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One Mission, One Goal: Veterans Health

About NCIRE

We are a scientific community of clinicians and researchers and we partner with the University of California, San Francisco (UCSF) and the San Francisco VA Health Care System (SFVAHCS) to bring the power of modern medicine to the health of our nation’s Veterans.

 

Research News

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Dr. Michael Steinman, MD Interviewed on the NavNeuro Podcast

Michael Steinman, MD, an NCIRE-supported Investigator, discusses polypharmacy, inappropriate polypharmacy, deprescribing as an intervention, specific drug classes with potential for cognitive side effects in older adults, and a neuropsychologist’s role in clinical care related to polypharmacy.

Dr. Steinman is a Staff Physician, Geriatrics, Palliative and Extended Care Service Line with the San Francisco VA Health Care System, and a Professor of Medicine at UCSF.

 

Listen Here: https://www.navneuro.com/96/

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Do functional status and Medicare claims data improve the predictive accuracy of an electronic health record mortality index? Findings from a national Veterans Affairs cohort

NCIRE-supported researcher Sei Lee, MD, MAS, who is a Professor of Medicine at UCSF, and Staff Physician, Geriatrics, Palliative and Extended Care Service Line with the San Francisco VA Health Care System, co-published a study that assessed whether adding functional status and/or Medicare claims data (which are often not available in EHRs) improves the accuracy of a previously developed Veterans Affairs (VA) EHR-based mortality index.

 

The retrospective cohort study followed 62,014 Veterans aged 75 years and older enrolled in VA primary care clinics from January 2014 to April 2020 and was published in the BMC Geriatrics journal.

 

Read More: https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-022-03126-z

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Meddling in the affairs of heart and lungs: How secondhand tobacco smoke affects the complex interactions between heart and lungs.

It is known that exposure to secondhand tobacco smoke – even in the distant past – is associated with reduced exercise capacity and abnormal lung function with air trapping in the lungs. However, what is not clearly known is the cardiovascular health effects of remote exposure to secondhand smoke. In a new study, which was funded by a research award from the Flight Attendant Medical Research Institute and published in the BMJ Open Respiratory Research, NCIRE-supported Investigator Mehdrad Arjomandi, MD, and colleagues found that past secondhand smoke exposure was associated with exercise capacity due to effects on both the lungs and the heart. 

 

The research team evaluated the health effects of remote exposure to secondhand smoke in nearly 250 never-smoking flight attendants who had worked in smoky aircraft cabin before smoking was banned on commercial airlines. They found the secondhand smoke exposure was associated with reduced exercise capacity both because of direct effects on cardiac output, also because air trapping in the lungs affected the heart. These findings suggest the presence of subtle cardiopulmonary pathology related to prolonged past exposure to secondhand smoke impairs the oxygen carrying machinery, which could be disadvantageous during the times of increased stress or disease. 

 

This study brings a deeper understanding of how secondhand smoke exposure continues to affect the heart, lungs, and exercise capacity years later.

Dr. Arjomandi is a Professor of Medicine at UCSF, and Assistant Professor in residence and the Director of Environmental Medicine Clinic with the San Francisco VA Health Center System.

 

Read More: https://bmjopenrespres.bmj.com/content/9/1/e001217.long

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Serious Illness Communication in Cancer Care in Africa: A Scoping Review of Empirical Research

Serious illness communication (SIC) in cancer care describes conversations between clinicians, patients, and families about prognosis and treatment decisions. Yet, cultural context influences SIC.

NCIRE-supported researcher Rebecca Sudore, MD, Staff Physician, Geriatrics Service at San Francisco VA Health Care System and Professor of Medicine, UCSF, joined fellow researchers to describe and synthesize the heterogeneous body of research on SIC practices, preferences, and needs in Africa to identify research and training priorities.

 

In their study, published in JCO Global Oncology, an American Society of Clinical Oncology Journal, the investigators identified 42 studies out of 1811 unique titles that focused on SIC within cancer or palliative care in Africa. The cohort found that research on SIC in Africa has increased in recent years. Most studies have focused on information delivery by clinicians; fewer on eliciting information from patients (e.g., shared decision-making, advanced care planning). Significant opportunities exist for further study and for communication skills training.

Read More: https://ascopubs.org/doi/abs/10.1200/GO.22.53000

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Congratulations to Barbara Bensing, PhD and Paul Sullam, MD for their recently published studies!

NCIRE-supported investigator Barbara Bensing, PhD co-authored the following published studies:

 

Molecular recognition of sialoglycans by streptococcal Siglec-like adhesins: toward the shape of specific inhibitors

Publication: RSC Chemical Biology, Oct 18, 2021

https://pubmed.ncbi.nlm.nih.gov/34977577/

 

O-linked α2,3 sialylation defines stem cell populations in breast cancer

Publication: Science Advances, January 7, 2022

https://pubmed.ncbi.nlm.nih.gov/34995107/

 

 

Paul Sullam, MD, a fellow NCIRE-supported investigator, joined his colleague Dr. Bensing to co-author the following studies:

Proteoglycan 4 (lubricin) is a highly sialylated glycoprotein associated with cardiac valve damage in animal models of infective endocarditis

Publication: Glycobiology, August 25, 2021 

https://pubmed.ncbi.nlm.nih.gov/34459483/

 

Origins of glycan selectivity in streptococcal Siglec-like adhesins suggest mechanisms of receptor adaptation. 

Publication: Nature Communications, May 18, 2022

https://urldefense.com/v3/__https://pubmed.ncbi.nlm.nih.gov/35585145/__;!!LQC6Cpwp!tJe2o4OGOp-PlJPPIkjwkApL4dwknSYNVgp02MZgDy71toNCbJLQopxZnpLxsiPpqphNWEgINTLHsF1jWFn2Prd-RYZx$

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Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes

Nursing home (NH) residents with diabetes represent a large, growing population at high-risk for adverse events from glucose-lowering medications (GLMs). Studies in community dwelling older adults have shown that glycemic overtreatment is common and can cause significant harms. Recent studies have documented increased risk of mortality, severe hypoglycemia, cognitive impairment, and falls as potential negative consequences of overtreatment.

Approximately 1.3 million adults resided in an NH in 2016; an estimated 25%–34% of these NH residents have diabetes. Yet, despite the large and growing numbers of NH residents with diabetes, little is known about GLM prescribing and deprescribing practices in this population.

To dive into this mystery, NCIRE-supported investigators Sei Lee, MD, Michael Steinman, MD, and their colleagues conducted a cohort study from January 1, 2013, to December 31, 2019, among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. The study defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose-lowering medication (GLM) other than metformin alone. The primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c.

Read More: https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.17735

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Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

NCIRE scientist Sei Lee, MD co-published a study that sought to determine the prevalence of sliding scale insulin (SSI) use and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen, in light of health guidelines that discourage SSI use after the first week of a nursing home (NH) admission.

The observational study gathered data from October 1, 2013, to June 30, 2017, of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week and compared the weekly prevalence of SSI versus two other short-acting insulin regimens – fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) – from week 2 to week 12 of admission.

Among those on SSI in week 2, the study examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia).

In week 2, 21% of the cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate–severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors.

The study was published in the Journal of the American Geriatrics Society.

 

Read More: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17771

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Association of Race and Ethnicity with Incidence of Dementia Among Older Adults

The racial and ethnic diversity of the U.S., including among patients receiving their care at the Veterans Health Administration (VHA), is increasing. Dementia is a significant public health challenge and may have greater incidence among older adults from underrepresented racial and ethnic minority groups.

Studies examining racial and ethnic disparities in dementia incidence in the U.S. have consistently reported higher rates of dementia for Black adults. Hispanic older adults are less well studied, but also have greater dementia incidence than White older adults. Much less is known about dementia incidence for American Indian or Alaska Native or for Asian individuals.

NCIRE Board Director Kristine Yaffe, MD, and fellow NCIRE-supported investigators John Boscardin, PhD, and Deborah Barnes, PhD, MPH co-published a study that sought to answer: Is there a difference in incidence of dementia by race and ethnicity among enrollees in the U.S. VHA?

This retrospective cohort study sampled 1,869,090 older adults receiving care at VHA medical centers, the largest integrated health care system in the US. Differences in incidence rates by geographical region across the US were also examined. The sample group were aged 55 years or older and with data evaluated from October 1, 1999, to September 30, 2019 (the date of final follow-up).

The study found that among older adults who received care at VHA medical centers, there were significant differences in dementia incidence based on race and ethnicity. Further research is needed to understand the mechanisms responsible for these differences.

 

The study was published in the JAMA Network.

 

Read More: https://jamanetwork.com/journals/jama/fullarticle/2791223

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Surrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates

Surrogate decision makers are required to make difficult end-of-life decisions with little preparation. Little is known about what surrogates may need to adequately prepare for their role, and few resources exist to prepare them.

NCIRE-supported scientists Deborah Barnes, PhD and Rebecca Sudore, MD, with a team of investigators, explored experiences and advice from surrogates about how best to prepare for the surrogate role. Using a semi-structured focus group model, the study recruited 69 participants through convenience sampling in San Francisco area hospitals, cancer support groups, and community centers for 13 focus groups. Surrogates were included if they were 18 years of age or older and reported having made medical decisions for others.

 

Experienced surrogate decision makers emphasized the importance of advance care planning (ACP) and advised that surrogates need their own preparation to initiate ACP conversations, learn patients' values, advocate for patients, and make informed surrogate decisions. Future interventions should address these preparation topics to ease surrogate burden and decrease disparities in surrogate decision making.

 

The study was published in the Journal of Palliative Medicine.

 

Read More: https://www.liebertpub.com/doi/10.1089/jpm.2021.0283

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