Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits [1 ed.] 9781620812853, 9781620812686

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Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

HEALTH CARE IN TRANSITION

VETERANS

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

HEALTH ISSUES, COPING STRATEGIES AND BENEFITS

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services. Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

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Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

HEALTH CARE IN TRANSITION

VETERANS

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

HEALTH ISSUES, COPING STRATEGIES AND BENEFITS MADISON MCCLEOD AND

CHAD S. HEWITT EDITORS

Nova Science Publishers, Inc. New York

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

Copyright © 2012 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com

NOTICE TO THE READER

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‟ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data ISBN 978-1-62081-285-3 (eBook) Library of Congress Control Number: 2012933164

Published by Nova Science Publishers, Inc. † New York

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

CONTENTS

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Preface

vii

Chapter 1

Transfusion Support for Veteran Patients Alex Ryder and Christopher A. Tormey

Chapter 2

Low Serum Vitamin D is Associated with Metabolic Syndrome in African American and Caucasian American Male Veterans B. Manickam,V. Neagu, V.Ryvkin, S.Kukreja and E. Barengolts

1

27

Chapter 3

Update on Eye Care Issues in Veterans Anat Galor, Ninel Z. Gregori, Jesse Pelletier, Raquel Goldhardt, Anna Junk and Sarah Wellik

Chapter 4

A Social Covenant: Creating Sanctuary for Homeless Veterans Susan L. Ray

65

The Rehabilitation of Shaken Soldier Syndrome: A Coordinated System of Community-Situated, Postacute Treatment for Blast-Injured Veterans Larry E. Schutz, Kenyatta O. Rivers, Elizabeth A. McNamara and Charles E. Hughes

75

Chapter 5

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

45

vi Chapter 6

Contents Genetic Markers in Suicidal and Non-suicidal Veterans with Combat-related Posttraumatic Stress Disorder Nela Pivac, Dragica Kozarić-Kovačić, Gordana Nedić, Matea Nikolac, Maja Mustapić, Ana Babić, Mirjana Grubišić-Ilić, Zrnka Kovačić and Dorotea Mück-Šeler

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

Index

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

125

165

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PREFACE In this book, the authors discuss topical issues relating to veterans including transfusion therapy for veteran patients; low serum vitamin D and its association with metabolic syndrome in African American and Caucasian American male veterans; eye care issues in veterans; substandard and lack of affordable housing in the veteran population; the rehabilitation of shaken soldier syndrome; and genetic markers in suicidal and non-suicidal veterans with combat-related post-traumatic stress disorder. Chapter 1- The transfusion of blood products is an important and often life-saving aspect of medical management for military veterans seeking care at Veterans Administration (VA) facilities. However, blood product infusion is a complex process that is associated with both infectious and non-infectious hazards. Thus, the aim of this chapter is to review transfusion therapy for veteran patients with a particular emphasis on those guidelines and risks most applicable to veteran populations. The authors will outline current, evidencebased approaches for transfusions of red blood cells, platelets, plasma, and cryoprecipitate and discuss how these relate to veteran groups. Moreover, the authors will share their practical experiences in transfusion management at a large, VA Healthcare System especially for areas of management (e.g. the use of factor concentrates for non-hemophilia patients) which currently lack discrete, evidence-based approaches. Finally, the authors will address the risks of transfusion with a focus on those aspects of transfusion hazards that have been well-studied and are particularly unique to veteran patients (e.g. RBC alloimmunization and delayed hemolytic transfusion reactions). Practical strategies to overcome these potential problems will also be reviewed. Chapter 2- Vitamin D and metabolic syndrome interaction has not been well studied; yet both define risk for developing cardiovascular disease

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

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viii

Madison McCleod and Chad S. Hewitt

(CVD). The authors assessed whether serum 25-hydroxyvitamin D (s25D) is associated with prevalent metabolic syndrome (MetS) and MetS components in a group of predominantly African American male (AAM) veterans at an urban veteran administration medical center (VAMC). Chapter 3- To review eye care issues important to veterans and describe ongoing research activities in the Miami Veterans Affairs Medical Center (VAMC) eye clinic department. Chapter 4- Substandard and lack of affordable housing were common themes found in the first national study on homelessness among the Canadian (CF) and Allied Forces (AF), veteran population. A person‟s ability to live in affordable good quality housing is a primary social determinant for their health and well-being. Affordable decent housing is needed for homeless veterans not only to break the vicious cycle of being forced back into the shelter system but also for their health and well-being. Homeless veterans deserve decent, affordable housing in the country that they served both in times of peace and in times of war. Creating a sanctuary or safe haven for homeless veterans requires the commitment of a social covenant. In this paper, the difference between a social contract and social covenant will be explored. Comparisons between Britain, United States and Canada in caring for veterans will be discussed. The social covenant and how its changing nature has affected resources allocated for the health care of military members and veterans will be explored. It will be argued that the Canadian military, the Canadian government and the Canadian public need to re-establish a social covenant with homeless veterans. Chapter 5- The return to civilian life of more than 320,000 recently brainwounded soldiers has overloaded and overtaxed the existing system of postmilitary medical care. The Veterans Administration has responded by developing specialized inpatient rehabilitation centers. The postacute care crucial to long-term adjustment has been consigned to newly-hired professionals and diverse civilian-sector clinics. These providers are generally inexperienced in long-term intervention and lack a competent theory to guide such intervention. The premier model developed by by experts in postacute rehabilitation of civilian TBI provides the logical starting point for the design of a centrally coordinated national system of care. This “holistic cognitive rehabilitation” paradigm, adapted for greater efficiency, can be disseminated to and administered by local personnel. The program features paraprofessional peer counseling, active family participation, modules of pre- prepared patientfamily education, high intensity therapy for the dysexecutive syndrome, and direct training of generalization. Special adaptations of both the counseling

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

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Preface

ix

and the cognitive training procedures address comorbid post- traumatic stress disorder. Finally, a number of technological enhancements of the basic therapy model are proposed and explained. Chapter 6- Posttraumatic stress disorder (PTSD) is a complex polygenic psychiatric disorder, precipitated by an exposure to a traumatic event. The risk factors for PTSD include, besides traumatic experience, other biological, genetic, environmental factors, and adversity in early life. Genetic studies in PTSD are still scarce. Combat-related PTSD is especially pervasive form of PTSD, frequently associated with suicidal behaviour. Various markers of serotonin (5-HT), dopamine, noradrenalin, hypothalamic-pituitary-adrenal axis function, brain derived neurotrophic factor (BDNF), and catechol-omethyltransferase (COMT) have been proposed as the possible markers of PTSD and/or suicidal behaviour. The authors‟ study determined polymorphisms of the genes for monoamine oxidase (MAO-B), dopaminebeta-hydroxylase (DBH), COMT, BDNF, serotonin transporter (5-HTT) and serotonin 5HT2A receptor in male Croatian war veterans with combat related PTSD, subdivided into non-suicidal and suicidal subjects. There were no significant differences in the frequencies of the genotypes or alleles for MAO-B, -1021C/T DBH, Val158/108Met COMT, Val66Met BDNF, 5-HTTLPR and 102T/C 5HT2A between suicidal and non-suicidal veterans with PTSD. Their results did not support the hypothesis that these genetic variants contributed to the risk of suicidal behaviour in combat- related PTSD. Since both suicidal behaviour and clinical features of PTSD are heterogeneous and complex, the research of the risk genes is associated with numerous methodological difficulties, especially with the problem of detecting a significant effect. The identification of subjects prone to suicidal behaviour is important for the prevention of suicidal attempts and proper treatment interventions, and therefore future studies should elucidate the relationship between candidate genetic risk factors and suicidal behaviour in the large homogenous sample of veterans with PTSD.

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

In: Veterans Editors: M. McCleod and C. S. Hewitt

ISBN: 978-1-62081-268-6 © 2012 Nova Science Publishers, Inc

Chapter 1

TRANSFUSION SUPPORT FOR VETERAN PATIENTS Alex Ryder1,2 and Christopher A. Tormey1,2 1

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Pathology and Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, CT, US 2 Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, US

ABSTRACT The transfusion of blood products is an important and often lifesaving aspect of medical management for military veterans seeking care at Veterans Administration (VA) facilities. However, blood product infusion is a complex process that is associated with both infectious and non-infectious hazards. Thus, the aim of this chapter is to review transfusion therapy for veteran patients with a particular emphasis on those guidelines and risks most applicable to veteran populations. The authors will outline current, evidence-based approaches for transfusions of red blood cells, platelets, plasma, and cryoprecipitate and discuss how these relate to veteran groups. Moreover, the authors will share their practical experiences in transfusion management at a large, VA Healthcare System especially for areas of management (e.g. the use of 

Corresponding Author: Christopher A. Tormey, MD, 333 Cedar Street, PO Box 208035, New Haven, CT 06520, 203-932-5711 ext. 2964 (phone), 203-937-4746 (fax), Email: [email protected]

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

2

Alex Ryder and Christopher A. Tormey factor concentrates for non-hemophilia patients) which currently lack discrete, evidence-based approaches. Finally, the authors will address the risks of transfusion with a focus on those aspects of transfusion hazards that have been well-studied and are particularly unique to veteran patients (e.g. RBC alloimmunization and delayed hemolytic transfusion reactions). Practical strategies to overcome these potential problems will also be reviewed.

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

INTRODUCTION The transfusion of blood products is an important and often life-saving aspect of medical management for military veterans seeking care at Veterans Administration (VA) facilities. However, blood product infusion is a complex process that is associated with both infectious and non-infectious hazards. Consideration must be given to these potential risks, as well as prospective benefits, when managing the transfusion needs of veteran patients. When possible, adopting an evidence-based approach to the transfusion of blood products is ideal, but guidelines for the administration of many blood components are not well established in this unique patient population. In these situations, practical experience can assist management decisions. It is also important to address transfusion hazards that have been well studied and are particularly unique to veteran patients, as well as practical strategies that can be used to overcome these potential problems.

RED BLOOD CELL TRANSFUSION Indications Transfusion of red blood cell (RBC) units is a first line therapy for anemic patients. Allogeneic RBC transfusion, however, is not a benign intervention, and carries multiple risks including transfusion reactions, volume overload, and the development of antibodies to red cell antigens, as well as to antigens found on residual leukocytes contained within a transfused unit. In order to minimize these risks, while providing the most effective red cell transfusion support for anemic patients, it is helpful to establish evidence-based laboratory criteria for the transfusion of RBC units to target patient populations.

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

Transfusion Support for Veteran Patients

3

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The veteran patient population includes a diverse mix of individuals including those with cardiac, renal and hepatic dysfunction, critically ill patients, perioperative patients, and oncology patients. Multiple randomized controlled studies have sought to identify hemoglobin and/or hematocrit “triggers” for RBC transfusion in diverse patient populations. The most pertinent conclusions for veteran patient populations can be drawn from a recent exhaustive review that analyzed data from 10 randomized controlled trials, each of which compared restrictive versus liberal red cell transfusion thresholds. The authors conclude that restrictive transfusion triggers are appropriate for patients without advanced cardiac disease, and go on to specify that transfusions are probably unnecessary in patients with hemoglobin as low as 7.0 g/dL in the absence of active bleeding. [1] For patients with active bleeding, for instance veteran patients in the post-operative state, hemoglobin levels of 8-9 g/dL are likely warranted to promote clotting. Other recent clinical practice standards offer similar transfusion thresholds, with the recommendation that critically ill patients can likewise tolerate hemoglobin of 7.0 g/dL without requiring allogeneic RBC transfusion. [2] Further, no studies have found evidence of any benefit to patients by maintaining hemoglobin greater than 10.0 g/dL, and this practice of excessive transfusion may be associated with worse outcomes [3].

Component Modification Allogeneic red cell units contain residual leukocytes, which are associated with a number of potential risks to recipient patients. In particular, when recipients are significantly immunosuppressed, donor lymphocytes are capable of inducing vigorous immune-mediated destruction of recipient cells in a wellrecognized phenomenon known as transfusion-associated graft-vs-host disease (TA-GVHD) [4]. The pathophysiology of TA-GVHD is reviewed below (see Risks of Transfusion). Fortunately, TA-GVHD can be prevented by gamma irradiation of cellular blood components. [4] Table 1 reviews the various indications for gamma irradiation [5]. Although gamma irradiation is considered safe and relatively low risk, the process can lead to increased potassium leakage from red cell membranes. Thus, the shelf life of irradiated red cells is reduced to 28 days from the date of irradiation. Because of the low risk nature of gamma irradiation, some members of the transfusion medicine community would support a policy of universal irradiation of cellular blood components, arguing that this would eliminate the possibility of TA-GVHD in

Veterans: Health Issues, Coping Strategies and Benefits : Health Issues, Coping Strategies and Benefits, edited by Madison

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Alex Ryder and Christopher A. Tormey

patients who fall into a category in Table 1, but whose physicians are unaware of this high-risk status. Studies still need to be completed to establish the logistic and economic feasibility of such a policy of universal cellular blood component irradiation [6].

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Table 1. Indications for Gamma Irradiation of Cellular Blood Components

Leukocyte reduction (leukoreduction) of cellular blood components is another commonly utilized method for reducing the negative effects of residual leukocytes. Red cell units collected by standard methods contain 1-3 x 109 leukocytes [7.8], and, according to AABB standards, leukocyte-reduced red cell units must contain