VA Central Iowa Health Care System

Recognizing that race is a social and not a biological construct, healthcare professionals and the public have called for removal of race in clinical algorithms. In response, the National Kidney Foundation and the American Society of Nephrology created the Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Diseases to examine the issue and provide recommendations. The final report from the Task Force recommends calculating estimated glomerular filtration rate (eGFR) without a race coefficient using the recently published CKD-EPI 2021 creatinine (cr) and creatinine-cystatin C (cr-cys) equations. The Task Force recommends immediately replacing older eGFRcr equations (MDRD Study and CKD-EPI 2009) with the new CKD-EPI 2021 equation. In a 2019 survey by the College of American Pathologists, 23% of 6200 laboratories reporting eGFRcr used an incorrect equation that is not suitable for use with standardized creatinine measurements, 34% used the CKD-EPI 2009 equation and 43% used the MDRD Study 2006 equation re-expressed for standardized creatinine measurement. Rapid transition to using the CKD-EPI 2021 equation is an opportunity for laboratories to standardize to a single equation to eliminate differences in eGFRcr due to different equations used by different laboratories, and to report eGFR without use of race. We provide guidance to laboratories for implementing the CKD-EPI 2021 equations for both eGFRcr and eGFRcr-cys.

OBJECTIVES: To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making. DESIGN: Prospective development and feasibility study. SETTING: Primary care practice in Connecticut. PARTICIPANTS: Older adults with 3 or more conditions or taking 10 or more medications (N=64). INTERVENTION: The development team of patients, caregivers, and clinicians used a user-centered design framework-ideate → prototype → test →redesign-to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators. MEASUREMENTS: We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). RESULTS: We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. CONCLUSION: Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

There is growing evidence that thrombotic and inflammatory pathways contribute to the severity of COVID-19. Common medications such as aspirin, that mitigate these pathways, may decrease COVID-19 mortality. This retrospective assessment was designed to quantify the correlation between pre-diagnosis aspirin and mortality for COVID-19 positive patients in our care. Data from the Veterans Health Administration national electronic health record database was utilized for the evaluation. Veterans from across the country with a first positive COVID-19 polymerase chain reaction lab result were included in the evaluation which comprised 35,370 patients from March 2, 2020 to September 13, 2020 for the 14-day mortality cohort and 32,836 patients from March 2, 2020 to August 28, 2020 for the 30-day mortality cohort. Patients were matched via propensity scores and the odds of mortality were then compared. Among COVID-19 positive Veterans, preexisting aspirin prescription was associated with a statistically and clinically significant decrease in overall mortality at 14-days (OR 0.38, 95% CI 0.32-0.46) and at 30-days (OR 0.38, 95% CI 0.33-0.45), cutting the odds of mortality by more than half. Findings demonstrated that pre-diagnosis aspirin prescription was strongly associated with decreased mortality rates for Veterans diagnosed with COVID-19. Prospective evaluation is required to more completely assess this correlation and its implications for patient care.

DESCRIPTION: In May 2022, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the use of opioids when managing chronic pain. This synopsis summarizes the recommendations that the authors believe are the most important to highlight. METHODS: In December 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2017 VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. The guideline development team included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline team developed key questions to guide a systematic evidence review that was done by an independent third party and distilled 20 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The guideline team also created 3 one-page algorithms to help guide clinical decision making. This synopsis presents the recommendations and highlights selected recommendations on the basis of clinical relevance. RECOMMENDATIONS: This guideline is intended for clinicians who may be considering opioid therapy to manage patients with chronic pain. This synopsis reviews updated recommendations for the initiation and continuation of opioid therapy; dose, duration, and taper of opioids; screening, assessment, and evaluation; and risk mitigation. New additions are highlighted, including recommendations about the use of buprenorphine instead of full agonist opioids; assessing for behavioral health conditions and factors associated with higher risk for harm, such as pain catastrophizing; and the use of pain and opioid education to reduce the risk for prolonged opioid use for postsurgical pain.

OBJECTIVE: Several studies have identified associations between social reactions to disclosure of sexual assault and psychological distress; however, no studies have evaluated shame as a mediator of this association. This study evaluated assault-related shame as a mediator of the associations between negative social reactions to disclosure of sexual assault and symptoms of posttraumatic stress disorder (PTSD), depression, and global distress and hypothesized that there would be an indirect effect of social reactions to disclosure upon symptoms of psychopathology via assault-related shame. METHOD: Participants were 207 female psychology undergraduates who reported past history of completed or attempted sexual assault and had disclosed the assault to at least 1 other person. Participants completed self-report measures of social reactions to sexual assault disclosure, assault-related shame, and symptoms of psychopathology. RESULTS: Participants reported significant histories of attempted or completed sexual assault and indicated clinically significant symptoms of depression and subthreshold symptoms of PTSD and global distress, on average. Evaluation of structural models confirmed the hypothesized indirect effect of negative social reactions to sexual assault disclosure upon symptoms of PTSD (z = 5.85, p < .001), depression (z = 4.56, p < .001), and global distress (z = 4.82, p < .001) via assault-related shame. CONCLUSIONS: These findings offer new insight concerning the intervening role of assault-related shame and highlight the importance of shame as a target for therapeutic intervention. This study suggests the need for future research concerning the role of shame in the etiology of PTSD and process of disclosure among survivors of attempted or completed sexual assault. (PsycINFO Database Record

A comprehensive discharge plan for a patient with a new stoma is needed to ensure the individual receives the necessary ostomy education prior to discharge. The plan should include teaching basic skills and providing information about how to manage the ostomy (ie, emptying and changing the pouch, how to order supplies, available manufacturers, dietary/fluid guidelines, potential complications, medications, and managing gas and odor), assisting with transitions in care, and providing information about resources for support and assistance. The purpose of this best practice guideline is to provide clinicians with a brief overview of the essential elements that should be included in the discharge plan to facilitate patient education and the transition of care from hospital to home.

The sudden emergence of COVID-19 has brought significant challenges to the care of Veterans. An improved ability to predict a patient's clinical course would facilitate optimal care decisions, resource allocation, family counseling, and strategies for safely easing distancing restrictions. The Care Assessment Need (CAN) score is an existing risk assessment tool within the Veterans Health Administration (VA), and produces a score from 0 to 99, with a higher score correlating to a greater risk. The model was originally designed for the nonacute outpatient setting and is automatically calculated from structured data variables in the electronic health record. This multisite retrospective study of 6591 Veterans diagnosed with COVID-19 from March 2, 2020 to May 26, 2020 was designed to assess the utility of repurposing the CAN score as objective and automated risk assessment tool to promptly enhance clinical decision making for Veterans diagnosed with COVID-19. We performed bivariate analyses on the dichotomized CAN 1-year mortality score (high vs. low risk) and each patient outcome using Chi-square tests of independence. Logistic regression models using the continuous CAN score were fit to assess its predictive power for outcomes of interest. Results demonstrated that a CAN score greater than 50 was significantly associated with the following outcomes after positive COVID-19 test: hospital admission (OR 4.6), prolonged hospital stay (OR 4.5), ICU admission (3.1), prolonged ICU stay (OR 2.9), mechanical ventilation (OR 2.6), and mortality (OR 7.2). Repurposing the CAN score offers an efficient way to risk-stratify COVID-19 Veterans. As a result of the compelling statistical results, and automation, this tool is well positioned for broad use across the VA to enhance clinical decision-making.

This report is a phenomenological study of 17 patients who developed multiple, partial seizure-like symptoms after sustaining relatively 'minor' closed head trauma. Unlike patients with classic complex partial seizure disorders, the symptoms of these head-injured patients did not tend to occur in stereotyped sequences. In contrast to meagre findings from neuroimaging and EEG evaluations, neuropsychological assessment of these patients often revealed evidence of static and episodic cognitive impairment. The majority of patients in this case series derived significant benefit from treatment with anticonvulsant medication; however, full return to premorbid levels of social and vocational competence was not typically observed. Recent findings from animal research on 'partial kindling' phenomena provide a hypothetical model for understanding how subclinical electrophysiological dysfunction may produce partial seizure-like symptoms and associated neurobehavioural dysfunction as longer-term sequelae of traumatic brain injury.

Importance: Acupuncture is a popular treatment that has been advocated for dozens of adult health conditions and has a vast evidence base. Objective: To map the systematic reviews, conclusions, and certainty or quality of evidence for outcomes of acupuncture as a treatment for adult health conditions. Evidence Review: Computerized search of PubMed and 4 other databases from 2013 to 2021. Systematic reviews of acupuncture (whole body, auricular, or electroacupuncture) for adult health conditions that formally rated the certainty, quality, or strength of evidence for conclusions. Studies of acupressure, fire acupuncture, laser acupuncture, or traditional Chinese medicine without mention of acupuncture were excluded. Health condition, number of included studies, type of acupuncture, type of comparison group, conclusions, and certainty or quality of evidence. Reviews with at least 1 conclusion rated as high-certainty evidence, reviews with at least 1 conclusion rated as moderate-certainty evidence, and reviews with all conclusions rated as low- or very low-certainty evidence; full list of all conclusions and certainty of evidence. Findings: A total of 434 systematic reviews of acupuncture for adult health conditions were found; of these, 127 reviews used a formal method to rate certainty or quality of evidence of their conclusions, and 82 reviews were mapped, covering 56 health conditions. Across these, there were 4 conclusions that were rated as high-certainty evidence, and 31 conclusions that were rated as moderate-certainty evidence. All remaining conclusions (>60) were rated as low- or very low-certainty evidence. Approximately 10% of conclusions rated as high or moderate-certainty were that acupuncture was no better than the comparator treatment, and approximately 75% of high- or moderate-certainty evidence conclusions were about acupuncture compared with a sham or no treatment. Conclusions and Relevance: Despite a vast number of randomized trials, systematic reviews of acupuncture for adult health conditions have rated only a minority of conclusions as high- or moderate-certainty evidence, and most of these were about comparisons with sham treatment or had conclusions of no benefit of acupuncture. Conclusions with moderate or high-certainty evidence that acupuncture is superior to other active therapies were rare.

No AccessJournal of Urology1 May 1964Carcinoma of the Prostate: A Continuing Co-Operative Study* The Veterans Administration Co-Operative Urological Research Group, George T. Mellinger, Lino J. Arduino, Leslie E. Becker, Henry I. Berman, Arthur J. Bischoff, Richard P. Doe, James S. Elliot, Edmund A. Gehan, Michel Glucksman, Alan J. Gross, Earl Haltiwanger, Robert B. Higgins, Joseph Jorgens, Ervin Kaplan, Howard C. Kramer, Lyndon E. Lee, Otto M. Lilien, Maxwell Malament, F.K. Mostofi, Maurice Nataro, William L. Parry, and A. Hardy Ulm The Veterans Administration Co-Operative Urological Research Group More articles by this author , George T. MellingerGeorge T. Mellinger More articles by this author , Lino J. ArduinoLino J. Arduino More articles by this author , Leslie E. BeckerLeslie E. Becker More articles by this author , Henry I. BermanHenry I. Berman More articles by this author , Arthur J. BischoffArthur J. Bischoff More articles by this author , Richard P. DoeRichard P. Doe More articles by this author , James S. ElliotJames S. Elliot More articles by this author , Edmund A. GehanEdmund A. Gehan More articles by this author , Michel GlucksmanMichel Glucksman More articles by this author , Alan J. GrossAlan J. Gross More articles by this author , Earl HaltiwangerEarl Haltiwanger More articles by this author , Robert B. HigginsRobert B. Higgins More articles by this author , Joseph JorgensJoseph Jorgens More articles by this author , Ervin KaplanErvin Kaplan More articles by this author , Howard C. KramerHoward C. Kramer More articles by this author , Lyndon E. LeeLyndon E. Lee More articles by this author , Otto M. LilienOtto M. Lilien More articles by this author , Maxwell MalamentMaxwell Malament More articles by this author , F.K. MostofiF.K. Mostofi More articles by this author , Maurice NataroMaurice Nataro More articles by this author , William L. ParryWilliam L. Parry More articles by this author , and A. Hardy UlmA. Hardy Ulm More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)64178-8AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1964 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byLindberg B (2018) Treatment of Rapidly Progressing Prostatic Carcinoma with EstracytJournal of Urology, VOL. 108, NO. 2, (303-306), Online publication date: 1-Aug-1972.Byar D and Mostofi F (2018) Cancer of the Prostate in Men Less than 50 Years Old: An Analysis of 51 CasesJournal of Urology, VOL. 102, NO. 6, (726-733), Online publication date: 1-Dec-1969.Young H and Kent J (2018) Plasma Testosterone Levels in Patients with Prostatic Carcinoma Before and after TreatmentJournal of Urology, VOL. 99, NO. 6, (788-792), Online publication date: 1-Jun-1968. Volume 91Issue 5May 1964Page: 590-594 Advertisement Copyright & Permissions© 1964 by The American Urological Association Education and Research, Inc.MetricsAuthor Information The Veterans Administration Co-Operative Urological Research Group More articles by this author George T. Mellinger More articles by this author Lino J. Arduino More articles by this author Leslie E. Becker More articles by this author Henry I. Berman More articles by this author Arthur J. Bischoff More articles by this author Richard P. Doe More articles by this author James S. Elliot More articles by this author Edmund A. Gehan More articles by this author Michel Glucksman More articles by this author Alan J. Gross More articles by this author Earl Haltiwanger More articles by this author Robert B. Higgins More articles by this author Joseph Jorgens More articles by this author Ervin Kaplan More articles by this author Howard C. Kramer More articles by this author Lyndon E. Lee More articles by this author Otto M. Lilien More articles by this author Maxwell Malament More articles by this author F.K. Mostofi More articles by this author Maurice Nataro More articles by this author William L. Parry More articles by this author A. Hardy Ulm More articles by this author Expand All Advertisement PDF downloadLoading ...

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

OBJECTIVE: This article explores the frequencies of use of alternative medications, available products, and their potential toxicities. METHOD: Survey data were gathered from 39 consecutive patients diagnosed with bulimia nervosa who were seeking treatment. A survey of area outlets (health food stores, pharmacies, grocery stores) was conducted to establish a database of available agents. Putative active ingredients were identified. MEDLINE literature searches, as well as reviews of specialized texts, were performed to identify the potential toxicities of the ingredients. RESULTS: Diet pill use was found in 64% of patients; 18 % reported use in the past month. The survey identified 167 products. Diuretic use was found in 31% of patients; 21% reported use in the past month. Twenty-five diuretic products were identified. DISCUSSION: Alternative medicines are frequently used in the population of patients seeking treatment for bulimia nervosa. An abundance of products are available with potentially significant toxicities.

Adenoviral vector-mediated p53 expression induced apoptosis is a well established gene therapy approach that has been evaluated extensively in epithelial tumors but only recently in lymphoid malignancies mainly due to the known resistance of the lymphoid lineage to adenovirus infection. Recently, it was shown that this resistance is not absolute and that cell lines derived from anaplastic large cell lymphoma (ALCL) and some other lymphoid malignancies are efficiently transduced by adenoviral vectors. Normal circulating T lymphocytes do not express coxsackie-adenovirus receptor (CAR) and alpha(nu)beta integrins and are relatively resistant to infection by adenovirus. These molecules serve as receptors for adenovirus entry into the cells. ALCL-derived SUDHL-1 cells were evaluated for transduction efficiency and expression of p53 after infection with an adenoviral vector containing wild-type p53 (AdWTp53). Cells derived from ALCL and circulating mononucleated cells (MNCs) were also evaluated for expression of CAR and alpha(nu)beta integrins. AdWTp53-mediated expression of p53 resulted in p21/WAF1 induction, G1 arrest, and apoptosis in SUDHL-1 cells. The expression of CAR and alpha(nu)beta5 integrin was high in SUDHL-1 cells and comparable to levels observed with epithelial tumor cells, but it was absent in MNCs. The susceptibility to adenoviral vector transduction of the tumor-derived cells implies an important biological difference between them and circulating MNCs, possibly underlying the malignant transformation that ALCL cells undergo. Further studies will be required to evaluate this initial observation in more cell lines and tissue derived from ALCL.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January–February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Primary lymphoma of the spleen is a relatively rare clinical entity. The majority of patients reported with this entity not only have splenic involvement but also have had lymph node and/or liver involvement. The patient reported presented with splenomegaly and was otherwise asymptomatic. Only splenic involvement was noted at operation and no other manifestation of the disease has become apparent, some 24 months post-splenectomy.

Supportive care guidelines recommend antimold prophylaxis in hematopoietic stem cell transplant (HSCT) recipients deemed to have high risk for invasive fungal infection, leading to long-term use of voriconazole after allogeneic HSCT in patients who remain immunocompromised. Voriconazole has been associated with periostitis, exostoses, and fluoride excess in patients after solid organ transplantation, HSCT, and leukemia therapy. The aims of this study were to describe the frequency and clinical presentation of patients presenting with pain and fluoride excess among allogeneic HSCT patients taking voriconazole, to identify when a plasma fluoride concentration was measured with respect to voriconazole initiation and onset of pain, and to describe the outcomes of patients with fluoride excess in the setting of HSCT. A retrospective review was conducted of all adult allogeneic HSCT patients receiving voriconazole at Mayo Clinic in Rochester, Minnesota, between January 1, 2009 and July 31, 2012. Of 242 patients included, 32 had plasma fluoride measured to explore the etiology of musculoskeletal pain. In 31 patients with fluoride measurement while on voriconazole, 29 (93.5%) had elevated levels. The median plasma fluoride was 11.1 μmol/L (range, 2.4 to 24.7). The median duration of voriconazole was 163 days (range, 2 to 1327). The median time to fluoride measurement was 128 days after voriconazole initiation (range, 28 to 692). At 1 year after the start of voriconazole after HSCT, 15.3% of patients had developed pain associated with voriconazole use and 35.7% developed pain while on voriconazole after 2 years. Of the patients with an elevated fluoride level, 22 discontinued voriconazole; pain resolved or improved in 15, stabilized in 3, and worsened in 4 patients. Ten patients continued voriconazole; pain resolved or improved in 7, was attributable to alternative causes in 2, and undefined in 1. Serum creatinine, estimated glomerular filtration rate, alkaline phosphatase, and voriconazole concentration did not predict for fluoride excess and associated pain. Periostitis due to fluoride excess is a common adverse effect of voriconazole that should be considered in patients presenting with pain and is often reversible after drug discontinuation. Alternative antifungal agents with a lower risk for fluoride excess should be considered in patients receiving voriconazole who develop fluoride excess and pain.

Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.

The provision of nonpharmacological pain management options is gaining increased attention that is due in part to the high prevalence of pain and the serious problems associated with using opioids to manage that pain. One such evidence-based [1] option, acupuncture, is included in the American College of Physicians clinical guidelines for low back pain [2] and in the pain management strategy recommended by the U.S. Department of Health and Human Services [3]. Although providers may refer patients to many evidence-based nonpharmacological pain management approaches, providers have relatively limited pain management options outside of opioids or analgesics for patients presenting with pain during the clinic visit. Given the prevalence of pain among the military and veteran populations, the U.S. Department of Defense (DoD) and Veterans Health Administration (VA) have committed to offering safe and practical nonpharmacological options for pain management. One emerging, potentially effective therapy offered in the DoD and VA settings for immediate, short-term pain relief is battlefield acupuncture (BFA). BFA is a form of auricular acupuncture developed by Colonel (Retired) Richard C. Niemtzow, MD, PhD, a radiation oncologist, for use among military personnel as an adjunct therapy to manage pain [4, 5]. It is notable for its ease of administration and for the fact that it can be learned and administered by a wide variety of non-acupuncturist clinicians [6–9]. The BFA protocol involves inserting semipermanent needles at each of five points in succession into each ear (see Figure 1) until pain relief is elicited or until all needles are inserted. Between needle insertions, the patient, if ambulatory, walks around for a few minutes to assess pain relief. The needles then remain in the ear for several days. The five points in the battlefield acupuncture protocol. Reproduced with permission from Niemtzow et al. [5]. The five points in the battlefield acupuncture protocol. Reproduced with permission from Niemtzow et al. [5]. Auricular acupuncture has been performed for thousands of years in several countries and is based on theories of the traditional Chinese acupuncture meridian system. As detailed in Drs. Niemtzow and Nogier’s article [5], French physician Dr. Paul Nogier popularized auricular acupuncture in the 1950s, using <2-mm gold-plated acupuncture semipermanent (ASP) needles, and was the first to produce a visual map of the auricular acupuncture points. Dr. Niemtzow then adapted that to develop BFA, which uses the four specific points that Dr. Nogier used plus the Shen Men point: 1) cingulate gyrus, 2) thalamus, 3) omega 2, 4) Shen Men, and 5) Point Zero. Dr. Niemtzow’s technique was readily used in the battlefield to reduce pain because the sterilized ASP needles can be easily carried, inserted in the ear in <5 minutes, used anywhere, and delivered by non-acupuncturists. Review articles provide additional detail on BFA and its history [4, 5, 7]. Several have posited various mechanisms for BFA’s effectiveness. One review of auricular acupuncture studies by Hou et al. posits that BFA affects not only the autonomic nervous system, but also the neuroendocrine system, neuroimmunologic factors, neuroinflammation, and neural reflex, as well as antioxidation [9]. A second review by He et al. notes, “… auricular acupuncture plays a role in vagal activity of autonomic functions of cardiovascular, respiratory, and gastrointestinal systems. Mechanism studies suggested that afferent projections from especially the auricular branch of the vagus nerve to the nucleus of the solitary tract form the anatomical basis for the vagal regulation of auricular acupuncture” [10]. The present commentary summarizes the work our research teams have conducted to examine BFA’s implementation and effectiveness within the DoD and VA health care systems. With a Joint Incentive Fund grant, the VA and DoD collaboratively developed a system-wide approach to disseminating acupuncture training, including BFA, with the goal of facilitating its delivery in any setting where patients needed pain relief [7, 8]. The two agencies began training clinicians in the BFA protocol in 2014, using a “train-the-trainer” model, in which a group of clinicians were trained, who then became instructors and trained additional providers in their geographic areas. By 2016, more than 2,000 clinicians had been trained, with slightly more than half of those being DoD clinicians. To date, the VA recognizes about 100 certified BFA instructors and more than 4,600 VA clinicians across a range of disciplines who have been trained to deliver BFA in accordance with their state licensures, including medical doctors, registered nurses, nurse practitioners, chiropractors, licensed acupuncturists, occupational therapists, doctors of osteopathic medicine, physician assistants, and physical therapists. BFA has been integrated into many VA medical departments and clinics, including primary care, pain clinics, physical therapy, emergency departments, inpatient settings, integrative health clinics or Whole Health programs, and chiropractic and acupuncture clinics [11]. With regard to the DoD, they are developing a Defense Health Agency Procedural Instruction (DHAPI) for acupuncture. It will be the first guidance for the DoD on acupuncture practice within military treatment facilities and will outline BFA as a Tier 1 acupuncture protocol that can be performed with a prescription. Clinicians outside the VA or DoD can now be trained in BFA via private sector classes if BFA is in their scope of practice [12]. Also, the VA is collaborating with the Indian Health Service to help them start a BFA training program. Given that BFA is an emerging therapy, to our knowledge, only four small studies have examined its effectiveness to date, with all finding short-term improvements in pain. Three were small randomized trials: 1) one among military medical center emergency department patients with acute pain [6], 2) another among patients of an Air Force family medicine clinic with pain from acute sore throat [13], and 3) one among emergency department patients with low back pain [14]. A feasibility study was conducted among patients using a military aeromedical evacuation system [15]. Two 2017 meta-analyses or reviews examined the broader array of auricular techniques (with BFA included), with both concluding that auricular acupuncture in general, either as a standalone or as an adjunct technique, appears to reduce pain for most people [16, 17]. Our team very recently conducted two examinations of BFA for pain in a national sample of 11,406 patients receiving 28,438 procedures from 808 providers [18, 19] and one additional study in a sample from one large BFA clinic [20]. All of the BFA clinics were within the VA and used the Defense and Veterans Pain Rating Scale (DVPRS) [21] (see Figure 2) immediately before and after BFA delivery. We used the DVPRS because it had been included in a standardized note template that was disseminated to all VA medical facilities (this template did not include pain functionality; no other patient-reported health outcomes are routinely available in the VA’s electronic health records). Only immediate posttreatment pain relief outcomes were available, so our data do not provide information about the effectiveness of BFA for reducing the long-term burden of pain. Defense and Veterans Pain Rating Scale. Reproduced with permission from Buckenmaier et al. [21]. Defense and Veterans Pain Rating Scale. Reproduced with permission from Buckenmaier et al. [21]. In our study of a high-volume VA BFA clinic (n = 751 patients) [20], we examined BFA’s effectiveness for self-reported pain when delivered in group vs. individual settings and when delivered repeatedly over time. Overall, we found a decrease in pain for 82% of patients. These decreases were common in both the group (80%) and individual settings (87%). BFA’s effectiveness persisted with repeated use; that is, each treatment appeared to have the same type of effect whether it was given once or on multiple occasions. In our first examination of the national sample of BFA users in the VA, we similarly found BFA to be beneficial to a high proportion of patients [18]. Specifically, more than three quarters of patients reported an immediate decrease in pain intensity after receipt of BFA, with nearly 60% reporting a 2-point (minimal clinically important) decrease. On average, the decrease in pain intensity was –2.2 points (standard deviation= 2.8) at initial BFA treatments and –2.1 points (standard deviation= 2.4) at subsequent BFA treatments. We also found that BFA was effective across a wide range of veterans, with many having preexisting chronic pain or physical or psychological comorbid conditions. Those with histories of opioid use experienced less improvement in pain intensity than others. In a second study of this national VA sample [19], we examined the degree to which BFA acts as a “gateway” to subsequent use of acupuncture. We conducted this examination because several BFA providers reported in our BFA implementation study (Giannitrapani et al. [22]) that patients who originally were reluctant to try complementary and integrative health therapies before using BFA became open to trying other complementary and integrative health therapies for pain when they felt their pain improve with BFA. Using a propensity score analysis, we found that patients who used BFA had more than ten times greater odds of subsequently using traditional acupuncture within 3 months after their BFA visit, after adjustment for several health conditions, demographic characteristics, and pain level. In addition to examining the effectiveness of BFA, we also examined how well it is being implemented in the VA. Our first study [11] identified the challenges that BFA providers experience in implementing BFA and any successful strategies used to overcome these challenges. We conducted semistructured telephone interviews with 23 BFA providers across the nation from June 2017 through January 2018. We asked about several implementation issues and identified eight main implementation issues that VA BFA providers faced: 1) Providers were organizing the delivery of BFA in a variety of ways; 2) some had insufficient time to provide BFA to meet patient demand; 3) some were facing some negative beliefs and lack of knowledge about BFA from medical facility leadership, other health care providers, and patients; 4) there was a lack of BFA indication guidelines or effectiveness data; 5) some experienced a time delay between training and practice due to administrative bureaucracy; 6) some experienced a loss in self-efficacy when they did not deliver BFA frequently; 7) some did not have sufficient room or needles to provide as many treatments as they would have liked; and 8) facility leadership and administrative buy-in is critical. Our second study on BFA implementation examined VA BFA providers’ perspectives on the advantages and disadvantages of BFA [22]. We used content from the above 23 interviews and conducted an additional 20 interviews with providers from high-performing sites across the nation. We found that BFA providers perceived BFA’s advantages to be: 1) It can simultaneously effectively control pain while reducing opioid use; 2) BFA may alleviate pain that has been unsuccessfully treated by conventional methods; 3) BFA gives providers a treatment option to offer patients with substance use disorder; 4) BFA can help build a trusting patient–provider relationship; 5) BFA can facilitate open communication; and 6) BFA can create the opportunity for hope. BFA providers also reported their perceptions of BFA’s disadvantages: 1) There are insufficient clinical guidelines on when to administer BFA; 2) BFA provides only short-term pain relief; 3) BFA can be uncomfortable for some; 4) BFA may not be an effective treatment option unless it can be provided “on demand”; and 5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. In sum, BFA providers perceived BFA to have many benefits, both clinical and relational, including potential utility in helping address the current opioid crisis. They also reported that BFA is easy to deliver and low risk and has clinical and relational utility. We also asked the high-performing sites how they overcame what we found to be the largest implementation hurdle—the minimal amount of clinical evidence. We found that some sites encouraged facility leadership and patients to observe and/or experience BFA. Clinical facility leaders were invited to attend BFA trainings, where they learned to administer BFA and received BFA from other attendees. Patients learned about BFA delivery and effectiveness by observing other patients receive BFA in a group format (with patient permission). The results of these two studies point to several facilitators and barriers to the implementation of a novel, seemingly effective, nonpharmacological pain management option. One prominent barrier to BFA’s implementation was the lack of a stronger evidence base. This barrier is typical for novel treatments, especially treatments that are considered complementary and integrative health. However, the evidence for other complementary and integrative health pain management options has grown significantly over recent years, which has the potential to open clinicians’ and patients’ minds to BFA as another pain management option. Also, that a lack of stronger evidence was an implementation barrier also points to the need for improved dissemination of the research findings that do exist. Another barrier to implementing novel therapies is having sufficient clinicians trained to deliver it. This training barrier is beginning to be eroded, now that BFA training is available outside the VA and DoD settings, as noted above. Being able to meet patient demands for effective nonpharmacological treatments is just part of the VA’s current (e.g., Whole Health transformation) [23] and long history of innovation, and with innovation comes expected implementation issues. Nevertheless, these implementation difficulties are counterbalanced by the positive aspects of the VA and DoD’s implementation of BFA. One such aspect is that millions of veterans and active military personnel now have another nonpharmacological pain management option available to them that, for many, has worked. Another positive result is that some health care systems or providers look to the VA’s health care system as ammunition for their own implementation of an emerging therapy (e.g., “if the government can make BFA available, why can’t we?”). As with most emerging therapies, additional research on BFA is needed on several fronts. For example, only three small trials have been conducted, and, given their size, they most likely lacked the power to accurately assess the effectiveness of BFA. As such, larger randomized controlled trials of BFA are warranted, with medium- and long-term follow-up. Additional research should be conducted to determine for what conditions BFA does and does not work well. Our [18] national examination began to address this question, as did some of the smaller randomized controlled trials, but clearly more work needs to be done. Also, studies should include measures of pain functionality or impairment, which many consider as important as or more important to assess than pain severity. Studies should incorporate measures such as quality of life and general well-being, which could reflect an improved overall health status due to BFA, in spite of pain continuing to be present. Also, to date, BFA has been examined only among military and veteran populations because it is not as frequently available in civilian settings. However, given the likelihood that it will be spreading to the population served by the Indian Health Service and the general population in the near future, more research is needed to examine BFA effectiveness among nonmilitary populations. Ultimately, clinical practice guidelines on dosage, frequency, and clinical indications will need to be developed from the evidence that emerges from this next wave of effectiveness research. On the basis of work conducted to date, there is some evidence that BFA is a potentially effective, immediate, but short-term nonpharmacological pain management tool that can be used in adjunct with other pain therapies. In our effectiveness studies, we observed that BFA produced a minimal clinically important improvement in pain for at least half of those who received the treatment, in every patient population examined, including patients who had recently filled an opioid prescription and patients with significant psychological and physical comorbidities. We also observed that both individual and group BFA sessions were effective, with the former being only marginally more effective than the latter. In implementing BFA, VA providers are delivering BFA by means of a variety of models. Although they continue to experience challenges in implementing BFA in their facilities (most notably, the perceived lack of evidence that accompanies most new treatments), new strategies to address these challenges are continually being developed. Given its effectiveness in providing immediate, short-term pain relief, from the perspective of both providers and patients, BFA is one potentially important tool in the toolkit to address patients’ pain. Finally, the immediate, short-term relief that BFA can provide may provide a “window” to allow some patients to engage in other, more long-term approaches, such as yoga and tai chi, ultimately moving toward more of a self-management model to address their chronic pain. All authors made a significant contribution to the study concept and design, acquisition of data, or analysis and interpretation of data; drafting/revising the manuscript for important intellectual content; and approval of the final version to be published. The authors contributed to the paper as follows: SLT wrote this article, obtained funding for this article, and led (and obtained funding for) four studies summarized in the article; KFG edited this article and led one of the studies summarized in the article; PEA edited this article and participated in two studies summarized in the article; ERT edited this article and participated in two studies summarized in the article; DGF edited this article and led one study summarized in the article; JRH edited this article and participated in two studies summarized in the article; JO edited this article and participated in two studies summarized in the article; BK edited this article and participated in three studies summarized in the article; and SBZ edited this article and participated in two studies summarized in the article. Funding sources: This work was supported by the Department of Veterans Affairs Quality Enhancement Research Initiative program (PEC 16–354). Disclosure: The views expressed in this article are those of the authors and do not necessarily represent the position or policy of the Department of Veterans Affairs or the United States government. All Veterans Health Administration authors of this manuscript attest that the activities that resulted in producing this manuscript were not conducted as part of a research project, but as part of the non-research evaluation conducted under the authority of name of the VA Office of Patient Centered Care and Cultural Transformation (OPCC&CT). The status of this work as quality improvement and not research was also confirmed following review by the Research and Development Committee at the VA Greater Los Angeles Healthcare System. Conflicts of interest: All authors declare no conflict of interest.

ABSTRACT: Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.

Telerehabilitation (TR) uses technology to deliver physical and cognitive rehabilitation. TR supports many clinical categories pertaining to geriatric patients. Benefits from TR include reduced travel demands, longer consultation durations, and greater access to specialists for older patients. Despite these advantages many older adult patients and clinicians are reluctant to select TR as part of their care. The aim of this review is to summarize the evidence supporting the use of TR in the care of older adult patients.