'One-stop' clinic ups mental health, social work visits for veterans

ScienceDaily (June 10, 2011) — Iraq and Afghanistan veterans who visited a U.S. Veterans Administration (VA) integrated care clinic were much more likely to undergo initial mental health and social work evaluations than veterans who visited a standard VA primary care clinic, according to a study led by a San Francisco VA Medical Center researcher.

The increase was especially significant for women veterans, younger veterans, veterans with mental health diagnoses, and veterans who screened positive for traumatic brain injury.

The study was published on June 7, 2011 in the electronic Online First section of the Journal of General Internal Medicine.

The decisive factor was the integrated care model, itself, said the lead author of the study, Karen Seal, MD, MPH, co-founder and co-director of the Integrated Care Clinic at the San Francisco VA Medical Center, which was the site of the study.

Under the conventional VA model, patients are seen by a primary care physician and, if they screen positive for mental illness according to the VA's standard protocol, are referred to a mental health provider. That referral appointment would not necessarily be available the same day, nor in the same clinic.

Under the integrated care model, all patients are referred immediately by their primary care physician to a mental health provider, called the "Post-Deployment Stress Specialist," and a social worker, called the "Combat Case Manager." All visits take place during the same appointment, in the same clinic, with no waiting.

"This demonstrates the value of the integrated care clinic model for our veterans, especially those who may be more vulnerable," said Seal, who is also an associate professor in residence of medicine and psychiatry at the University of California, San Francisco.

The study also showed, however, that the rate of follow-up mental health care -- the number of subsequent visits with mental health providers that took place after initial evaluation -- was not any higher under the integrated care model than under standard care.

"We are really good at initial engagement, but unfortunately, we are not as successful at helping veterans stay with and complete a course of mental health treatment," said Seal. "We need to learn how to help veterans stick with the more difficult first few sessions of PTSD treatment, so they can get through to the other side when they really start to feel better." Seal explained that successful PTSD treatment usually takes nine to 12 sessions.

The study examined the medical records of 526 Iraq and Afghanistan veterans who came to SFVAMC between 2005 and 2009 for their first primary care visit after returning from combat deployment. Veterans who visited after April 1, 2007 -- the date that the Integrated Care Clinic was founded -- were given an appointment at either the Integrated Care Clinic or a conventional care clinic.

The 30-day mental health evaluation rate was 92 percent for the integrated care patients versus 59 percent for standard care patients. The rate for social work evaluation was 77 percent versus 56 percent.

For women veterans, the rate of initial mental health evaluations in integrated care was three times the conventional care rate. "This is good news, because women veterans have a high burden of mental health problems, and, at the same time, a disproportionate number of barriers to care, such as child care issues and other logistical constraints," said Seal.

Seal noted that the overall rate of initial mental health evaluations was higher in the integrated care model even after allowing for an overall VA systemwide improvement in first-time mental health evaluations that occurred after 2007.

She speculated that one promising approach to helping veterans complete their course of PTSD treatment might be the VA Patient Aligned Care Team (PACT) model, a new team-based method of providing primary care in the VA system. "One member of the patient care team could be assigned to make reminder phone calls for example, to encourage veterans to stick with and complete their mental health treatment," Seal said.

Co-authors of the study are Greg Cohen, MSW, and Daniel Bertenthal, MPH, of SFVAMC; Beth E. Cohen, MD, MAS, and Shira Maguen, PhD, of SFVAMC and UCSF; and Aaron Daley, MA, of SFVAMC.

The study was supported by funds from the US Department of Defense that were administered by the Northern California Institute for Research and Education.

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by University of California - San Francisco.

Journal Reference:

Karen H. Seal, Greg Cohen, Daniel Bertenthal, Beth E. Cohen, Shira Maguen, Aaron Daley. Reducing Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic. Journal of General Internal Medicine, 2011; DOI: 10.1007/s11606-011-1746-1

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Bioengineers identify the cellular mechanisms of traumatic brain injury; New hope for treatment of TBI in veterans wounded by explosions

ScienceDaily (July 25, 2011) — Bioengineers at Harvard have identified, for the very first time, the mechanism for diffuse axonal injury and explained why cerebral vasospasm is more common in blast-induced brain injuries than in brain injuries typically suffered by civilians.

The research addresses two major aspects of traumatic brain injury (TBI), with significant implications for the medical treatment of soldiers wounded by explosions.

Two papers, published in the journals Proceedings of the National Academy of Sciences (PNAS) and PLoS ONE, provide the most comprehensive explanation to date of how mechanical forces can be translated into subtly disastrous physiological changes within the brain's neurons and vasculature.

"These results have been a long time coming," says principal investigator Kevin Kit Parker, a Professor of Bioengineering at Harvard's School of Engineering and Applied Sciences (SEAS) and a major in the U.S. Army. "So many young men and women are returning from military service with brain injuries, and we just don't know how to help them."

When the brain encounters a jarring force, such as an exploding roadside bomb, the delicate tissue slams against the skull. The result, if the patient survives, can be a temporary concussion, a more dangerous hemorrhage, or long-term TBI, which can even lead to the early onset of Parkinson's or Alzheimer's diseases.

Inspired by Parker's own military experience, the Disease Biophysics Group (based at SEAS and at the Wyss Institute for Biologically Inspired Engineering at Harvard) has taken up the cause. Using cutting-edge tissue engineering techniques -- essentially creating a living brain on a chip -- biologists, physicists, engineers, and materials scientists collaborate to study brain injury and potential targets for treatment.

Now, researchers in his group have identified the cellular mechanism that initiates diffuse axonal injury, offering urgently needed direction for research in therapeutic treatments.

Their studies show that integrins, receptor proteins embedded in the cell membrane, provide the crucial link between external forces and internal physiological changes.

Integrins connect the structural components within the cell (such as actin and other cytoskeletal proteins) with the extracellular matrix that binds cells together into tissue. Collectively, this network of structural and signaling components is referred to as the focal adhesion complex.

Parker's research has demonstrated that the forces unleashed by an explosion physically disrupt the structure of the focal adhesion complex, setting off a chain reaction of destructive molecular signals within the nerve cells of the brain.

Inside the neuron, integrins normally mediate the activation of the proteins RhoA and Rho kinase (ROCK). When the focal adhesion complex is disturbed, the Rho-ROCK signaling pathway goes haywire: it directs the motor protein actin to retract the cell's arm-like axons, disconnecting the neurons from each other and collapsing the cellular networks that constitute the brain.

"Our research has shown that abrupt mechanical forces, such as those from a blast wave and transduced by integrins, can result in neural injury," says Matthew A. Hemphill, who with Borna Dabiri (S.B. '07) and Sylvain Gabriele, is a lead author of the paper in PLoS One. Dabiri and Hemphill are currently graduate students at SEAS, and Gabriele is a former postdoctoral fellow in Parker's lab.

Adds Dabiri: "Encouragingly, we also found that treating the neural tissue with HA-1077, which is a ROCK inhibitor, within the first 10 minutes of injury, reduced the number of focal swellings. We think that further study of ROCK inhibition could lead to viable treatments within the near future."

A second direction of research in Parker's lab has solved another mystery in TBI, explaining why cerebral vasospasm, a dangerous remodeling of the brain's blood vessels, occurs more commonly in TBI caused by explosions than in other types of brain trauma.

"Until now, other researchers looking at TBI focused on ion channels and membrane poration, and it was generally accepted that cerebralvasospasm was only caused by hemorrhaging. It turns out that it's much morecomplicated than that," says Patrick W. Alford, a former postdoctoral fellow in Parker's lab and lead author of the paper in PNAS. "Integrins and Rho-ROCK signaling appear to be players in both diffuse axonal injury and cerebral vasospasm."

As reported in PNAS, the forces exerted on arteries are different during an explosive blast than during blunt force trauma. Subarachnoid hemorrhage, which can occur in very severe head injuries, is known to cause vasospasm, but Parker's new research shows that the unique force of an explosion can also cause vasospasm by itself.

The blast from an explosion creates a surge in blood pressure, which stretches the walls of the blood vessels in the brain. To study this, Parker's team of bioengineers built artificial arteries, made of living vascular cells, and used a specialized machine to rapidly stretch them, simulating an explosion. While this stretching did not overtly damage the cellular structure, it did cause an immediate hypersensitivity to the protein endothelin-1.

Endothelin-1 is known to stimulate vascular cells to absorb calcium ions, which affect actin -- the same protein involved in the retraction of axons.

In the 24 hours following the simulated blast, the vascular tissues hypercontract and undergo a complete phenotypic switch, disrupting the overall function of the tissue. Both of these behaviors are characteristic of cerebral vasospasm.

Most importantly, as in the neural tissue, the Rho-ROCK signaling pathway plays an important role in the behavior of actin and the cells' contraction. Parker's team found that inhibition of Rho soon after the injury can mitigate the harmful effects of the blast on the brain's vascular system.

"We have established a toe-hold as we try to climb up on top of this problem," says Parker. "In many ways, this work is just the beginning."

Parker's coauthors on the paper in PLoS One are Hemphill, currently at the University of Mons in Belgium; Dabiri, who beganworking in Parker's lab as an undergraduate; Gabriele, who is now at the University of Mons; Lucas Kerscher, a visiting student; Christian Franck, formerly a postdoctoral fellow at SEAS and now at Brown University; Josue A. Goss, a staff engineer at SEAS; and Alford, who is now at the University ofMinnesota.

Parker's coauthors on the paper in PNAS are Alford; Dabiri; Goss; Hemphill; and Mark D. Brigham, a graduate student at SEAS.

The Disease Biophysics Group received financial support from the Defense Advanced Research Projects Agency (DARPA) Preventing Violent Explosive Neurologic Trauma (PREVENT) Program, the Department of Defense, and the Harvard School of Engineering and Applied Sciences (SEAS).

The researchers also gratefully acknowledge the use of facilities at the Harvard Center for Nanoscale Systems, a member of the National Nanotechnology Infrastructure Network (NNIN), which is funded by the National Science Foundation (NSF).

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by Harvard University, via EurekAlert!, a service of AAAS.

Journal References:

P. W. Alford, B. E. Dabiri, J. A. Goss, M. A. Hemphill, M. D. Brigham, K. K. Parker. Blast-induced phenotypic switching in cerebral vasospasm. Proceedings of the National Academy of Sciences, 2011; DOI: 10.1073/pnas.1105860108Matthew A. Hemphill, Borna E. Dabiri, Sylvain Gabriele, Lucas Kerscher, Christian Franck, Josue A. Goss, Patrick W. Alford, Kevin Kit Parker. A Possible Role for Integrin Signaling in Diffuse Axonal Injury. PLoS ONE, 2011; 6 (7): e22899 DOI: 10.1371/journal.pone.0022899

Note: If no author is given, the source is cited instead.

Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

View the original article here