Mixed Topics

Rheumatologic conditions and infections may imitate each other, often making diagnosis challenging. Therefore, it is imperative to obtain adequate histories and have a keen eye for these potentially confounding differential diagnoses. Immunosuppressants used in managing rheumatologic etiologies have detrimental consequences in undiagnosed underlying infections. Consequently, worsening symptoms with standard therapy should raise awareness to a different diagnosis.

Nontuberculous mycobacteria (NTM) are slow-growing organisms difficult to yield in culture. Initial negative synovial fluid stains and cultures when suspecting NTM infectious arthritis or tenosynovitis should not exclude the diagnosis if there is a strong clinical scenario. The identification of Mycobacterium marinum (M marinum) infection in the hand is of utmost importance given that delayed treatment may cause significant and even permanent disability.

We present the case of a 73-year-old male patient with progressively worsening right-hand tenosynovitis who was evaluated for crystal-induced and sarcoid arthropathies in the setting of negative synovial biopsy cultures but was subsequently diagnosed with M marinum infectious tenosynovitis after a second surgical debridement.

Case Presentation

A 73-year-old male patient with history of type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, bilateral knee osteoarthritis, obstructive sleep apnea, and posttraumatic stress disorder presented to the emergency department (ED) with right wrist swelling and pain for 4 days. The patient reported that he was working in his garden when symptoms started. He did not recall any skin abrasions or wounds, insect bites, thorn punctures, trauma, or exposure to swimming pools or fish tanks. Patient was afebrile, and vital signs were within normal range. On physical examination, there was erythema, swelling, and tenderness in the dorsum of the right hand and over the dorsal aspect of the fourth metacarpophalangeal joint (Figure 1). The skin was intact.

Symptoms had not responded to 7 days of cefalexin nor to a short course of oral steroids. Leukocytosis of 14.35 × 10⁹/L (reference range, 3.90-9.90 × 10⁹/L) with neutrophilia at 11.10 × 10^9/L (reference range, 1.73-6.37 × 10⁹/L) was noted. Sedimentation rate and C-reactive protein levels were normal. Right-hand X-ray was remarkable for chondrocalcinosis in the triangular fibrocartilage. Right upper extremity magnetic resonance imaging (MRI) revealed diffuse inflammation in the right wrist and hand (Figure 2). There was no evidence of septic arthritis or osteomyelitis. Consequently, orthopedic service recommended no surgical intervention. Additionally, the patient had preserved range of motion that further indicated tenosynovitis, which could be medically managed with antibiotics, rather than a septic joint.

One dose of IV piperacillin/tazobactam was given at the ED, and he was admitted to the internal medicine ward with right hand and wrist cellulitis and indolent suppurative tenosynovitis. Empiric IV ceftriaxone and vancomycin were started as per infectious disease (ID) service with adequate response defined as a reduction of the swelling, erythema, and tenderness of the right hand and wrist. Differential diagnosis included sporotrichosis, nocardia vs NTM infection.

Interventional radiology was consulted for right wrist drainage. However, only 1 mL of fluid was obtained. Synovial fluid was sent for cell count and differential, crystal analysis, bacterial cultures, fungal cultures, and acid-fast bacilli (AFB) stains and culture. Neutrophils were 43% and lymphocytes were 57%. Crystal analysis was negative. Bacterial culture and mycology were negative. AFB stain and culture results were negative after 6 weeks. Based on gardening history and risk of thorn exposure and low suspicion for common bacterial pathogens, ID service switched antibiotics to moxifloxacin, minocycline, and linezolid for broad coverage to complete 3 weeks as outpatient. The patient reported significantly improved pain and handgrip with notable decrease in swelling. Nonetheless, 3 weeks after completing antibiotics, the right-hand pain recurred, raising concern for complex regional syndrome vs crystalline arthropathy.

Discussion

M marinum is an NTM found in bodies of water and marine settings. Infection arises after direct contact of lacerated skin with contaminated water. In a review article of 5 cases of M marinum tenosynovitis, they found that all individuals had wounds with exposure to fish or shrimp while in the water or while handling seafood.¹ The incidence of this infection is infrequent, estimated to be 0.04 cases per 100,000, with only about 25% of these cases presenting as tenosynovitis.² The incubation period ranges from 2 to 4 weeks.³ Late identification of this organism is common because of its slow development. For example, presentation from first exposure to symptom onset may take as long as 32 days.¹ In addition, in the same review, surgical intervention occurred in 63 days.¹ It has been reported that AFB stains are positive in just 9% of cases, which confounds diagnosis even more.⁴ After synovial tissue culture is obtained, it takes approximately 6 weeks for the organism to grow. Moreover, diagnosis may take longer if it is not suspected.⁵

Four types of M marinum infections have been described.⁵ The status of the immune system plays a role in how the manifestations present. The first type is limited, which is seen in immunocompetent persons, characterized by skin involvement, such as erythematous nodular lesions, that may improve on their own in months or years.⁴ Conversely, in immunosuppressed patients, the second type of infection may cause sporotrichoid spreading described as following lymphangitic pattern. The third type presents with musculoskeletal findings, such as arthritis, tenosynovitis, bursitis, or osteomyelitis, as seen in our patient. The fourth type consists of systemic manifestations.⁵ Medications that lower the immune system, such as corticosteroids, chemotherapy, and biologic disease modifying agents, may increase the risk for developing this entity.⁴ Specifically, antitumor necrosis factor inhibitors have been historically associated with mycobacterium infections.⁶

Patients are frequently diagnosed with soft tissue infection, such as abscesses or cellulitis, as in our case. They may at times be found to have other musculoskeletal conditions such as trigger finger.¹ Other similar presenting entities are psoriatic arthritis, rheumatoid arthritis, and remitting seronegative arthritis.⁴ These clinical resemblances complicate the scenario, especially when initial cultures are negative, as the treatment for these rheumatic diseases is immunosuppression, which adversely impact the fastidious infection. In our case, the improved swelling and range of motion after the 3-week course of empiric antibiotics for suppurative tenosynovitis was initially reassuring that the previous infection had been successfully treated. Subsequently, the presence of chondrocalcinosis in the triangular fibrocartilage in the right-hand X-rays, persistent pain, and the tophi-like appearance of the right third proximal interphalangeal nodule raised concerns for crystalline arthropathies, such as calcium pyrophosphate deposition vs gout. Nonetheless, given the lack of response to low-dose steroids, an ongoing infectious process was strongly considered.

Sarcoidosis was a concern after the first synovial biopsy revealed noncaseating granulomas and negative stains and cultures. Sarcoid tenosynovitis is rare with only 22 cases described as per a 2015 report.⁷ Musculoskeletal involvement in sarcoidosis has been reported in 1 to 13% of sarcoid patients.⁷ Once again, unresponsiveness to steroids led to another synovial biopsy for culture due to potential infection. Akin to other cases, more than one surgical debridement was required to diagnose our patient.

Conclusions

Our case reinforces the vital role of history gathering in establishing diagnoses. It underscores the value of clinical suspicion especially in patients unresponsive to standard treatment for inflammatory arthritis, namely corticosteroids. Tissue biopsy with culture for AFB is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Clinicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

Rheumatologic conditions and infections may imitate each other, often making diagnosis challenging. Therefore, it is imperative to obtain adequate histories and have a keen eye for these potentially confounding differential diagnoses. Immunosuppressants used in managing rheumatologic etiologies have detrimental consequences in undiagnosed underlying infections. Consequently, worsening symptoms with standard therapy should raise awareness to a different diagnosis.

Nontuberculous mycobacteria (NTM) are slow-growing organisms difficult to yield in culture. Initial negative synovial fluid stains and cultures when suspecting NTM infectious arthritis or tenosynovitis should not exclude the diagnosis if there is a strong clinical scenario. The identification of Mycobacterium marinum (M marinum) infection in the hand is of utmost importance given that delayed treatment may cause significant and even permanent disability.

We present the case of a 73-year-old male patient with progressively worsening right-hand tenosynovitis who was evaluated for crystal-induced and sarcoid arthropathies in the setting of negative synovial biopsy cultures but was subsequently diagnosed with M marinum infectious tenosynovitis after a second surgical debridement.

Case Presentation

A 73-year-old male patient with history of type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, bilateral knee osteoarthritis, obstructive sleep apnea, and posttraumatic stress disorder presented to the emergency department (ED) with right wrist swelling and pain for 4 days. The patient reported that he was working in his garden when symptoms started. He did not recall any skin abrasions or wounds, insect bites, thorn punctures, trauma, or exposure to swimming pools or fish tanks. Patient was afebrile, and vital signs were within normal range. On physical examination, there was erythema, swelling, and tenderness in the dorsum of the right hand and over the dorsal aspect of the fourth metacarpophalangeal joint (Figure 1). The skin was intact.

Symptoms had not responded to 7 days of cefalexin nor to a short course of oral steroids. Leukocytosis of 14.35 × 10⁹/L (reference range, 3.90-9.90 × 10⁹/L) with neutrophilia at 11.10 × 10^9/L (reference range, 1.73-6.37 × 10⁹/L) was noted. Sedimentation rate and C-reactive protein levels were normal. Right-hand X-ray was remarkable for chondrocalcinosis in the triangular fibrocartilage. Right upper extremity magnetic resonance imaging (MRI) revealed diffuse inflammation in the right wrist and hand (Figure 2). There was no evidence of septic arthritis or osteomyelitis. Consequently, orthopedic service recommended no surgical intervention. Additionally, the patient had preserved range of motion that further indicated tenosynovitis, which could be medically managed with antibiotics, rather than a septic joint.

One dose of IV piperacillin/tazobactam was given at the ED, and he was admitted to the internal medicine ward with right hand and wrist cellulitis and indolent suppurative tenosynovitis. Empiric IV ceftriaxone and vancomycin were started as per infectious disease (ID) service with adequate response defined as a reduction of the swelling, erythema, and tenderness of the right hand and wrist. Differential diagnosis included sporotrichosis, nocardia vs NTM infection.

Interventional radiology was consulted for right wrist drainage. However, only 1 mL of fluid was obtained. Synovial fluid was sent for cell count and differential, crystal analysis, bacterial cultures, fungal cultures, and acid-fast bacilli (AFB) stains and culture. Neutrophils were 43% and lymphocytes were 57%. Crystal analysis was negative. Bacterial culture and mycology were negative. AFB stain and culture results were negative after 6 weeks. Based on gardening history and risk of thorn exposure and low suspicion for common bacterial pathogens, ID service switched antibiotics to moxifloxacin, minocycline, and linezolid for broad coverage to complete 3 weeks as outpatient. The patient reported significantly improved pain and handgrip with notable decrease in swelling. Nonetheless, 3 weeks after completing antibiotics, the right-hand pain recurred, raising concern for complex regional syndrome vs crystalline arthropathy.

Discussion

M marinum is an NTM found in bodies of water and marine settings. Infection arises after direct contact of lacerated skin with contaminated water. In a review article of 5 cases of M marinum tenosynovitis, they found that all individuals had wounds with exposure to fish or shrimp while in the water or while handling seafood.¹ The incidence of this infection is infrequent, estimated to be 0.04 cases per 100,000, with only about 25% of these cases presenting as tenosynovitis.² The incubation period ranges from 2 to 4 weeks.³ Late identification of this organism is common because of its slow development. For example, presentation from first exposure to symptom onset may take as long as 32 days.¹ In addition, in the same review, surgical intervention occurred in 63 days.¹ It has been reported that AFB stains are positive in just 9% of cases, which confounds diagnosis even more.⁴ After synovial tissue culture is obtained, it takes approximately 6 weeks for the organism to grow. Moreover, diagnosis may take longer if it is not suspected.⁵

Four types of M marinum infections have been described.⁵ The status of the immune system plays a role in how the manifestations present. The first type is limited, which is seen in immunocompetent persons, characterized by skin involvement, such as erythematous nodular lesions, that may improve on their own in months or years.⁴ Conversely, in immunosuppressed patients, the second type of infection may cause sporotrichoid spreading described as following lymphangitic pattern. The third type presents with musculoskeletal findings, such as arthritis, tenosynovitis, bursitis, or osteomyelitis, as seen in our patient. The fourth type consists of systemic manifestations.⁵ Medications that lower the immune system, such as corticosteroids, chemotherapy, and biologic disease modifying agents, may increase the risk for developing this entity.⁴ Specifically, antitumor necrosis factor inhibitors have been historically associated with mycobacterium infections.⁶

Patients are frequently diagnosed with soft tissue infection, such as abscesses or cellulitis, as in our case. They may at times be found to have other musculoskeletal conditions such as trigger finger.¹ Other similar presenting entities are psoriatic arthritis, rheumatoid arthritis, and remitting seronegative arthritis.⁴ These clinical resemblances complicate the scenario, especially when initial cultures are negative, as the treatment for these rheumatic diseases is immunosuppression, which adversely impact the fastidious infection. In our case, the improved swelling and range of motion after the 3-week course of empiric antibiotics for suppurative tenosynovitis was initially reassuring that the previous infection had been successfully treated. Subsequently, the presence of chondrocalcinosis in the triangular fibrocartilage in the right-hand X-rays, persistent pain, and the tophi-like appearance of the right third proximal interphalangeal nodule raised concerns for crystalline arthropathies, such as calcium pyrophosphate deposition vs gout. Nonetheless, given the lack of response to low-dose steroids, an ongoing infectious process was strongly considered.

Sarcoidosis was a concern after the first synovial biopsy revealed noncaseating granulomas and negative stains and cultures. Sarcoid tenosynovitis is rare with only 22 cases described as per a 2015 report.⁷ Musculoskeletal involvement in sarcoidosis has been reported in 1 to 13% of sarcoid patients.⁷ Once again, unresponsiveness to steroids led to another synovial biopsy for culture due to potential infection. Akin to other cases, more than one surgical debridement was required to diagnose our patient.

Conclusions

Our case reinforces the vital role of history gathering in establishing diagnoses. It underscores the value of clinical suspicion especially in patients unresponsive to standard treatment for inflammatory arthritis, namely corticosteroids. Tissue biopsy with culture for AFB is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Clinicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

Rheumatologic conditions and infections may imitate each other, often making diagnosis challenging. Therefore, it is imperative to obtain adequate histories and have a keen eye for these potentially confounding differential diagnoses. Immunosuppressants used in managing rheumatologic etiologies have detrimental consequences in undiagnosed underlying infections. Consequently, worsening symptoms with standard therapy should raise awareness to a different diagnosis.

Nontuberculous mycobacteria (NTM) are slow-growing organisms difficult to yield in culture. Initial negative synovial fluid stains and cultures when suspecting NTM infectious arthritis or tenosynovitis should not exclude the diagnosis if there is a strong clinical scenario. The identification of Mycobacterium marinum (M marinum) infection in the hand is of utmost importance given that delayed treatment may cause significant and even permanent disability.

We present the case of a 73-year-old male patient with progressively worsening right-hand tenosynovitis who was evaluated for crystal-induced and sarcoid arthropathies in the setting of negative synovial biopsy cultures but was subsequently diagnosed with M marinum infectious tenosynovitis after a second surgical debridement.

Case Presentation

A 73-year-old male patient with history of type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, bilateral knee osteoarthritis, obstructive sleep apnea, and posttraumatic stress disorder presented to the emergency department (ED) with right wrist swelling and pain for 4 days. The patient reported that he was working in his garden when symptoms started. He did not recall any skin abrasions or wounds, insect bites, thorn punctures, trauma, or exposure to swimming pools or fish tanks. Patient was afebrile, and vital signs were within normal range. On physical examination, there was erythema, swelling, and tenderness in the dorsum of the right hand and over the dorsal aspect of the fourth metacarpophalangeal joint (Figure 1). The skin was intact.

Symptoms had not responded to 7 days of cefalexin nor to a short course of oral steroids. Leukocytosis of 14.35 × 10⁹/L (reference range, 3.90-9.90 × 10⁹/L) with neutrophilia at 11.10 × 10^9/L (reference range, 1.73-6.37 × 10⁹/L) was noted. Sedimentation rate and C-reactive protein levels were normal. Right-hand X-ray was remarkable for chondrocalcinosis in the triangular fibrocartilage. Right upper extremity magnetic resonance imaging (MRI) revealed diffuse inflammation in the right wrist and hand (Figure 2). There was no evidence of septic arthritis or osteomyelitis. Consequently, orthopedic service recommended no surgical intervention. Additionally, the patient had preserved range of motion that further indicated tenosynovitis, which could be medically managed with antibiotics, rather than a septic joint.

One dose of IV piperacillin/tazobactam was given at the ED, and he was admitted to the internal medicine ward with right hand and wrist cellulitis and indolent suppurative tenosynovitis. Empiric IV ceftriaxone and vancomycin were started as per infectious disease (ID) service with adequate response defined as a reduction of the swelling, erythema, and tenderness of the right hand and wrist. Differential diagnosis included sporotrichosis, nocardia vs NTM infection.

Interventional radiology was consulted for right wrist drainage. However, only 1 mL of fluid was obtained. Synovial fluid was sent for cell count and differential, crystal analysis, bacterial cultures, fungal cultures, and acid-fast bacilli (AFB) stains and culture. Neutrophils were 43% and lymphocytes were 57%. Crystal analysis was negative. Bacterial culture and mycology were negative. AFB stain and culture results were negative after 6 weeks. Based on gardening history and risk of thorn exposure and low suspicion for common bacterial pathogens, ID service switched antibiotics to moxifloxacin, minocycline, and linezolid for broad coverage to complete 3 weeks as outpatient. The patient reported significantly improved pain and handgrip with notable decrease in swelling. Nonetheless, 3 weeks after completing antibiotics, the right-hand pain recurred, raising concern for complex regional syndrome vs crystalline arthropathy.

Discussion

M marinum is an NTM found in bodies of water and marine settings. Infection arises after direct contact of lacerated skin with contaminated water. In a review article of 5 cases of M marinum tenosynovitis, they found that all individuals had wounds with exposure to fish or shrimp while in the water or while handling seafood.¹ The incidence of this infection is infrequent, estimated to be 0.04 cases per 100,000, with only about 25% of these cases presenting as tenosynovitis.² The incubation period ranges from 2 to 4 weeks.³ Late identification of this organism is common because of its slow development. For example, presentation from first exposure to symptom onset may take as long as 32 days.¹ In addition, in the same review, surgical intervention occurred in 63 days.¹ It has been reported that AFB stains are positive in just 9% of cases, which confounds diagnosis even more.⁴ After synovial tissue culture is obtained, it takes approximately 6 weeks for the organism to grow. Moreover, diagnosis may take longer if it is not suspected.⁵

Four types of M marinum infections have been described.⁵ The status of the immune system plays a role in how the manifestations present. The first type is limited, which is seen in immunocompetent persons, characterized by skin involvement, such as erythematous nodular lesions, that may improve on their own in months or years.⁴ Conversely, in immunosuppressed patients, the second type of infection may cause sporotrichoid spreading described as following lymphangitic pattern. The third type presents with musculoskeletal findings, such as arthritis, tenosynovitis, bursitis, or osteomyelitis, as seen in our patient. The fourth type consists of systemic manifestations.⁵ Medications that lower the immune system, such as corticosteroids, chemotherapy, and biologic disease modifying agents, may increase the risk for developing this entity.⁴ Specifically, antitumor necrosis factor inhibitors have been historically associated with mycobacterium infections.⁶

Patients are frequently diagnosed with soft tissue infection, such as abscesses or cellulitis, as in our case. They may at times be found to have other musculoskeletal conditions such as trigger finger.¹ Other similar presenting entities are psoriatic arthritis, rheumatoid arthritis, and remitting seronegative arthritis.⁴ These clinical resemblances complicate the scenario, especially when initial cultures are negative, as the treatment for these rheumatic diseases is immunosuppression, which adversely impact the fastidious infection. In our case, the improved swelling and range of motion after the 3-week course of empiric antibiotics for suppurative tenosynovitis was initially reassuring that the previous infection had been successfully treated. Subsequently, the presence of chondrocalcinosis in the triangular fibrocartilage in the right-hand X-rays, persistent pain, and the tophi-like appearance of the right third proximal interphalangeal nodule raised concerns for crystalline arthropathies, such as calcium pyrophosphate deposition vs gout. Nonetheless, given the lack of response to low-dose steroids, an ongoing infectious process was strongly considered.

Sarcoidosis was a concern after the first synovial biopsy revealed noncaseating granulomas and negative stains and cultures. Sarcoid tenosynovitis is rare with only 22 cases described as per a 2015 report.⁷ Musculoskeletal involvement in sarcoidosis has been reported in 1 to 13% of sarcoid patients.⁷ Once again, unresponsiveness to steroids led to another synovial biopsy for culture due to potential infection. Akin to other cases, more than one surgical debridement was required to diagnose our patient.

Conclusions

Our case reinforces the vital role of history gathering in establishing diagnoses. It underscores the value of clinical suspicion especially in patients unresponsive to standard treatment for inflammatory arthritis, namely corticosteroids. Tissue biopsy with culture for AFB is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Clinicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

Menopause gets a bad rap in medical literature and throughout society, say authors of a new analysis. And they argue that the negativity undermines women’s health outlook in the years that should be a natural life transition.

Menopause has been medicalized over centuries and talked about as if it were a disease, they say, and that may increase women’s anxiety and apprehension about the midlife stage.

It’s time to change the narrative, says Martha Hickey, MD, with the department of obstetrics and gynaecology at the Royal Women’s Hospital in Victoria, Australia, and her coauthors. Their analysis was published online in the BMJ.

“The message that menopause signals decay and decline, which can potentially be delayed or reversed by hormonal treatments, persists and is reinforced by the media, medical literature, and information for women, often driven by marketing interests,” they write.

Such messages may chip away at women’s confidence. Dr. Hickey and colleagues cite surveys in the United States and Ireland that found that most women (65%-77%) feel unprepared for menopause.

“Together with limited public discussion and education and shame attached to ageing in women, this may contribute to embarrassment and negative expectations about menopause,” the authors write.
 

The ‘untold misery of oestrogen-starved women’

These messages have deep roots. Take for instance, gynecologist Robert Wilson’s words in his 1966 book “Feminine Forever.” The authors note he recommended estrogen for all menopausal women “to treat their ‘serious, painful and often crippling disease’ and avoid the ‘untold misery of alcoholism, drug addiction, divorce, and broken

homes caused by these unstable, oestrogen-starved women.’ ”

Women experience menopause in very different ways. Experience with menopause also differs by country, the authors explain. “Women’s experience of menopause is also strongly influenced by social values around reproduction and ageing, with positive or negative ramifications,” they write.

“For example, women tend to have worse experiences of menopause in countries where their value is predicated on youth and reproductive capacity and ageing is associated with decline.”

The authors argue that the medicalization of menopause has condensed the wide range of women’s experiences at a typical age into “a narrowly defined disease requiring treatment.”
 

Promoting exercise, stopping smoking among positive messages

An editorial by Haitham Hamoda, MD, and Sara Moger, with the British Menopause Society, notes that more than 75% of women experiencing menopause report symptoms, and more than 25% describe severe symptoms.

The editorialists point out that the National Institute of Health and Care Excellence and others recommend an individualized approach to addressing menopause that includes a comprehensive approach – advice on exercise, weight management, stopping smoking, and reducing alcohol as well as options such as hormone therapy (HT).

The literature says the main indication for HT is for severe symptoms and not as a preventive measure. “Evidence does not support use of HT to reduce the risk of dementia,” they point out.

While some women may benefit from HT, that should not be explored to the exclusion of other avenues of help, Dr. Hickey and colleagues write. Risks must also be considered.
 

Menopause blamed in a difficult time of life

Jennifer Howell, MD, an obstetrician/gynecologist and certified menopause provider at Duke University in Durham, N.C., told this news organization that menopause is often blamed in a time of life when women naturally are experiencing an array of stressful and emotional changes.

It often coincides with children heading to college, navigating midlife challenges in marriage, helping aging parents, managing demanding careers, and health issues.

People want a reason for changes women experience, and too often the finger gets pointed at menopause, Dr. Howell said.

The message women hear has always been, “It’s got to be your hormones. And people want to hear that there’s a hormonal solution.”

Making menopause the target also has led to nonevidence-based “snake-oil” type remedies sold in unregulated powders, creams, and pellets, Dr. Howell noted.

Dr. Howell has treated thousands of menopausal women in her clinic and she says she spends a good deal of time with them explaining a holistic view of the process, much like what the authors describe, with lifestyle changes and treatment options.

Sometimes HT is the solution, Dr. Howell says, but “it’s become a crutch. Hormones are not a panacea.”

She is frustrated with the amount of disinformation circulating online. Groups like the North American Menopause Society put out reliable evidence-based information, but they compete “with a lot of nonsense,” she says.

The message that women should hear, she says is that “[menopause] is a natural part of aging and there may or may not be symptoms that come along with it. If there are, there are things we can do,” she says.

Menopause gets a bad rap in medical literature and throughout society, say authors of a new analysis. And they argue that the negativity undermines women’s health outlook in the years that should be a natural life transition.

Menopause has been medicalized over centuries and talked about as if it were a disease, they say, and that may increase women’s anxiety and apprehension about the midlife stage.

It’s time to change the narrative, says Martha Hickey, MD, with the department of obstetrics and gynaecology at the Royal Women’s Hospital in Victoria, Australia, and her coauthors. Their analysis was published online in the BMJ.

“The message that menopause signals decay and decline, which can potentially be delayed or reversed by hormonal treatments, persists and is reinforced by the media, medical literature, and information for women, often driven by marketing interests,” they write.

Such messages may chip away at women’s confidence. Dr. Hickey and colleagues cite surveys in the United States and Ireland that found that most women (65%-77%) feel unprepared for menopause.

“Together with limited public discussion and education and shame attached to ageing in women, this may contribute to embarrassment and negative expectations about menopause,” the authors write.
 

The ‘untold misery of oestrogen-starved women’

These messages have deep roots. Take for instance, gynecologist Robert Wilson’s words in his 1966 book “Feminine Forever.” The authors note he recommended estrogen for all menopausal women “to treat their ‘serious, painful and often crippling disease’ and avoid the ‘untold misery of alcoholism, drug addiction, divorce, and broken

homes caused by these unstable, oestrogen-starved women.’ ”

Women experience menopause in very different ways. Experience with menopause also differs by country, the authors explain. “Women’s experience of menopause is also strongly influenced by social values around reproduction and ageing, with positive or negative ramifications,” they write.

“For example, women tend to have worse experiences of menopause in countries where their value is predicated on youth and reproductive capacity and ageing is associated with decline.”

The authors argue that the medicalization of menopause has condensed the wide range of women’s experiences at a typical age into “a narrowly defined disease requiring treatment.”
 

Promoting exercise, stopping smoking among positive messages

An editorial by Haitham Hamoda, MD, and Sara Moger, with the British Menopause Society, notes that more than 75% of women experiencing menopause report symptoms, and more than 25% describe severe symptoms.

The editorialists point out that the National Institute of Health and Care Excellence and others recommend an individualized approach to addressing menopause that includes a comprehensive approach – advice on exercise, weight management, stopping smoking, and reducing alcohol as well as options such as hormone therapy (HT).

The literature says the main indication for HT is for severe symptoms and not as a preventive measure. “Evidence does not support use of HT to reduce the risk of dementia,” they point out.

While some women may benefit from HT, that should not be explored to the exclusion of other avenues of help, Dr. Hickey and colleagues write. Risks must also be considered.
 

Menopause blamed in a difficult time of life

Jennifer Howell, MD, an obstetrician/gynecologist and certified menopause provider at Duke University in Durham, N.C., told this news organization that menopause is often blamed in a time of life when women naturally are experiencing an array of stressful and emotional changes.

It often coincides with children heading to college, navigating midlife challenges in marriage, helping aging parents, managing demanding careers, and health issues.

People want a reason for changes women experience, and too often the finger gets pointed at menopause, Dr. Howell said.

The message women hear has always been, “It’s got to be your hormones. And people want to hear that there’s a hormonal solution.”

Making menopause the target also has led to nonevidence-based “snake-oil” type remedies sold in unregulated powders, creams, and pellets, Dr. Howell noted.

Dr. Howell has treated thousands of menopausal women in her clinic and she says she spends a good deal of time with them explaining a holistic view of the process, much like what the authors describe, with lifestyle changes and treatment options.

Sometimes HT is the solution, Dr. Howell says, but “it’s become a crutch. Hormones are not a panacea.”

She is frustrated with the amount of disinformation circulating online. Groups like the North American Menopause Society put out reliable evidence-based information, but they compete “with a lot of nonsense,” she says.

The message that women should hear, she says is that “[menopause] is a natural part of aging and there may or may not be symptoms that come along with it. If there are, there are things we can do,” she says.

Menopause gets a bad rap in medical literature and throughout society, say authors of a new analysis. And they argue that the negativity undermines women’s health outlook in the years that should be a natural life transition.

Menopause has been medicalized over centuries and talked about as if it were a disease, they say, and that may increase women’s anxiety and apprehension about the midlife stage.

It’s time to change the narrative, says Martha Hickey, MD, with the department of obstetrics and gynaecology at the Royal Women’s Hospital in Victoria, Australia, and her coauthors. Their analysis was published online in the BMJ.

“The message that menopause signals decay and decline, which can potentially be delayed or reversed by hormonal treatments, persists and is reinforced by the media, medical literature, and information for women, often driven by marketing interests,” they write.

Such messages may chip away at women’s confidence. Dr. Hickey and colleagues cite surveys in the United States and Ireland that found that most women (65%-77%) feel unprepared for menopause.

“Together with limited public discussion and education and shame attached to ageing in women, this may contribute to embarrassment and negative expectations about menopause,” the authors write.
 

The ‘untold misery of oestrogen-starved women’

These messages have deep roots. Take for instance, gynecologist Robert Wilson’s words in his 1966 book “Feminine Forever.” The authors note he recommended estrogen for all menopausal women “to treat their ‘serious, painful and often crippling disease’ and avoid the ‘untold misery of alcoholism, drug addiction, divorce, and broken

homes caused by these unstable, oestrogen-starved women.’ ”

Women experience menopause in very different ways. Experience with menopause also differs by country, the authors explain. “Women’s experience of menopause is also strongly influenced by social values around reproduction and ageing, with positive or negative ramifications,” they write.

“For example, women tend to have worse experiences of menopause in countries where their value is predicated on youth and reproductive capacity and ageing is associated with decline.”

The authors argue that the medicalization of menopause has condensed the wide range of women’s experiences at a typical age into “a narrowly defined disease requiring treatment.”
 

Promoting exercise, stopping smoking among positive messages

An editorial by Haitham Hamoda, MD, and Sara Moger, with the British Menopause Society, notes that more than 75% of women experiencing menopause report symptoms, and more than 25% describe severe symptoms.

The editorialists point out that the National Institute of Health and Care Excellence and others recommend an individualized approach to addressing menopause that includes a comprehensive approach – advice on exercise, weight management, stopping smoking, and reducing alcohol as well as options such as hormone therapy (HT).

The literature says the main indication for HT is for severe symptoms and not as a preventive measure. “Evidence does not support use of HT to reduce the risk of dementia,” they point out.

While some women may benefit from HT, that should not be explored to the exclusion of other avenues of help, Dr. Hickey and colleagues write. Risks must also be considered.
 

Menopause blamed in a difficult time of life

Jennifer Howell, MD, an obstetrician/gynecologist and certified menopause provider at Duke University in Durham, N.C., told this news organization that menopause is often blamed in a time of life when women naturally are experiencing an array of stressful and emotional changes.

It often coincides with children heading to college, navigating midlife challenges in marriage, helping aging parents, managing demanding careers, and health issues.

People want a reason for changes women experience, and too often the finger gets pointed at menopause, Dr. Howell said.

The message women hear has always been, “It’s got to be your hormones. And people want to hear that there’s a hormonal solution.”

Making menopause the target also has led to nonevidence-based “snake-oil” type remedies sold in unregulated powders, creams, and pellets, Dr. Howell noted.

Dr. Howell has treated thousands of menopausal women in her clinic and she says she spends a good deal of time with them explaining a holistic view of the process, much like what the authors describe, with lifestyle changes and treatment options.

Sometimes HT is the solution, Dr. Howell says, but “it’s become a crutch. Hormones are not a panacea.”

She is frustrated with the amount of disinformation circulating online. Groups like the North American Menopause Society put out reliable evidence-based information, but they compete “with a lot of nonsense,” she says.

The message that women should hear, she says is that “[menopause] is a natural part of aging and there may or may not be symptoms that come along with it. If there are, there are things we can do,” she says.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

The cupboard in Dr. Nicolás Rascovan’s microbial paleogenomics lab at Institut Pasteur in Paris is filled up with cardboard boxes that look as if they were shipped from an office supply store. Yet, instead of pencils and Post-it notes, the boxes are filled with ancient human remains from South America – several-thousand-year-old vertebrae, petrus bones (which protect inner ear structures), and teeth – all neatly packed in plastic bags. From these artifacts Dr. Rascovan hopes to retrieve DNA of ancient pathogens – which could help us better understand how microbes emerge and evolve and how pandemics spread. It could even, perhaps, rewrite history. “It’s a story of a continent in a closet,” Dr. Rascovan says.

Over the past decade, technologic advances in DNA recovery and sequencing have made it possible for scientists such as Dr. Rascovan, an Argentinian molecular biologist, to analyze ancient specimens relatively quickly and affordably. They’ve been hunting for – and finding – DNA of centuries-old microbes in various archeological samples: from smallpox variola virus and Mycobacterium tuberculosis in mummified tissues, to the Black Death bacteria, Yesinia pestis, in neolithic teeth, to Plasmodium falciparum preserved in historical blood stains.

The ultramodern Parisian offices of the microbial paleogenomics group, a team of five scientists led by Dr. Rascovan, clash with the logo they half-jokingly chose for themselves and plastered all over the lab’s walls: a Jurassic Park–inspired dinosaur baring its giant, ancient teeth, made to look like an image seen under a microscope. Ancient teeth are certainly central to the group’s work, because it’s there where ancient pathogens’ DNA is most likely to be preserved – after death, teeth act like tiny, sealed-up boxes for microbes. “If you have a pathogen that is circulating in the blood, it will sometimes get into the teeth, and when you die, the DNA will stay there,” Dr. Rascovan says.

To process ancient teeth, Dr. Rascovan enters a lab clad head to toe in protective gear. That’s not so much to save himself from potentially deadly disease as to save the samples from contamination, he says. According to Sebastian Duchene Garzon, a microbiologist at the University of Melbourne, “the likelihood of ancient pathogen DNA leading to infections at present is remote, although certainly not impossible, because of how degraded the DNA usually is and because it would still need all the molecular machinery to infect a modern host.”

To process ancient teeth in his lab, Dr. Rascovan starts with a thorough cleaning that involves bleach to remove any modern DNA contamination. Next, he cuts the tooth with a Dremel rotary tool to open it up and get into its pulp – which is not only very durable but also naturally sterile – a perfect place to find ancient pathogens. He then scrapes the pulp into a powder that can be poured into a tube for DNA extraction.

So far, Dr. Rascovan’s biggest breakthrough didn’t come from the teeth he cut up himself, though. It came from analyzing publicly available DNA data from studies of ancient human genomes. When such genomes are sequenced from fossil teeth or bones, scientists pick out the material they need for study of our ancestors’ evolutionary history. However, among the double helixes coding hominid genetic instructions often hide scraps of microbial DNA, which in the past were frequently simply discarded.

Dr. Rascovan downloaded data from published articles on ancient human DNA that had been found in teeth and reanalyzed them, searching for bacteria. One night, when he was alone in his office going through lines and lines of data, he spotted it: DNA of the plague-causing bacteria, Y. pestis. When Dr. Rascovan cross-checked to determine in which samples the bacteria’s DNA was found, his heart raced. “It was not supposed to be there,” he says. He had just discovered the most ancient case of plague in humans – which occurred 4,900 years ago in Sweden.

Scientists used to believe that plague pandemics came to Europe from the Eurasian Steppe. Yet here was the DNA of Y. pestis lodged in the teeth of two farmers, a woman and a man, who died in Scandinavia before the plague’s supposed arrival from the East. Their bodies were buried in an unusually large common grave – of itself a possible indication of an epidemic.

When Dr. Rascovan and his colleagues applied molecular-clock analyses of the phylogenetic tree of the plague bacteria and compared various strains to see which one was the most ancestral, they confirmed that the Swedish strain of Y. pestis, named Gok2, was indeed the oldest – the origin of the Steppe strains rather than its distant cousin. Plague, it seemed, wasn’t brought to Europe during mass migrations from the East. Instead, it might have originated there.

Such work is not simply about rewriting history. By updating our knowledge of ancient pandemics, we can learn how different factors influence each other in fostering outbreaks. For Dr. Rascovan, the Swedish plague story underscores the importance of our lifestyle and environment for the emergence and spread of dangerous pathogens. The Gok2 strain didn’t contain a gene that makes plague particularly virulent, called ymt, yet it might have played an important role in Bronze Age Europe. At that time, mega-settlements of 10,000 to 20,000 people existed in what is now Ukraine, Romania, and Moldova, yet those settlements were frequently burned to the ground and abandoned. According to Dr. Rascovan and his colleagues, that could fit with the plague pandemic story (although this remains very much a hypothesis).

In Mexico, environmental factors might have played an important role in the severity of the 16th century “cocoliztli” epidemic (the word means “pestilence” in a local language), considered one of the most devastating epidemics in New World history. The disease, which caused vomiting, red spots on the skin, and bleeding from various body orifices, didn’t have a known cause. Some hypothesized the bug might have been smallpox, judging by the severity of the outbreak. A 2018 study of a victim’s DNA showed it contained the genome of Salmonella enterica, a bacterium that causes enteric fever – a microbe generally milder than smallpox. The study’s authors argued that specific conditions may have been necessary at the onset of the epidemic for the S. enterica microbe to cause such devastating outcomes. A mix of severe draught, forced relocations of the local population by their Spanish rulers, and new subsistence farming practices all negatively affected hygienic conditions in the local settlements. According to Dr. Rascovan, such research can “place pandemics into their broader context” – with potential lessons for the future.

One of the microbes Dr. Rascovan and his team are hoping to find in the ancient teeth stocked in their lab’s closet is tuberculosis – a pathogen that kills 1.5 million people a year, yet whose evolutionary history remains largely a mystery. The focus of Dr. Rascovan and his colleagues remains on fossils shipped from South America, since we still know very little about microbes that were associated with pre-Columbian populations. South Americans have been isolated from the rest of the world for 20,000 years, making them particularly interesting candidates for the study of emergence, evolution, and spread of pathogens.

Dr. Rascovan believes that ancient microbial genomic data can help scientists better understand antibiotic resistance through comparisons of bacterial evolution before and after the discovery of antibiotics. In general, he says, by studying only current pathogens and the modern outbreaks they cause, we see only a narrow sample of something that is much more diverse and much larger. “We are missing an important part of information. Ancient samples can bring us a perspective,” he says.

A version of this article first appeared on Medscape.com.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

It was wonderful to see long-term friends and colleagues again in New Orleans! Warmed me from the bottom of my COVID-scarred heart.

I had trepidation and anxiety about further COVID exposure, as I am sure many of you all did. I have carefully resumed traveling, although the rules on masking continue to change and confuse us all.

But I did it. I went to the American Psychiatric Association meeting in New Orleans and am so glad I did.

There was of course a lot of discussion about the pandemic, which separated us physically for 3 years – too many virtual meetings. And quiet discussions of grief and loss, both before and during the APA.

I just learned that Joe Napoli, MD, died. He was one of the hearts of the APA Disaster Psychiatry Committee. Others were lost as well, and I am processing those losses.

I do not want this column to be just a promotion for the APA, although it has been my home organization for decades. So, let me define further the cons and pros of going to the meeting. (Yes, I am deliberately reversing the order of these words.) I warn all the readers in advance that this is a soapbox.
 

Cons

The convention center in New Orleans is ridiculously long. Our convention was in Hall G down at end of its telescoping length. Only a couple of doors were open – clearly quite a challenge for folks with disabilities, or those aging into possible disability, like myself. I helped a psychiatrist with impaired vision down the endless hall and of course, felt good about it. (My motto: “Perform acts of kindness, and you will feel better yourself.”)

Another con: Too much going on at the same time. That’s a perpetual problem.

And the noise at the parties was way too loud. We could not hear each other.
 

Pros

Seeing people I have known for 40 years – with masks, without masks. Hugs or bows (on my part, I bow I do not yet hug in COVID times).

The receptions. Great networking. Mid-level psychiatrists who I had forgotten I had mentored. The “young ones” – the psychiatry residents. They seem to be a great and ambitious group.

I did several talks, including one on female veterans, and another on clinical management of the homeless population. The audiences were large and engaged. I am wondering how to make these topics an APA priority, especially engagement with strategies to take care of the unhoused/homeless folks.

Let me give you a brief synopsis of both of those talks, as they represent some of my passions. The first on female veterans. We tend to focus on PTSD and military sexual trauma. I am also concerned about reproductive and musculoskeletal concerns. Too many female service members get pregnant, then quit the military as they cannot manage being a Service member and a mother. They think they can make it (go to school, get a job) but they cannot manage it all.

Veterans services usually focus on single older men. There are not enough rooms and services for female veterans with children. In fairness to the Department of Veterans Affairs, they are trying to remedy this lack.

Transitioning to the homeless population in general, this is an incredible problem which is not easily solved. The VA has done an incredible job here, but the whole country should be mobilized.

My focus at the talk was the importance of assessing and treating medical problems. Again, homeless women are at high risk for barriers to contraception, sexual assault, pregnancy, and the corresponding difficulties of finding housing that will accept infants and small children.

Then there are the numerous medical issues in the unhoused population. Diabetes, hypertension, ulcers on the feet leading to cellulitis and amputation. I am advocating that we psychiatrists behave as medical doctors and think of the whole person, not just of the mind.

Another pro of the APA meeting: such desire to share what we know with the world. I found a few more potential authors for book chapters, specifically Dr. Anne Hansen to write a chapter in my capacity volume. And getting recruited myself, by Maria Llorente, MD, for one on centenarians (people who aged over 100.) Not sure if I know very much now, but I will try.

But another con: I am very tired of endless “scope of practice” discussions about what psychologists and nurse practitioners should do. They are all my comrades. We have plenty of business for all, in this never-ending anxiety tide of COVID.

Another con: I tested positive for COVID after my return, as did several of my friends.

I am sure our readers have many more takes on returning to the APA. These are a few of my thoughts.

Dr. Ritchie is chair of psychiatry at Medstar Washington (D.C.) Hospital Center. She is a member of the Clinical Psychiatry News editorial advisory board, and has no conflicts of interest.

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

Your gut microbiome will thank you later

A healthy gut seems like the new catch-all to better overall health these days. Nutrition and diet culture has us drinking kombucha and ginger tea and coffee, but what if we told you that going to happy hour might also help?

In a recent double-blind study published in the Journal of Agricultural and Food Chemistry, 19 men were divided into two groups and asked to drink 11 ounces of alcoholic lager (5.2% by volume) or nonalcoholic lager with dinner for 4 weeks.

Beer? Yes. Beer.

Engin Akyurt/Pixabay

We humans have trillions of microorganisms running rampant through our digestive tracts. When they’re happy, we have a lower chance of developing heart disease and diabetes. You know what else has millions of happy microorganisms from fermentation? Beer. It also has polyphenols that can help the body’s tissues fight cancers, as well as heart disease and inflammation. So beer is looking a little more healthy now, isn’t it?

In the study, the researchers found that both the alcoholic- and nonalcoholic-lager groups had a boost in bacterial diversity in the gut and higher fecal alkaline phosphatase levels, which showed improved intestinal health. They acknowledged, however, that the nonalcoholic route would be safer and healthier for overall health.

So add a lager to the list of gut-healthy foods that you should be consuming. It may give the phrase “beer gut” a whole new meaning.
 

We’ve lost our minds, but at least we know how fast they’re going

The phrase “quantum consciousness” sounds like something out of a particularly cheesy episode of Star Trek: “Oh no, Captain, the quantum consciousness has invaded our computer, and the only way to drive it out is to reverse the polarity of a focused tachyon beam.”

Massimiliano De Deo, LNGS-INFN

When it comes to understanding such basic existential issues as the origin of consciousness, however, quantum mechanics wasn’t off the table. The theory of the quantum origin of consciousness dates back to the 1990s (thanks in part to noted physician Roger Penrose), and goes something like this: There are microtubules within neurons in the brain that are small enough and isolated enough from the warm, wet, and chaotic brain environment where quantum effects can briefly come into play. We’re talking miniscule fractions of a second here, but still, long enough for quantum calculations to take place in the form of system wavefunction collapse, courtesy of gravity.

To plunge even deeper into the rabbit hole of quantum mechanics, the reason Schrödinger’s cat doesn’t occur in real life is wavefunction collapse; the more massive a quantum system is, the more likely it is to collapse into one state or another (alive or dead, in the cat’s case). The quantum origin of consciousness, or Orch OR theory, holds that human consciousness arises from electrical oscillations within the neuronal microtubules caused by the computations stemming from the collapse of small quantum systems.

That is an awful lot of overly simplified explanation, especially considering the study that just came out essentially disproved it. Oops. The research, published in Physics of Life Reviews, is pretty simple. The researchers went to a lab deep underground to avoid interference from cosmic rays, and sat around for months, observing a chunk of germanium for signs of spontaneous radiation, attributable to the same sort of wavefunction collapse that is supposedly occurring in our brains. They found nothing out of the ordinary, pretty definitively disproving most of Orch OR theory.

The researchers were unwilling to completely dismiss the idea (this is quantum mechanics, after all, uncertainty kind of goes with the territory), but it does seem like we’ll have to search elsewhere for sources of human consciousness. Personally, we’re big fans of the cymbal-playing monkey.
 

Missing links: A real fish story

Dear LOTME:

Ear’s a question that’s been keeping me up at night. Is the human middle ear the result of top-secret government experiments involving alien technology, Abraham Lincoln, and the Illuminati?

Restless in Roswell

Dear Restless:

The paleoanthropologic community has been sorting through this mystery for decades, and fossils discovered in China over the past 20 years finally provide a much less conspiratorially satisfying answer.

IVPP

For some time now, experts in the field have believed that the bones of the human middle ear evolved from the spiracular gill of a fish. The spiracle is a small hole behind each eye that opens to the mouth in some fishes and was used to breathe air in the earliest, most primitive species. But how did we get from spiracle to ear?

The missing links come in the form of the cranial anatomy of Shuyu, a 438-million-year-old, fingernail-sized skull of a jawless fish, and the 419-million-year-old fossil of a completely preserved fish with gill filaments in the first branchial chamber.

“These fossils provided the first anatomical and fossil evidence for a vertebrate spiracle originating from fish gills,” senior author Gai Zhikun, PhD, of the Institute of Vertebrate Paleontology and Paleoanthropology, Beijing, said in a written statement.

In many ways, it seems, we are fish: “Many important structures of human beings can be traced back to our fish ancestors, such as our teeth, jaws, middle ears, etc,” added Zhu Min, PhD, also of the institute.

So, Restless, the next time you hear the soothing sounds of an angry mob storming the Capitol or you chew on a slab, slice, or chunk of mutant, laboratory-produced chicken in your favorite fast-food restaurant, be sure to thank Shuyu.
 

Can you lend me an ear?

If you thought locusts were only a nuisance, think again. They have their uses. If you take a locust’s ear and put it inside a robot, the robot will be able to hear and receive signals. Who knew?

850977/Pixabay

Researchers from Tel Aviv University in Israel showed the robot’s hearing abilities by giving clap signals that told the robot what to do: One clap means go forward, two claps mean move back. What do you think the robot would do if it heard the clap break from Cha Cha Slide?

“Our task was to replace the robot’s electronic microphone with a dead insect’s ear, use the ear’s ability to detect the electrical signals from the environment, in this case vibrations in the air, and, using a special chip, convert the insect input to that of the robot,” Ben M. Maoz, PhD, said in a statement from the university.

And how does a dead locust ear work in a robot? Well, Dr. Maoz explained: “My laboratory has developed a special device – Ear-on-a-Chip – that allows the ear to be kept alive throughout the experiment by supplying oxygen and food to the organ while allowing the electrical signals to be taken out of the locust’s ear and amplified and transmitted to the robot.”

The research won’t stop at hearing, he said, as the other four senses also will be taken into consideration. This could help us sense dangers in the future, such as earthquakes or diseases. We said it before and we’ll say it again: We’re rooting for you, science!

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

A phase 3 trial has associated the neurokinin-3 (NK3)–receptor inhibitor fezolinetant, an oral therapy taken once daily, with substantial control over the symptoms of menopause, according to results of the randomized SKYLIGHT 2 trial.

The nonhormonal therapy has the potential to address an important unmet need, Genevieve Neal-Perry, MD, PhD, said at the annual meeting of the Endocrine Society.

The health risks of hormone therapy (HT) have “caused quite a few women to consider whether hormone replacement is right for them, and, in addition, there are other individuals who have hormone-responsive cancers or other disorders that might prohibit them [from using HT],” Dr. Neal-Perry said.

The NK3 receptor stimulates the thermoregulatory center in the hypothalamus. By blocking the NK3 receptor, vasodilation and other downstream effects are inhibited, explained Dr. Neal-Perry. She credited relatively recent advances in understanding the mechanisms of menopausal symptoms for identifying this and other potentially targetable mediators.

SKYLIGHT 2 trial: Two phases

In the double-blind multinational phase 3 SKYLIGHT 2 trial, 484 otherwise healthy symptomatic menopausal women were randomized to 30 mg of fezolinetant, 45 mg of fezolinetant, or placebo. The 120 participating centers were in North American and Europe.

In the first phase, safety and efficacy were evaluated over 12 weeks. In a second extension phase, placebo patients were rerandomized to one of the fezolinetant study doses. Those on active therapy remained in their assigned groups. All patients were then followed for an additional 40 weeks.

The coprimary endpoints were frequency and severity of moderate to severe vasomotor symptoms as reported by patients using an electronic diary. There were several secondary endpoints, including patient-reported outcomes regarding sleep quality.

As expected from other controlled trials, placebo patients achieved about a 40% reduction in moderate to severe vasomotor symptom frequency over the first 12 weeks. Relative to placebo, symptom frequency declined more quickly and steeply on fezolinetant. By week 12, both achieved reductions of about 60%. Statistical P values for the differences in the three arms were not provided, but Dr. Neal-Perry reported they were significant.

Vasomotor severity, like frequency, is reduced

The change in vasomotor severity, which subjects in the trial rated as better or worse, was also significant. The differences in the severity curves were less, but they separated in favor of the two active treatment arms by about 2 weeks, and the curves continued to show an advantage for fezolinetant over both the first 12 weeks and then the remaining 40 weeks.

Overall, the decline in vasomotor symptom frequency remained on a persistent downward slope on both doses of fezolinetant for the full 52 weeks of the study, so that the reduction at 52 weeks was on the order of 25% greater than that seen at 12 weeks.

At 52 weeks, “you can see that individuals on placebo who were crossed over to an active treatment had a significant reduction in their hot flashes and look very much like those who were randomized to fezolinetant at the beginning of the study,” said Dr. Neal-Perry, who is chair of the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill.

Other outcomes also favored fezolinetant over placebo. For example, a reduction in sleep disturbance observed at 12 weeks was sustained over the full 52 weeks of the study. The reduction in sleep symptoms appeared to be slightly greater on the higher dose, but the benefit at 52 weeks among patients after the crossover was similar on either active arm.

No serious side effects identified

There were no serious drug-related treatment-emergent adverse events in any treatment group. One patient in the placebo arm (< 1%), two patients in the 30-mg fezolinetant arm (1.2%), and five patients in the 45-mg arm (3%) discontinued therapy for an adverse event considered to be treatment related.

“The most common side effect associated with fezolinetant was headache. There were no other side effects that led patients to pull out of the study,” Dr. Neal-Perry reported at the meeting, which was held in Atlanta and virtually.

According to Dr. Neal-Perry the vasomotor symptoms relative to menopause, which occur in almost all women, are moderate to severe in an estimated 35%-45%. Some groups, such as those with an elevated body mass index and African Americans, appear to be at even greater risk. Study enrollment was specifically designed to include these high-risk groups, but the subgroup efficacy data have not yet been analyzed.

Other drugs with a similar mechanism of action have not been brought forward because of concern about elevated liver enzymes, but Dr. Neal-Perry said that this does not appear to be an issue for fezolinetant, which was designed with greater specificity for the NK3 target than previous treatments.

If fezolinetant is approved, Dr. Neal-Perry expects this agent to fulfill an important unmet need because of the limitations of other nonhormonal solutions for control of menopause symptoms.

HT alternatives limited

For control of many menopause symptoms, particularly hot flashes, hormone therapy (HT) is the most efficacious, but Richard J. Santen, MD, emeritus professor and an endocrinologist at the University of Virginia, Charlottesville, agreed there is a need for alternatives.

In addition to those who have contraindications for HT, Dr. Santen said in an interview that this option is not acceptable to others “for a variety of reasons.” The problem is that the alternatives are limited.

“The SSRI agents and gabapentin are alternative nonhormonal agents, but they have side effects and are not as effective,” he said. Hot flashes “can be a major disruptor of quality of life,” so he is intrigued with the positive results achieved with fezolinetant.

“A new drug such as reported at the Endocrine Society meeting would be an important new addition to the armamentarium,” he said.

Dr. Neal-Perry reports no conflicts of interest.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Exposure to per- and polyfluoroalkyl substances (PFAS) – a class of widely used synthetic chemicals dubbed “forever chemicals” – may be a modifiable risk factor for the development of hypertension.

In a large, prospective study, researchers found an association between higher blood levels of PFAS and increased risk of hypertension in middle-aged women. Women in the highest tertile of overall PFAS concentrations had a 71% increased risk of developing hypertension.

“Our findings suggest that long-term cumulative exposure, even before midlife, may increase the risk of high blood pressure, and therefore, the benefit of reducing the population exposure to PFAS and potential prevention of high blood pressure and other health conditions would be enormous,” Sung Kyun Park, ScD, MPH, University of Michigan School of Public Health, Ann Arbor, said in an interview.

The study was published online  in Hypertension.
 

Everywhere and forever

“PFAS are forever chemicals as well as everywhere chemicals,” Dr. Park noted.

Possible sources of PFAS exposure run the gamut from nonstick cookware, food wrappers, and waterproof fabrics to cosmetics and drinking water. They have been detected in the blood of most people and have been linked to a variety of health concerns.

“A few studies showed an association between PFAS and hypertension, but those were cross-sectional and examined prevalence of hypertension. It was unclear whether PFAS are associated with the development (incidence) of hypertension,” Dr. Park explained.

For their study, the researchers examined the association between serum concentrations of PFAS and risks of incident hypertension in 1,058 initially normotensive women participating in the Study of Women’s Health Across the Nation-Multi-Pollutant Study (SWAN-MPS). They were followed annually between 1999 and 2017.

During 11,722 person-years of follow-up, 470 of the women developed hypertension, at a rate of 40.1 cases per 1,000 person-years. Hypertension was defined as blood pressure of at least 140 mm Hg systolic or at least 90 mm Hg diastolic or receiving antihypertensive treatment.

Women in the highest tertile of baseline serum concentration of perfluorooctane sulfonate (PFOS) had a 42% higher risk of developing hypertension, compared with peers in the lowest tertile (adjusted hazard ratio, 1.42; 95% confidence interval, 1.19-1.68; P trend = .01).

Similar results were found for perfluorooctanoate (PFOA) and 2-N-ethyl-perfluorooctane sulfonamido acetate (EtFOSAA), with 47% (aHR, 1.47; 95% CI, 1.24-1.75; P trend = .01) and 42% (aHR, 1.42; 95% CI, 1.19-1.70; P trend = .01) higher risks of incident hypertension, comparing the highest to the lowest tertiles.

The risks persisted after adjusting for various factors, including race, study site, education, financial strain, smoking status, alcohol use, total calorie intake, and menopausal status.

In the PFAS “mixture” analysis, women in the highest tertile of overall PFAS concentrations were 71% more likely to develop hypertension during follow-up, compared with women in the lowest tertile (aHR, 1.71; 95% CI, 1.15-2.54; P trend = .008).

“These findings suggest that PFAS might be an underappreciated contributing factor to women’s cardiovascular disease risk,” the researchers write.

They caution that the study only included middle-aged women and that it is unclear whether the findings hold for middle-aged men.

“This is an important question, but the answer is that we do not know,” Dr. Park told this news organization.

“Women become more susceptible to metabolic changes and hypertension risk during the menopausal transition. Our findings suggest that PFAS may play a role in the development of hypertension in women during this critical life stage,” Dr. Park said.

The researchers say more research is needed to confirm and expand the findings and to find ways to reduce PFAS exposure.

“If confirmed in future studies, these findings suggest that understanding human exposure to PFAS and developing effective strategies to reduce PFAS exposure may help prevent the development of hypertension and thereby reduce the global burden of CVD,” the researchers write.
 

‘The more we learn, the worse it gets’

This is an “interesting” study and shows that “the more we learn about PFAS, the worse it seems to get,” Ankur Shah, MD, division of kidney disease and hypertension, Warren Alpert Medical School of Brown University, Providence, R.I., said in an interview.

“This multisite, multiracial and multiethnic, community-based longitudinal study establishes an association between PFAS and hypertension,” said Dr. Shah, who wasn’t involved in the study.

“This adds to a growing literature base of associations of PFAS with illnesses, including malignancy, thyroid disorders, diabetes, ulcerative colitis, hyperlipidemia, and pregnancy-induced hypertension,” he noted.

Dr. Shah also noted that the authors adjusted for race and ethnicity, study site, education, financial strain, smoking status, environmental tobacco smoke, alcohol consumption, total calorie intake, and menopausal status “and still found a strong association.”

“Still to be determined are both whether PFAS are the causative agent or if there is an unmeasured/unadjusted for entity which has resulted in both increased PFAS exposure and hypertension, as well as if PFAS are causative, if reduction in PFAS exposure would be result in blood pressure reduction,” Dr. Shah added.

The study had no sources of funding. Dr. Park and Dr. Shah have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.

Children who attend center-based childcare are more likely to maintain a healthier body weight than children who receive nonparental, non–center-based care – especially if they come from lower-income families – a new study finds.

The findings of the prospective Canadian study suggest that professional childcare centers that engage in standard practices are having a positive and lasting impact on children’s health, reported lead author Michaela Kucab, RD, MHSc, of the University of Toronto and colleagues.

“Attending center-based childcare in early childhood may influence important health behaviors including nutrition, physical activity, and routines related to child growth and weight status,” the investigators wrote in their abstract, which Ms. Kucab presented at the virtual conference sponsored by the American Society for Nutrition.

Their study involved 3,503 children who attended childcare in Canada during early childhood (mean age at baseline was 2.7 years) with follow-up from ages 4-10.
 

Overweight/obesity risk reduced

Children who received full-time, center-based care had a 22% lower risk of overweight/obesity and a mean body mass index z score (zBMI) that was 0.11 points lower at age 4 and 7 years than those who received non–center-based care. The benefits of center-based care were even more pronounced among children from lower-income families, who, at age 10, had a 48% lower risk of overweight/obesity and a mean zBMI that was 0.32 points lower with center-based versus non–center-based care.

In a written comment, Ms. Kucab and principal author Jonathon Maguire, MD, MSc, of the University of Toronto, explained that the former difference in zBMI translates to approximately half a pound of bodyweight in an average child, whereas the larger difference in zBMI among children from lower-income families would amount to approximately three pounds. They emphasized that these are rough estimations.

Ms. Kucab and Dr. Maguire noted that body weight differences correlated with the amount of time spent in center-based care.

“There was an observed trend, whereby the estimated mean difference [in zBMI] became slightly larger (or stronger) with a higher intensity of center-based childcare compared to non–center-based childcare,” they said.

To learn more about the earliest impacts of center-based care, the investigators are conducting a clinical trial, The Nutrition Recommendation Intervention Trials in Children’s Health Care (NuRISH), which will involve 600 children aged younger than 2 years.
 

Center-based childcare may reduce disadvantages of low-income children

“Although more research is needed, our findings suggest that center-based childcare may help” reduce disadvantages children from low-income families experience related to their heath,” Ms. Kucab said in a press release.

Laurent Legault, MD, an associate professor specializing in endocrinology in the department of pediatrics at McGill University, Montreal, highlighted the “quite significant” sample size of more than 3,000 participants, noting that “it’s quite tough to have numerous children” involved in a study, especially with several years of follow-up.

Dr. Legault also praised the investigators for considering socioeconomic status, “which is absolutely paramount, because, unfortunately, it’s not necessarily an even playing field for these families.”

He said the findings deserve to be promoted, as they highlight the benefits of center-based care, including ones with room for physical activity, opportunities for social interaction with other children, and a structured routine.

Still, Dr. Legault said it’s “very difficult to pinpoint specifically” what led to healthier body weights. “The problem, of course, is that obesity is very multifactorial in nature,” although “early intervention is more likely to be efficient.”

Center-based care appears to be one such intervention, he said, which should “push people to make centered care more affordable and easy to access for everyone.”The investigators and Dr. Legault reported no conflicts of interest.

This article is part of a series of articles on the Home Improvements and Structural Alterations program (HISA), a home modification (HM) program within the Veterans Health Administration (VHA). HISA is a benefit awarded to veterans with disabilities (VWDs) and is instrumental in affording physical accessibility and structural alterations to veterans’ homes.¹ The overarching goals of this project are to describe and understand HISA use by VWDs. Previous work has shown geographical variation in the number of HISA prescriptions across counties in the US (Figure 1).¹ The current work seeks to describe and predict the county-level rates of HISA use. Information about what predicts HISA utilization at the county level is important because it enhances understanding of program utilization at a national level. The long-term goal of the series is to provide knowledge about HM services within VHA to improve community-based independent living of VWDs by increasing awareness and utilization of HM services. 

Background

A health care professional (HCP) approves a HM support award by evaluating the practicality of the support to improve the built environment of a given veteran’s disability.^1,2 Previously we detailed some of the preliminary research into the HISA program, including HISA user demographic and clinical characteristics, types of HMs received, user suggestions for improvement, and geospatial analysis of HISA prescriptions concentration.^1-4

The geospatial analyses of HISA prescriptions revealed clusters of high numbers of HISA users (hot spots) and low numbers of HISA users (cold spots), indicating that HISA is either not prescribed or uniformly used across the US. The previous research prompted investigation into county-level variables that may impact HISA utilization rates. This inquiry focuses on county characteristics associated with HISA use rates, such as measures of clinical care and quality of care (eg, access to health services variables, lack of insurance, preventable hospital stays), physical environment, and sociodemographic characteristics. Clinical care and quality of care measures promote the interaction with HCPs. Moreover, access to health care is an important indicator of health outcomes.^5,6 An individual’s capacity to access health services, such as a HM program, greatly impacts well-being, safety, independence, and health.^2,4 Well-being, safety, independence, and health become compromised if individuals cannot access care, if needed care is lacking in their area, if HCPs are not available, or are unwilling to provide care due to lack of insurance coverage.^7-12 In locations where health care services are minimal due to lack of specialists or health care facilities, the quality of (or access to) care may be compromised, resulting in preventable conditions becoming problematic.^13,14 These conditions may result in unnecessary hospitalizations for conditions that could have been treated during routine care. Financial barriers to care particularly among low-income people and the uninsured have proven detrimental to health.^15,16 On the other hand, preventable hospital stays are a quality of care measure (ie, a proxy for poor quality of care). HISA operates within a health care system; thus, it is imperative to include these measures impacting health. 

In this study, we sought to identify county-level predictors—in particular, county-level proxies for access to care—that may be associated with county-level HISA use. We define HISA utilization rate as the percentage of a county’s VHA patients who have received a HISA award.

Methods

This study used data from the National Prosthetics Patient Database (NPPD), US Department of Veterans Affairs (VA) medical database inpatient and outpatient datasets, VHA Support Service Center (VSSC) data cubes, and the County Health Rankings database (CHRD). First, the study cohort was identified from NPPD users who have obtained a HISA award from fiscal years (FY) 2015 to 2018. Analysis started with FY 2015 following new regulations (38 CFR § 17) governing the operations of the HISA program.² The study cohort was matched with records from NPPD and VA inpatient and outpatient datasets to obtain information about the veterans’ demographic characteristics and their HM characteristics and costs. The number of VHA end-of-year (EOY) patients per county was extracted from the VSSC Current Enrollment Cube, which was used in calculation of the county-level HISA utilization rate.¹⁷ Finally, zip code–based locational data were used to calculate approximate drive time and distance from the HISA user’s approximate location to the facility where they received their HM prescription. Drive times and drive distances were calculated with Esri ArcGIS Pro (v2.6.3) by placing zip code centroid and VHA facilities on a nationwide road network that contains both road speeds and distances.

Calculations

Patient-level data were aggregated up to county-level variables by calculating the sum, mean, or percent per county. HISA user sample characteristics, including sex, race, rurality (urban, rural), marital status, and Class 1 vs Class 2 disability-related eligibility groups, were aggregated to the county level by calculating percentages of HISA users of the given characteristics out of total HISA users in the county. Disability-related eligibility groups (Class 1 vs Class 2 HISA users) determines the maximum lifetime award dollar amount. Specifically, those with service-connected disabilities or those with a ≥ 50% disability rating (regardless of whether or not their disability is service connected) are classified as Class 1 HISA users and are eligible to receive a maximum lifetime award of $6800. Those with a recorded disability that is not connected to their military service, and who have a disability rating of < 50% are classified as Class 2 HISA users and are eligible to receive a lifetime maximum award of $2000.

The county-level number of HISA users was used as the numerator for calculation of county-level HISA utilization rate. Counties with zero HISA users were excluded. The number of EOY VHA patients per county in FY 2018 was divided by 1000 and used as the denominator in the calculation of county-level HISA utilization rate. Thus, the outcome variable is HISA utilization rate per 1000 VHA patients in FY 2018 (HISA utilization rate).

County-Level Variables

County-level variables were downloaded from the 2020 CHRD.^5,6 An explanation of the CHRD model and the factors used in this study are shown in the eAppendix (available at doi: 10.12788/fp.0279).⁶ County-level aggregated HISA user data and the CHRD data were matched using county Federal Information Processing Standards codes. Access to care measures collected from CHRD included percentages uninsured and ratios of population to primary care physicians, dentists, mental health professionals, and other primary care professionals. Other CHRD measures included those for quality of care (rate of preventable hospital stay) and housing quality (percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, percent of homeownership). Of secondary interest was county population rurality, as previous research findings showed the annual average of HISA users who are from rural areas ranged from 30 to 35%.

Analysis Methods

SAS (v9.4), R (v4.0.2), and RStudio (v1.3.1093) were used for data preparation and analysis.¹⁸ Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Sociodemographic characteristics from CHRD and HISA data were included as important control predictors in the regression model, though our focus for this paper are the access to care and housing quality predictors.

Model diagnostics (examination of model residuals, Breusch-Godfrey test, Breusch-Pagan test) revealed significant heteroskedasticity of the model; thus, robust standard errors and associated P values were computed using the R estimatr package (v0.30.2).¹⁹ Some predictor variables of interest (eg, ratio of mental health professionals) were removed during the model building process either due to problems of multicollinearity or excessive missingness that would have resulted in listwise deletion.

Results

County-level HISA utilization rate per 1000 EOY VHA patients ranged from 0.09 to 59.7%, with a 6.6% mean and 5% median (Figure 2). The data were highly positively skewed. The final model included 33 total predictor variables (Table 1). The final regression model was a significantly better predictor of county-level HISA utilization rate than a null model (F[33-2184], 10.18; P < .001). The adjusted model R² showed that the overall model accounted for approximately 23% of variance in county-level HISA utilization rate (Table 2).

Among the primary variables of interest, percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005), indicating that the higher the proportion of uninsured adults—with all other predictors held constant—the lower the HISA utilization rate. Percent uninsured adults ranged from 2.7 to 42.4% across counties, with a mean (SD) of 12.7% (5.8%) and 11.4% median.

Discussion

This study examined whether county-level characteristics, specifically variables for access to care, quality of care, and housing quality, were predictive of a county’s HISA utilization rate. Given that this series of work on the HISA program is (to our knowledge) the first of its kind, and given the exploratory nature of this analysis, we did not have specific predictions for the effects of any one given variable. Nevertheless, some of the results were surprising, and we believe they warrant additional study. In particular, the opposing direction of effects for access to care and quality of care variables were hard to reconcile.

The county percent of uninsured adults (an access to care variable, specifically, a proxy for poor access to care) was negatively associated with county-level HISA utilization rate, whereas the county rate of preventable hospital stays (a quality of care variable, but also potentially an access to care variable, and specifically, proxies for poor quality of care or poor access to care) was positively associated with county-level HISA utilization rate. To describe the relationships more generally, one coefficient in the regression model indicated that the poorer the access to care, the lower the HISA utilization rate (higher percent of uninsured adults predicts lower HISA utilization rate), while another coefficient in the regression model indicated the poorer the quality of and access to care, the higher the HISA utilization rate (higher rate of preventable hospital stays predicts higher HISA utilization rate). Future study is warranted to disentangle and reconcile the various community-level predictors of this service.

Housing quality measures (eg, percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, and percent of homeownership) are important in the consideration of whether a HM will be performed or should be performed. For example, if a person is cost burdened by the amount of expenditure spent in housing there will be little discretionary funds to perform a HM. Individuals who do not own their home may experience complications in obtaining permission from landlords to perform a HM. County-level predictors of housing quality (percent of households with high housing costs, overcrowding, and lack of kitchen or plumbing) were not significantly associated with county-level HISA utilization rate but are also nevertheless relevant to the discussion of home modifications. Of particular interest is the percent of households with lack of kitchen or plumbing variable, which was positively related to county-level HISA utilization rate although not statistically significant. HM elements related to the kitchen (eg, heighten countertop) add to the accessibility of the home allowing for the performing of activities of daily living such as cooking. Between FY 2015 and FY 2018, we discovered 131 prescriptions for kitchen (n = 90) and plumbing (n = 41) HMs, which is a very small proportion of the 30,780 total HMs (there were 24,397 bathroom HMs). The nonsignificant coefficient for this variable may reflect the small number of veterans that obtained these HM.

Limitations

The potentially conflicting direction of effects for a significant access to care variable (percent uninsured adults) and a significant access to care and quality of care variable (preventable hospital stays) are interesting and warrant additional study, but the inability to interpret or explain this apparent inconsistency constitutes a limitation of the current data and analyses presented here. Another limitation is that this analysis uses county-level predictors for what is ultimately an individual-level outcome. It would have been ideal to have both individual- and county-level data to conduct a multilevel analysis; in particular, individual-level data within counties of individuals (both veterans and nonveterans) who did not receive a HISA award (including both those who applied and were denied, and who did not apply) would be highly valuable.

Conclusions

Our continuing research into veterans’ use of HM fills a gap in the literature about the characteristics of HISA users, the impact of county-level variables on the use of HISA, and the geographic distribution and use of HISA within the VHA. While it is important to examine the influence of broader systems on individual outcomes, there could be myriad other factors that are more proximal and more closely related to whether any one individual applies for, let alone receives, a HISA award. Indeed, a low overall adjusted model R² indicates that there is considerable variability in county-level HISA utilization rate that was not accounted for by the current model; this further speaks to warranted additional study.

More research is needed to understand and account for geographical variation in HISA utilization rate across the US. However, this work serves as an exploratory first step at quantifying and predicting HISA utilization rate at a broad level, with the ultimate goal of increasing access to HMs for veterans with disabilities.

Acknowledgments

This research was supported by grant 15521 from the US Department of Veterans Affairs, Office of Rural Health. Furthermore, the research was supported in part by grant K12 HD055929 from the National Institutes of Health. We want to acknowledge Cheri E. Knecht, Project Coordinator, for her assistance throughout all aspects of our research study and for her thoughtful contributions during the writing of this manuscript.

This article is part of a series of articles on the Home Improvements and Structural Alterations program (HISA), a home modification (HM) program within the Veterans Health Administration (VHA). HISA is a benefit awarded to veterans with disabilities (VWDs) and is instrumental in affording physical accessibility and structural alterations to veterans’ homes.¹ The overarching goals of this project are to describe and understand HISA use by VWDs. Previous work has shown geographical variation in the number of HISA prescriptions across counties in the US (Figure 1).¹ The current work seeks to describe and predict the county-level rates of HISA use. Information about what predicts HISA utilization at the county level is important because it enhances understanding of program utilization at a national level. The long-term goal of the series is to provide knowledge about HM services within VHA to improve community-based independent living of VWDs by increasing awareness and utilization of HM services. 

Background

A health care professional (HCP) approves a HM support award by evaluating the practicality of the support to improve the built environment of a given veteran’s disability.^1,2 Previously we detailed some of the preliminary research into the HISA program, including HISA user demographic and clinical characteristics, types of HMs received, user suggestions for improvement, and geospatial analysis of HISA prescriptions concentration.^1-4

The geospatial analyses of HISA prescriptions revealed clusters of high numbers of HISA users (hot spots) and low numbers of HISA users (cold spots), indicating that HISA is either not prescribed or uniformly used across the US. The previous research prompted investigation into county-level variables that may impact HISA utilization rates. This inquiry focuses on county characteristics associated with HISA use rates, such as measures of clinical care and quality of care (eg, access to health services variables, lack of insurance, preventable hospital stays), physical environment, and sociodemographic characteristics. Clinical care and quality of care measures promote the interaction with HCPs. Moreover, access to health care is an important indicator of health outcomes.^5,6 An individual’s capacity to access health services, such as a HM program, greatly impacts well-being, safety, independence, and health.^2,4 Well-being, safety, independence, and health become compromised if individuals cannot access care, if needed care is lacking in their area, if HCPs are not available, or are unwilling to provide care due to lack of insurance coverage.^7-12 In locations where health care services are minimal due to lack of specialists or health care facilities, the quality of (or access to) care may be compromised, resulting in preventable conditions becoming problematic.^13,14 These conditions may result in unnecessary hospitalizations for conditions that could have been treated during routine care. Financial barriers to care particularly among low-income people and the uninsured have proven detrimental to health.^15,16 On the other hand, preventable hospital stays are a quality of care measure (ie, a proxy for poor quality of care). HISA operates within a health care system; thus, it is imperative to include these measures impacting health. 

In this study, we sought to identify county-level predictors—in particular, county-level proxies for access to care—that may be associated with county-level HISA use. We define HISA utilization rate as the percentage of a county’s VHA patients who have received a HISA award.

Methods

This study used data from the National Prosthetics Patient Database (NPPD), US Department of Veterans Affairs (VA) medical database inpatient and outpatient datasets, VHA Support Service Center (VSSC) data cubes, and the County Health Rankings database (CHRD). First, the study cohort was identified from NPPD users who have obtained a HISA award from fiscal years (FY) 2015 to 2018. Analysis started with FY 2015 following new regulations (38 CFR § 17) governing the operations of the HISA program.² The study cohort was matched with records from NPPD and VA inpatient and outpatient datasets to obtain information about the veterans’ demographic characteristics and their HM characteristics and costs. The number of VHA end-of-year (EOY) patients per county was extracted from the VSSC Current Enrollment Cube, which was used in calculation of the county-level HISA utilization rate.¹⁷ Finally, zip code–based locational data were used to calculate approximate drive time and distance from the HISA user’s approximate location to the facility where they received their HM prescription. Drive times and drive distances were calculated with Esri ArcGIS Pro (v2.6.3) by placing zip code centroid and VHA facilities on a nationwide road network that contains both road speeds and distances.

Calculations

Patient-level data were aggregated up to county-level variables by calculating the sum, mean, or percent per county. HISA user sample characteristics, including sex, race, rurality (urban, rural), marital status, and Class 1 vs Class 2 disability-related eligibility groups, were aggregated to the county level by calculating percentages of HISA users of the given characteristics out of total HISA users in the county. Disability-related eligibility groups (Class 1 vs Class 2 HISA users) determines the maximum lifetime award dollar amount. Specifically, those with service-connected disabilities or those with a ≥ 50% disability rating (regardless of whether or not their disability is service connected) are classified as Class 1 HISA users and are eligible to receive a maximum lifetime award of $6800. Those with a recorded disability that is not connected to their military service, and who have a disability rating of < 50% are classified as Class 2 HISA users and are eligible to receive a lifetime maximum award of $2000.

The county-level number of HISA users was used as the numerator for calculation of county-level HISA utilization rate. Counties with zero HISA users were excluded. The number of EOY VHA patients per county in FY 2018 was divided by 1000 and used as the denominator in the calculation of county-level HISA utilization rate. Thus, the outcome variable is HISA utilization rate per 1000 VHA patients in FY 2018 (HISA utilization rate).

County-Level Variables

County-level variables were downloaded from the 2020 CHRD.^5,6 An explanation of the CHRD model and the factors used in this study are shown in the eAppendix (available at doi: 10.12788/fp.0279).⁶ County-level aggregated HISA user data and the CHRD data were matched using county Federal Information Processing Standards codes. Access to care measures collected from CHRD included percentages uninsured and ratios of population to primary care physicians, dentists, mental health professionals, and other primary care professionals. Other CHRD measures included those for quality of care (rate of preventable hospital stay) and housing quality (percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, percent of homeownership). Of secondary interest was county population rurality, as previous research findings showed the annual average of HISA users who are from rural areas ranged from 30 to 35%.

Analysis Methods

SAS (v9.4), R (v4.0.2), and RStudio (v1.3.1093) were used for data preparation and analysis.¹⁸ Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Sociodemographic characteristics from CHRD and HISA data were included as important control predictors in the regression model, though our focus for this paper are the access to care and housing quality predictors.

Model diagnostics (examination of model residuals, Breusch-Godfrey test, Breusch-Pagan test) revealed significant heteroskedasticity of the model; thus, robust standard errors and associated P values were computed using the R estimatr package (v0.30.2).¹⁹ Some predictor variables of interest (eg, ratio of mental health professionals) were removed during the model building process either due to problems of multicollinearity or excessive missingness that would have resulted in listwise deletion.

Results

County-level HISA utilization rate per 1000 EOY VHA patients ranged from 0.09 to 59.7%, with a 6.6% mean and 5% median (Figure 2). The data were highly positively skewed. The final model included 33 total predictor variables (Table 1). The final regression model was a significantly better predictor of county-level HISA utilization rate than a null model (F[33-2184], 10.18; P < .001). The adjusted model R² showed that the overall model accounted for approximately 23% of variance in county-level HISA utilization rate (Table 2).

Among the primary variables of interest, percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005), indicating that the higher the proportion of uninsured adults—with all other predictors held constant—the lower the HISA utilization rate. Percent uninsured adults ranged from 2.7 to 42.4% across counties, with a mean (SD) of 12.7% (5.8%) and 11.4% median.

Discussion

This study examined whether county-level characteristics, specifically variables for access to care, quality of care, and housing quality, were predictive of a county’s HISA utilization rate. Given that this series of work on the HISA program is (to our knowledge) the first of its kind, and given the exploratory nature of this analysis, we did not have specific predictions for the effects of any one given variable. Nevertheless, some of the results were surprising, and we believe they warrant additional study. In particular, the opposing direction of effects for access to care and quality of care variables were hard to reconcile.

The county percent of uninsured adults (an access to care variable, specifically, a proxy for poor access to care) was negatively associated with county-level HISA utilization rate, whereas the county rate of preventable hospital stays (a quality of care variable, but also potentially an access to care variable, and specifically, proxies for poor quality of care or poor access to care) was positively associated with county-level HISA utilization rate. To describe the relationships more generally, one coefficient in the regression model indicated that the poorer the access to care, the lower the HISA utilization rate (higher percent of uninsured adults predicts lower HISA utilization rate), while another coefficient in the regression model indicated the poorer the quality of and access to care, the higher the HISA utilization rate (higher rate of preventable hospital stays predicts higher HISA utilization rate). Future study is warranted to disentangle and reconcile the various community-level predictors of this service.

Housing quality measures (eg, percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, and percent of homeownership) are important in the consideration of whether a HM will be performed or should be performed. For example, if a person is cost burdened by the amount of expenditure spent in housing there will be little discretionary funds to perform a HM. Individuals who do not own their home may experience complications in obtaining permission from landlords to perform a HM. County-level predictors of housing quality (percent of households with high housing costs, overcrowding, and lack of kitchen or plumbing) were not significantly associated with county-level HISA utilization rate but are also nevertheless relevant to the discussion of home modifications. Of particular interest is the percent of households with lack of kitchen or plumbing variable, which was positively related to county-level HISA utilization rate although not statistically significant. HM elements related to the kitchen (eg, heighten countertop) add to the accessibility of the home allowing for the performing of activities of daily living such as cooking. Between FY 2015 and FY 2018, we discovered 131 prescriptions for kitchen (n = 90) and plumbing (n = 41) HMs, which is a very small proportion of the 30,780 total HMs (there were 24,397 bathroom HMs). The nonsignificant coefficient for this variable may reflect the small number of veterans that obtained these HM.

Limitations

The potentially conflicting direction of effects for a significant access to care variable (percent uninsured adults) and a significant access to care and quality of care variable (preventable hospital stays) are interesting and warrant additional study, but the inability to interpret or explain this apparent inconsistency constitutes a limitation of the current data and analyses presented here. Another limitation is that this analysis uses county-level predictors for what is ultimately an individual-level outcome. It would have been ideal to have both individual- and county-level data to conduct a multilevel analysis; in particular, individual-level data within counties of individuals (both veterans and nonveterans) who did not receive a HISA award (including both those who applied and were denied, and who did not apply) would be highly valuable.

Conclusions

Our continuing research into veterans’ use of HM fills a gap in the literature about the characteristics of HISA users, the impact of county-level variables on the use of HISA, and the geographic distribution and use of HISA within the VHA. While it is important to examine the influence of broader systems on individual outcomes, there could be myriad other factors that are more proximal and more closely related to whether any one individual applies for, let alone receives, a HISA award. Indeed, a low overall adjusted model R² indicates that there is considerable variability in county-level HISA utilization rate that was not accounted for by the current model; this further speaks to warranted additional study.

More research is needed to understand and account for geographical variation in HISA utilization rate across the US. However, this work serves as an exploratory first step at quantifying and predicting HISA utilization rate at a broad level, with the ultimate goal of increasing access to HMs for veterans with disabilities.

Acknowledgments

This research was supported by grant 15521 from the US Department of Veterans Affairs, Office of Rural Health. Furthermore, the research was supported in part by grant K12 HD055929 from the National Institutes of Health. We want to acknowledge Cheri E. Knecht, Project Coordinator, for her assistance throughout all aspects of our research study and for her thoughtful contributions during the writing of this manuscript.

This article is part of a series of articles on the Home Improvements and Structural Alterations program (HISA), a home modification (HM) program within the Veterans Health Administration (VHA). HISA is a benefit awarded to veterans with disabilities (VWDs) and is instrumental in affording physical accessibility and structural alterations to veterans’ homes.¹ The overarching goals of this project are to describe and understand HISA use by VWDs. Previous work has shown geographical variation in the number of HISA prescriptions across counties in the US (Figure 1).¹ The current work seeks to describe and predict the county-level rates of HISA use. Information about what predicts HISA utilization at the county level is important because it enhances understanding of program utilization at a national level. The long-term goal of the series is to provide knowledge about HM services within VHA to improve community-based independent living of VWDs by increasing awareness and utilization of HM services. 

Background

A health care professional (HCP) approves a HM support award by evaluating the practicality of the support to improve the built environment of a given veteran’s disability.^1,2 Previously we detailed some of the preliminary research into the HISA program, including HISA user demographic and clinical characteristics, types of HMs received, user suggestions for improvement, and geospatial analysis of HISA prescriptions concentration.^1-4

The geospatial analyses of HISA prescriptions revealed clusters of high numbers of HISA users (hot spots) and low numbers of HISA users (cold spots), indicating that HISA is either not prescribed or uniformly used across the US. The previous research prompted investigation into county-level variables that may impact HISA utilization rates. This inquiry focuses on county characteristics associated with HISA use rates, such as measures of clinical care and quality of care (eg, access to health services variables, lack of insurance, preventable hospital stays), physical environment, and sociodemographic characteristics. Clinical care and quality of care measures promote the interaction with HCPs. Moreover, access to health care is an important indicator of health outcomes.^5,6 An individual’s capacity to access health services, such as a HM program, greatly impacts well-being, safety, independence, and health.^2,4 Well-being, safety, independence, and health become compromised if individuals cannot access care, if needed care is lacking in their area, if HCPs are not available, or are unwilling to provide care due to lack of insurance coverage.^7-12 In locations where health care services are minimal due to lack of specialists or health care facilities, the quality of (or access to) care may be compromised, resulting in preventable conditions becoming problematic.^13,14 These conditions may result in unnecessary hospitalizations for conditions that could have been treated during routine care. Financial barriers to care particularly among low-income people and the uninsured have proven detrimental to health.^15,16 On the other hand, preventable hospital stays are a quality of care measure (ie, a proxy for poor quality of care). HISA operates within a health care system; thus, it is imperative to include these measures impacting health. 

In this study, we sought to identify county-level predictors—in particular, county-level proxies for access to care—that may be associated with county-level HISA use. We define HISA utilization rate as the percentage of a county’s VHA patients who have received a HISA award.

Methods

This study used data from the National Prosthetics Patient Database (NPPD), US Department of Veterans Affairs (VA) medical database inpatient and outpatient datasets, VHA Support Service Center (VSSC) data cubes, and the County Health Rankings database (CHRD). First, the study cohort was identified from NPPD users who have obtained a HISA award from fiscal years (FY) 2015 to 2018. Analysis started with FY 2015 following new regulations (38 CFR § 17) governing the operations of the HISA program.² The study cohort was matched with records from NPPD and VA inpatient and outpatient datasets to obtain information about the veterans’ demographic characteristics and their HM characteristics and costs. The number of VHA end-of-year (EOY) patients per county was extracted from the VSSC Current Enrollment Cube, which was used in calculation of the county-level HISA utilization rate.¹⁷ Finally, zip code–based locational data were used to calculate approximate drive time and distance from the HISA user’s approximate location to the facility where they received their HM prescription. Drive times and drive distances were calculated with Esri ArcGIS Pro (v2.6.3) by placing zip code centroid and VHA facilities on a nationwide road network that contains both road speeds and distances.

Calculations

Patient-level data were aggregated up to county-level variables by calculating the sum, mean, or percent per county. HISA user sample characteristics, including sex, race, rurality (urban, rural), marital status, and Class 1 vs Class 2 disability-related eligibility groups, were aggregated to the county level by calculating percentages of HISA users of the given characteristics out of total HISA users in the county. Disability-related eligibility groups (Class 1 vs Class 2 HISA users) determines the maximum lifetime award dollar amount. Specifically, those with service-connected disabilities or those with a ≥ 50% disability rating (regardless of whether or not their disability is service connected) are classified as Class 1 HISA users and are eligible to receive a maximum lifetime award of $6800. Those with a recorded disability that is not connected to their military service, and who have a disability rating of < 50% are classified as Class 2 HISA users and are eligible to receive a lifetime maximum award of $2000.

The county-level number of HISA users was used as the numerator for calculation of county-level HISA utilization rate. Counties with zero HISA users were excluded. The number of EOY VHA patients per county in FY 2018 was divided by 1000 and used as the denominator in the calculation of county-level HISA utilization rate. Thus, the outcome variable is HISA utilization rate per 1000 VHA patients in FY 2018 (HISA utilization rate).

County-Level Variables

County-level variables were downloaded from the 2020 CHRD.^5,6 An explanation of the CHRD model and the factors used in this study are shown in the eAppendix (available at doi: 10.12788/fp.0279).⁶ County-level aggregated HISA user data and the CHRD data were matched using county Federal Information Processing Standards codes. Access to care measures collected from CHRD included percentages uninsured and ratios of population to primary care physicians, dentists, mental health professionals, and other primary care professionals. Other CHRD measures included those for quality of care (rate of preventable hospital stay) and housing quality (percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, percent of homeownership). Of secondary interest was county population rurality, as previous research findings showed the annual average of HISA users who are from rural areas ranged from 30 to 35%.

Analysis Methods

SAS (v9.4), R (v4.0.2), and RStudio (v1.3.1093) were used for data preparation and analysis.¹⁸ Multiple regression analysis was used to predict county-level utilization rate from county-level variables. Sociodemographic characteristics from CHRD and HISA data were included as important control predictors in the regression model, though our focus for this paper are the access to care and housing quality predictors.

Model diagnostics (examination of model residuals, Breusch-Godfrey test, Breusch-Pagan test) revealed significant heteroskedasticity of the model; thus, robust standard errors and associated P values were computed using the R estimatr package (v0.30.2).¹⁹ Some predictor variables of interest (eg, ratio of mental health professionals) were removed during the model building process either due to problems of multicollinearity or excessive missingness that would have resulted in listwise deletion.

Results

County-level HISA utilization rate per 1000 EOY VHA patients ranged from 0.09 to 59.7%, with a 6.6% mean and 5% median (Figure 2). The data were highly positively skewed. The final model included 33 total predictor variables (Table 1). The final regression model was a significantly better predictor of county-level HISA utilization rate than a null model (F[33-2184], 10.18; P < .001). The adjusted model R² showed that the overall model accounted for approximately 23% of variance in county-level HISA utilization rate (Table 2).

Among the primary variables of interest, percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005), indicating that the higher the proportion of uninsured adults—with all other predictors held constant—the lower the HISA utilization rate. Percent uninsured adults ranged from 2.7 to 42.4% across counties, with a mean (SD) of 12.7% (5.8%) and 11.4% median.

Discussion

This study examined whether county-level characteristics, specifically variables for access to care, quality of care, and housing quality, were predictive of a county’s HISA utilization rate. Given that this series of work on the HISA program is (to our knowledge) the first of its kind, and given the exploratory nature of this analysis, we did not have specific predictions for the effects of any one given variable. Nevertheless, some of the results were surprising, and we believe they warrant additional study. In particular, the opposing direction of effects for access to care and quality of care variables were hard to reconcile.

The county percent of uninsured adults (an access to care variable, specifically, a proxy for poor access to care) was negatively associated with county-level HISA utilization rate, whereas the county rate of preventable hospital stays (a quality of care variable, but also potentially an access to care variable, and specifically, proxies for poor quality of care or poor access to care) was positively associated with county-level HISA utilization rate. To describe the relationships more generally, one coefficient in the regression model indicated that the poorer the access to care, the lower the HISA utilization rate (higher percent of uninsured adults predicts lower HISA utilization rate), while another coefficient in the regression model indicated the poorer the quality of and access to care, the higher the HISA utilization rate (higher rate of preventable hospital stays predicts higher HISA utilization rate). Future study is warranted to disentangle and reconcile the various community-level predictors of this service.

Housing quality measures (eg, percent of households with high housing costs, percent of households with overcrowding, percent of households with lack of kitchen or plumbing, percent of households with severe housing cost burden, and percent of homeownership) are important in the consideration of whether a HM will be performed or should be performed. For example, if a person is cost burdened by the amount of expenditure spent in housing there will be little discretionary funds to perform a HM. Individuals who do not own their home may experience complications in obtaining permission from landlords to perform a HM. County-level predictors of housing quality (percent of households with high housing costs, overcrowding, and lack of kitchen or plumbing) were not significantly associated with county-level HISA utilization rate but are also nevertheless relevant to the discussion of home modifications. Of particular interest is the percent of households with lack of kitchen or plumbing variable, which was positively related to county-level HISA utilization rate although not statistically significant. HM elements related to the kitchen (eg, heighten countertop) add to the accessibility of the home allowing for the performing of activities of daily living such as cooking. Between FY 2015 and FY 2018, we discovered 131 prescriptions for kitchen (n = 90) and plumbing (n = 41) HMs, which is a very small proportion of the 30,780 total HMs (there were 24,397 bathroom HMs). The nonsignificant coefficient for this variable may reflect the small number of veterans that obtained these HM.

Limitations

The potentially conflicting direction of effects for a significant access to care variable (percent uninsured adults) and a significant access to care and quality of care variable (preventable hospital stays) are interesting and warrant additional study, but the inability to interpret or explain this apparent inconsistency constitutes a limitation of the current data and analyses presented here. Another limitation is that this analysis uses county-level predictors for what is ultimately an individual-level outcome. It would have been ideal to have both individual- and county-level data to conduct a multilevel analysis; in particular, individual-level data within counties of individuals (both veterans and nonveterans) who did not receive a HISA award (including both those who applied and were denied, and who did not apply) would be highly valuable.

Conclusions

Our continuing research into veterans’ use of HM fills a gap in the literature about the characteristics of HISA users, the impact of county-level variables on the use of HISA, and the geographic distribution and use of HISA within the VHA. While it is important to examine the influence of broader systems on individual outcomes, there could be myriad other factors that are more proximal and more closely related to whether any one individual applies for, let alone receives, a HISA award. Indeed, a low overall adjusted model R² indicates that there is considerable variability in county-level HISA utilization rate that was not accounted for by the current model; this further speaks to warranted additional study.

More research is needed to understand and account for geographical variation in HISA utilization rate across the US. However, this work serves as an exploratory first step at quantifying and predicting HISA utilization rate at a broad level, with the ultimate goal of increasing access to HMs for veterans with disabilities.

Acknowledgments

This research was supported by grant 15521 from the US Department of Veterans Affairs, Office of Rural Health. Furthermore, the research was supported in part by grant K12 HD055929 from the National Institutes of Health. We want to acknowledge Cheri E. Knecht, Project Coordinator, for her assistance throughout all aspects of our research study and for her thoughtful contributions during the writing of this manuscript.