhode IslandCurriculum 279Peripheral Arterial Disease: Update ofOverview and Treatment 398Physical Therapy for Pelvic FloorDysfunction 10Physician Intervention for IntimatePartner Violence 307Physician’s Lexicon [PL] 37, 67, 115,159, 184, 216, 259,289, 317, 347, 379, 417Point of View 113, 157, 190,222, 288, 382, 422Political Correctness is Unethical 226Prevention of Relapsing Mediocrity:How to Maintain PerformanceImprovement in Hospitals [POV] 382Practicing Physicians’ Guide to PressureUlcers in 2008 [GPP] 29Prostate Cancer Screening Practice andKnowledge in Rhode Island [PHB] 65Public Health Briefing [PHB] 34, 65, 111,155, 219, 256, 285Quality Health Care and the ProfessionalNurse – A Physician’s Perspective[POV] 190Redesigning the Clinical Curriculum atthe Warren Alpert Medical School ofBrown University 300Reimbursement for Experience-BasedMedicine 2Reproductive Issues in InflammatoryBowel Disease 148Resettlement of Refugees from Africa andIraq in Rhode Island: The Impact ofViolence and Burden of Disease[HBN] 318Rhode Island Board of Licensure andDiscipline: 2008 in Review ]PHB] 155Rhode Island HEALTH Web Data QuerySystem: Death Certificate Module[HBN] 32Rhode Island ICU Collaborative: TheFirst Statewide Collaborative FourYears Later 273Robot-Assisted Laparoscopic UrologicSurgery 327Role of Health Information Technology inImproving Quality and Safety in RI:Can New Money Solve Old Problems? 268Role of Urogynecology in Women’s PelvicFloor Disorders 4Screening Colonoscopy in the UnderservedPopulation [PHB] 285Seasonal Influenza Vaccination Coverageamong Pregnant Women in RhodeIsland [HBN] 345Serious Mechanical Complication afterSubclavian Vein Catheterization[IM] 211Self-Report of Sugar-Sweetened Beverageand Fast Food Consumption byAnnual Household Income [HBN] 63Special Care Issues of Women Livingwith HIV/AIDS 229Steps to Managing Difficult Behavior inPeople with Dementia [GPP] 182Tar Wars 2009 Rhode Island StatewidePoster Contest 286Tempered View of Bacteria 387Thermal Ablation: Clinical Applications,Safety and Efficacy 407Those Viable Words [PL] 216Through Caverns Measureless to Man 43Time for a Real “Change” in PrimaryCare [POV] 113Trauma Care of the Elderly Patient 181Traumatic Brain Injury in Rhode Island[HBN] 109Treating Depression in the Older Adult[GPP] 214Treatment Failure Gout 369Treatment of Pediatric Obesity 48Update on Minimally Invasive Therapiesfor Benign Prostatic Hyperplasia 336Update on Myelodysplastic Syndrome[GPP] 315Upper and (old) Lower Facial VII NervePalsies on Opposite Sides [IM] 314Ureteroscopic Management of RenalCalculi in a Pelvic Kidney [IM] 342Urinary Incontinence 16Use of Angiotensin-Converting EnzymeInhibitors/Angiotensin ReceptorBlockers and Lipid-lowering Therapiesamong Rhode Islanders with DiabetesEnrolled in Medicare Part D Plans in2006 and 2007 AP] 373“Value” Equation: Costs and Quality of RhodeIsland’s Health Plans (2007) [HBN] 217Vital Statistics 37, 67, 115, 159Wanderings of the Vagus Nerve [PL] 379Warren Alpert Medical School of BrownUniversity: Class of 2009 292Way Things Were, or, In the Days of the“Giants” 162What’s New in Surgical Treatment forCrohn’s Disease 103Why People in RI Won’t Drive Far:A Scientific Explanation 118Words Foretelling the Future [PL] 347X Marks the Spot: Cosmetic SurgeryGone Awry [CC] 416

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