VA continues expansion of integrated network system to enable health care staff to share best practice uses of department’s 3D printing capabilities
Today the U.S. Department of Veterans Affairs (VA) announced that it continues to expand its national integrated virtual 3D printing network that began January 2017 at VA’s Puget Sound Healthcare System, growing it from just three hospitals with 3D printing capabilities in early 2017 to 20 at the close of 2018.
This growing network allows VA health care staff to share ideas, solve problems and pool resources on best practice uses of 3D printing for improving Veterans’ care.
Currently, Veterans Health Administration (VHA) innovators across the 20 sites are using 3D printing to solve a wide range of issues, from presurgical planning to manufacturing hand and foot orthotics.
“VA remains at the forefront of innovative work in 3D printing by expanding our expertise across VA,” said VA Secretary Robert Wilkie. “Through this growing virtual network, VA continues to help define how 3D printing technology will be used broadly in medicine for the benefit of patients.”
At the Puget Sound Healthcare System, prints of model kidneys for patients with renal cancer aid in presurgical planning, allowing surgeons to plan their surgical approach to maximize preservation of normal kidney tissue and avoid disturbing unaffected vessels that surround a tumor. This can save doctors up to two hours per surgery, reduce the time patients are under anesthesia, and increase operating room availability.
Occupational therapists are also using 3D printers to manufacture specialized hand orthotics, to provide same-day fitting and delivery, which offers immediate care and reduces the need for multiple visits. The digital blueprint can then be saved, so a replacement can be printed quickly if the orthotic breaks or is damaged.
VA researchers are working with collaborators to create a bioprinting program that uses 3D printing to fabricate replacement tissues that are customized to an individual patient. This would decrease wait times for tissues and organs, reduce the need for grafting surgeries and enable hospital and health care providers to improve the quality and safety of medical procedures. The group is targeting a competitive three-year timeline to have a bioprinted vascular bone implanted into a patient.
The 3D printing virtual Center of Excellence is part of the VHA Innovation Ecosystem. The Ecosystem includes the Diffusion of Excellence Initiative and VHA Innovators Network, two programs that aim to identify and scale innovations and best practices across VA by empowering and enabling employees.
The VA actually spent money — and years — on a scientific study to tell us daily drinking is unhealthy
In 1664, Sir Isaac Newton ascertained that the force drawing objects toward each other was gravity, helping to elucidate why planets orbit around our solar system’s star.
In 1823, Jan Evangelista Purkinje observed that fingerprints are unique to each individual and are left behind on items people touch, thus transforming the efficiency of law enforcement investigations.
In 1928, Alexander Fleming discovered penicillin, drastically altering the medical landscape and how bacterial infections are treated.
And in 2018, a groundbreaking scientific study by the Veterans Affairs Department revealed that daily alcohol use isn’t great for your health.
My name is Ozymandias, King of Kings. Look on my Works, ye Mighty, and despair!
Bravo. Money well spent by the VA, the oft-criticized organization that makes paying Veterans what they’re owed for disabilities, education and housing appear as laborious as Thanos' quest to amass all six Infinity Stones.
Who needs resources directed at such tedious, shoulder-shrugging tasks when, instead, we can be assured that the tens of people in the entire Milky Way Galaxy currently consuming daily booze for the purpose of health benefits have their knowledge checked? But it’s gluten free!
“There has been mounting evidence that finds light drinking isn’t good for your health,” said Dr. Sarah Hartz, principal researcher of the study.
Hartz, an assistant professor at Washington University in St. Louis added that she wasn’t surprised by the results, and that “two large international studies published this year reached similar conclusions,” the VA release said.
An unsurprisingly intelligent researcher and professor not being surprised by unsurprising results should surprise no one.
The predictable findings showed that “downing one to two drinks at least four days per week was linked to a 20 percent increase in the risk of premature death, compared with drinking three times a week or less,” according to the Veterans Affairs blog. “The finding was consistent across the group of more than 400,000 people studied" over a course of seven to 10 years.
Participants ranged in age from 18 to 85 years — Hold on. Four-hundred thousand? It took studying more than 400,000 participants over a period of seven to 10 years to reach that verdict?
The VA could just as easily have saved everyone’s time and paid some poor schmuck named Bobby Joe 10 bucks to stumble down to his local watering hole, take a picture — using his high-tech Motorola Razr — of an all-too-frequent bar-goer who long ago developed aged, leathery skin and a portly stature, and still arrived at the same conclusion.
Never has a single ripped individual graced the cover of a health magazine while flanked by the words, “Shred your gut by slamming beers!” or “Get jacked on jack and cokes!”
Was John Basedow pummeling daily boxes of wine while pumping out “Fitness Made Simple” VHS tapes? Doubt it.
Time and resource management skills have seldom been recognized as strengths of the Veterans Affairs, but these Mariana Trench-like depths are hard to fathom.
Byzantine-era computer software creating backlogs of Veteran claims, insufficient manpower to operate said antiquated systems, and now, blinding us with science. It’s poetry in motion.
WASHINGTON — New research linking Veterans’ high blood pressure with wartime exposure to chemical defoliants could dramatically expand federal disability benefits for tens of thousands of Vietnam-era troops.
The findings, from the National Academies of Sciences, Engineering and Medicine, conclude that “sufficient evidence” exists linking hypertension and related illnesses in Veterans to Agent Orange and other defoliants used in Vietnam, Thailand and South Korea in the 1960s and 1970s.
They recommend adding the condition to the list of 14 presumptive diseases associated with Agent Orange exposure, a group that includes Hodgkin’s Disease, prostate cancer and Parkinson’s Disease. That’s an upgrade from past research that showed a possible but not conclusive link between the toxic exposures and high blood pressure problems later in life.
If Veterans Affairs officials follow through with the recommendation, it could open up new or additional disability benefits to thousands of aging Veterans who served in those areas and who are now struggling with heart problems.
Veterans who struggle with high blood pressure issues are eligible for health care at VA facilities. But the illness is eligible for disability benefits in only select cases.
Adding an illness to VA’s presumptive list means that Veterans applying for disability benefits need not prove that their sickness is directly connected to their time in service. Instead, they only need show that they served in areas where the defoliant was used and that they now suffer from the diseases.
That’s a significant difference, since proving direct exposure and clear health links can be nearly impossible for ailing Veterans searching for decades-old paper records.
A change in the designation of hypertension by VA could also add significant new costs to the department’s disability payout expenses.
In 2010, when then Veterans Affairs Secretary Eric Shinseki expanded the list of presumptive illnesses for Agent Orange exposure to include ischemic heart disease and Parkinson's, the department estimated additional costs of more than $42 billion over a decade.
It’s unclear how many Veterans suffer from high blood pressure and would be eligible for disability payments if the change is made. In a statement, VA spokesman Curt Cashour said the department “is in the process of evaluating this report and appreciates the work” of the group.
Regardless the cost, officials from the Veterans of Foreign Wars are already calling for VA officials to move ahead with adding hypertension to the list.
“There is no doubt in anyone’s mind that Agent Orange made Veterans sick, it made their children sick, and it brought pain and suffering and premature death to many,” VFW National Commander B.J. Lawrence said in a statement. “Even though it’s been a half century since they were exposed, the results of that exposure is something they continue to live with daily.”
Over the last year, advocates for “blue water” Navy Veterans — sailors who served in ships off the coastline of Vietnam — have been fighting with department officials over a decision to deny them presumptive status in Agent Orange related claims.
VA officials have insisted that scientific evidence does not exist linking their illnesses to exposure to the defoliant miles away from the Vietnam mainland.
The new study is available at the National Academies Press website.
Los Angeles, CA
Health disparities have persisted over time in the U.S. for a wide range of conditions affecting vulnerable populations. In the VA healthcare system, where financial barriers to receiving care are minimized, disparities are diminished, but still present for many important health outcomes. The Office of Health Equity-QUERI Partnered Evaluation Initiative will use a population health approach to examine the distribution of diagnosed health conditions, mortality, and healthcare quality across the entire VA healthcare system, as defined by Veterans' membership, or not, in vulnerable population groups. Investigators also will evaluate whether characteristics of the healthcare delivery settings (e.g., geography, treatment setting) and of the types of care that individuals use, including new models of care such as Telehealth, influence the quality of care that Veterans receive.
The Office of Health Equity-QUERI Partnered Evaluation Initiative has four specific aims:
- Assess where disparities exist between vulnerable Veteran populations and reference groups for diseases and conditions that are considered the principal causes of disability and mortality, particularly among vulnerable Veteran populations
- Examine gaps and trends in quality of healthcare across treatment settings among vulnerable Veteran populations.
- Determine the extent to which new models of care alter the association between vulnerable population status and gaps in quality of healthcare.
- In partnership with VA's Office of Health Equity, convene an Advisory Board to examine the context for and identify next steps needed to reduce identified disparities for the purpose of informing development of action plans to reduce disparities in VA healthcare.
This evaluation will identify high-priority VA health outcome and quality gaps to address, key organizational and other contextual factors that may impact action plans, and the highest priority next steps to reduce health disparities in VHA.
Investigators will use a population health approach to examine the distribution of diagnosed health conditions, mortality, and healthcare quality across the entire VA healthcare user population, as defined by their membership or not in vulnerable population groups. These vulnerable groups are defined by: race/ethnicity, sex, socioeconomic status, rurality of residence, service-connected disability status, serious mental illness, and age group. Secondary VA administrative data sources will be used to build on an existing database containing a complete multi-year cohort of VA patients.
The key partner is VA's Office of Health Equity, which "strives to advance health equity and reduce health disparities for all, especially vulnerable populations based on racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion."
Each year, tuberculosis (TB) kills more people than any other single infectious disease. Although tuberculosis can often be treated through a long and grueling course of antibiotics, not everyone is completely cured. Even among patients who are infected with Mycobacterium tuberculosis (Mtb) strains that are considered to be susceptible to the standard treatment regimen, 5 percent of patients relapse within six months of completing standard treatment. Scientists supported by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, and through NIAID’s Tuberculosis Research Units Network (TBRU-N), found that a more refined analysis of TB strains collected from volunteers before treatment could accurately predict whether those volunteers would be likely to relapse after standard treatment was completed.
The consequences of TB relapse can reach beyond an individual patient, as any bacteria that remain in the patient after treatment has ended are more likely to be resistant to antibiotics. Multidrug-resistant tuberculosis is often much more difficult to treat, and its spread is a serious concern.
If health professionals could know whether a patient might relapse after standard treatment, they could decide to prescribe a different, or longer, treatment regimen. However, predicting whether a patient will relapse can be difficult. Research published in the New England Journal of Medicine in August sought to determine if identifying the level of drug required to kill the Mtb strains in a new patient’s sputum, a viscous mucus, could predict whether the patient would relapse later, once treatment was complete.
The researchers used data and samples from volunteers who had participated in a prior study run by the Tuberculosis Trial Consortium of the Centers for Disease Control and Prevention. Roughly 1,000 adult volunteers from the United States and Canada, all of whom tested positive to drug-susceptible TB, enrolled in the study between April 1995 and February 2001. Before the study began, volunteers gave samples of sputum, which were stored for later testing. Volunteers then underwent both eight weeks of standard antibiotic therapy and an additional 16 weeks of either once-per-week rifapentine and isoniazid treatments, or twice-weekly rifampicin and isoniazid treatments. For two years after treatment completion, researchers followed the volunteers, noting who relapsed.
In this current study, researchers analyzed the TB strains in the volunteers’ stored sputum. They studied Mtb strains collected from all 57 volunteers who relapsed after completion of treatment and whose sputum bacteria could be cultured, and from 68 randomly selected volunteers who were cured as controls. The researchers cultured the bacteria isolated from the sputum of the 125 volunteers before they started TB treatment and tested for the bacteria’s susceptibility to isoniazid and rifampicin at different concentrations. The researchers found that strains collected from volunteers who relapsed required higher concentrations of isoniazid and rifampicin to halt their growth, on average, as compared to strains collected from patients who were cured. Based on these results, researchers developed a model to predict how likely a patient with drug-susceptible TB will relapse.
The researchers then conducted a follow-up study to validate their model using a group of volunteers enrolled in a different study led by NIAID’s Division of Microbiology and Infectious Diseases at sites in Brazil, the Philippines, and Uganda. These volunteers, who had also been diagnosed with drug-susceptible TB, also provided sputum samples prior to undergoing standard treatment with isoniazid, rifampin, ethambutol, and pyrazinamide, followed by two months of isoniazid and rifampin. Some volunteers were randomly assigned to an additional two months of isoniazid and rifampin. Using the model developed in the first study, researchers demonstrated that bacteria in pre-treatment sputum samples from 11 volunteers who experienced a relapse required higher concentrations of drugs to be killed in culture, as compared to bacteria cultured from pre-treatment sputum from 14 volunteers who did not relapse.
The results of this study provide a first step in identifying which patients are likely to relapse after completion of TB standard therapy. This has the potential to improve TB treatment success rates and decrease the development of drug-resistant Mtb.
VA scientists elected as National Academy of Medicine members for outstanding professional achievement, commitment to service
Four senior U.S. Department of Veterans Affairs (VA) researchers were recently elected as new members of the National Academy of Medicine (NAM), one of the highest honors in the fields of health and medicine.
VA Drs. Ann McKee, Albert Siu, Lucila Ohno-Machado and Rachel Werner were selected on Oct. 15 by current NAM members for their contributions to medical sciences, health care and public health.
“VA is extremely proud to have Drs. McKee, Siu, Ohno-Machado and Werner on our health care team,” said VA Secretary Robert Wilkie. “Their accomplishments and the tremendous work they do each day to improve the health and lives of our Veterans exemplifies the level of excellence we aspire to achieve as an agency.”
McKee, chief of Neuropathology at the VA Boston Healthcare System and professor of neurology and pathology at Boston University School of Medicine, was elected for her groundbreaking work on chronic traumatic encephalopathy (CTE), Alzheimer’s disease, aging, and vascular neuropathology. Her research in those areas has revolutionized medicine’s understanding of the clinicopathological and molecular features of CTE in athletes and Veterans exposed to neurotrauma or blast injury, and changed the public dialogue on sports-related risks.
Siu, who directs the Geriatric Research, Education and Clinical Center at the James J. Peters VA Medical Center in New York, is a professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai, New York. He was elected for his seminal contributions to evidence-based practice in health-services research and in pioneering programs that intersect geriatrics and palliative care.
Ohno-Machado, a research scientist at the VA San Diego Healthcare System and chair of biomedical informatics at UC San Diego Health, was elected for creating an algorithm that allows sharing access to clinical data while respecting the privacy of individuals and institutions.
Werner, a core investigator at the Center for Health Equity Research and Promotion at the Philadelphia VA Medical Center, is a professor of medicine and director of Health Policy and Outcomes Research at the Perelman School of Medicine, University of Pennsylvania. She was elected for advancing the understanding of how health care provider performance measurement and incentives often bring unintended and undesired equity consequences that compete with efficiency goals.
For more information on VA Research, visit www.research.va.gov.
Energy drinks like Rip-It and Wild Tiger may be essential fuel for hard-charging U.S. service members, but they’re only exacerbating mental health issues and behavioral issues, according to a new study in Military Medicine.
- The research found that soldiers who consumed at least two energy drinks a day were far more prone to “mental health problems, aggressive behaviors, and fatigue,” with high consumption reported in one out of every six soldiers months after the end of a high-stress deployment.
- Most alarmingly, however, is the assertion that ongoing energy drink consumption and the resulting aggressive behaviors “are associated with being less responsive to evidence-based treatments for PTSD” — a conclusion that suggests soldiers are mortgaging their long-term health for their short-term performance downrange.
- This conclusion was based on a survey of 627 male infantry soldiers, mostly junior enlisted between the ages of 18 and 24, seven months after the end of an unnamed combat deployment in order to gauge long-term impact.
- The problematic behaviors recorded in Military Medicine include extreme irritability (66%), sleep issues (35%), alcohol abuse (29.8%) and depression (9.6%), as well as a higher rate of post-traumatic stress disorder (11.2%), following the end of a deployment.
- It’s important to note that most of these behaviors aren’t a product of the energy drinks themselves, but a long-term impact of an abnormal sleep cycle: “Interestingly, energy drink use was associated with fatigue,” the authors note. “This relationship suggests that energy drink use may potentially exacerbate, rather than alleviate, fatigue.”
In Richmond, Virginia, experiments include implanting pacemakers in dogs, then inducing abnormal heart rhythms and running the animals on treadmills to test cardiac function before euthanizing them by injection or draining their blood.
VA spokesman Curt Cashour said former secretary David Shulkin approved the continuation of the experiments on March 28, the same day he was fired by President Donald Trump.
But Shulkin told USA TODAY on Monday that he “wasn’t asked, nor did I request a review for an approval,” of the ongoing dog experiments. He said he delegated that responsibility to the agency’s research specialists.
Whether he – or his successor – signed off on them is important because a law Trump signed on March 23 requires that dog experiments be “directly approved” by the VA secretary to receive agency funding. It doesn’t specify written permission. Cashour said Shulkin gave the go-ahead orally in an early-afternoon meeting March 28 with five other top VA executives.
Revelations that the tests are set to continue under new VA Secretary Robert Wilkie are sure to trigger a fresh round of debate. The records reviewed by USA TODAY show there are nine active experiments at four VA facilities, and more are likely in the future.
An investigation uncovering surgery failures and deaths in VA experiments on dogs has led to more scrutiny from the agency's chiefs and Congress, but that's not stopping tests involving pain for dogs. USA TODAY
VA: ‘Ethically sound’
VA officials contend the research could lead to discoveries that may help Veterans with heart conditions or breathing problems, which can accompany paralysis. Cashour said researchers use dogs “only when no other species would provide meaningful results and the work is ethically sound.” The VA says more than 99 percent of agency studies involve rats or mice.
When asked to cite the most recent breakthroughs credited to the VA dog research, Cashour pointed to the invention of an implantable cardiac pacemaker and procedures that led to the first successful liver transplant. Those experiments date to the 1960s, according to the VA’s website.
Lawmakers who have been pushing to end invasive dog experiments at the VA say they are disappointed the agency’s new leadership is moving forward with the testing.
“Why there’s this commitment to it, I don’t know because it doesn’t yield any results,” said Rep. Dina Titus, D-Nev., lead co-sponsor of a bill with Rep. Dave Brat, R-Va., that would stop the experiments. “It’s not economically sound, they could be looking at new technologies, and morally people just don’t support testing on puppies.”
Although they were glad Trump signed the legislation in March requiring the VA secretary's approval to fund the experiments, Titus, Brat and Rep. Brian Mast, R-Fla., said they will continue pushing to stop them altogether.
“We haven’t executed what we wanted as intent, which was to bring this to an end in its entirety,” said Mast, a Veteran who lost both his legs in Afghanistan and is now a member of the House VA Committee.
The issue started gaining traction with lawmakers in spring 2017, when an advocacy group, White Coat Waste Project, released documents showing VA researchers in Richmond had botched surgeries on dogs.
Within months, the House unanimously passed legislation to defund the experiments, but the measure stalled in the Senate after VA officials launched a public campaign to stop it.
That campaign included getting support from Veterans’ groups, such as The American Legion and Paralyzed Veterans of America. It also included an op-ed by Shulkin, the now-former VA secretary, published in USA TODAY outlining the need for the canine testing.
Before he was fired, Shulkin said his views on the subject had changed, and he put a moratorium on new experiments beginning without his permission. In March, he ordered that all ongoing studies be reviewed by VA research executives.
Cashour, the VA spokesman, said that review concluded dogs are “the only viable models" for nine experiments.
In a letter to lawmakers obtained by USA TODAY, the VA said they include the tests on spinal cords in Cleveland, brains in Milwaukee, the five heart experiments in Richmond and another cardiac study in St. Louis.
Four studies were discontinued or paused after the review. Researchers determined mice could be used instead of dogs for a Los Angeles experiment on narcolepsy, and pigs could be used for a Milwaukee study on blood flow. Another brain experiment in Milwaukee was put on hold for further review, and a second Los Angeles experiment was closed out.
When asked what the new secretary’s views are on dog experiments, Cashour pointed to Shulkin’s op-ed from last summer and said the VA’s position is unchanged under Wilkie.
Still, the VA recently commissioned a $1.3 million study overseen by the National Academy of Sciences to evaluate the need for dogs as research subjects.
“This is important to ensure that the debate surrounding this issue is grounded in careful analysis that takes into account the full context of the issue,” Cashour said.
Call to suspend experiments
White Coat Waste Project, the group that started the campaign to end the experiments, says they should be suspended until the study is completed.
“I think it calls into question the integrity of the VA’s intentions if it is going to continue funding and conducting dog experiments that it has just paid an organization over a million dollars to scrutinize,” said Justin Goodman, the vice president of advocacy and public policy for the organization.
Some Veterans’ groups that supported the experiments last year did not return messages seeking confirmation of their continued support, including The American Legion and Vietnam Veterans of America.
Paul Rieckhoff, CEO and founder of Iraq and Afghanistan Veterans of America, said his group still backs the experiments as long as they are done the right way.
"We’re not advocating all dog research per se, but when done ethically, it can lead to medical breakthroughs," he said.
But Paralyzed Veterans of America, which initially expressed support for continuing dog testing, told USA TODAY its position has since evolved.
“We no longer oppose efforts to end VA fatal medical research on dogs,” spokeswoman Liz Deakin said.
The group’s former executive director, a Marine Veteran who was paralyzed in a vehicle accident as he prepared to deploy to Afghanistan after the 9/11 attacks, also has rescinded his support.
Sherman Gillums Jr., who is now chief strategy officer at American Veterans, said after reviewing the science and speaking to experts at the VA and elsewhere, he concluded the dog experiments haven’t translated to human medical advances for decades.
“It’s time for us to look at better ways and spend money smarter than we’ve done it in the past – especially if it’s going to involve causing pain to the same animals that most Veterans need as service dogs,” he told USA TODAY. “To imagine them in cages being tested on with no real outcome that gives anybody hope, it just seems cruel.”
AMERICAN LAKE, WA-- Bob Crouch is headed into his 16th occupational therapy appointment at the American Lake branch of the VA Puget Sound Health Care System.
Crouch's thumb was amputated after a household accident, and he lost the use of his fingers during one of three surgeries.
Mary Matthews-Brownell is helping him stretch and exercise his hand to unclench his fingers. But their main goal is to get the Vietnam Veteran gaming again.
"It's whatever they're passionate about. That's what occupational therapy is all about," said Matthews-Brownell. "Whatever it is they want to do, I want to help them do it."
Without his whole thumb, Crouch can't maneuver gaming controls. He knows it might sound silly to some people, but he loves his PlayStation 3.
"I finally saved all my pennies, nickles and dimes," he said. "I managed to find one that I could afford that was in a pawn shop."
A few months after buying it in 2015, he lost his thumb.
"Anyone who plays video games knows, it's all about the thumbs," said Dr. Beth Ripley of the VA. "You've gotta have thumbs."
So the VA offered to print him a new one. In the VA's Innovations Lab, doctors and engineers move 3D printing from the research bench to the bedside.
"We have a very clear mission at the VA and that is to serve Veterans, period," Ripley said. "So if it can help a Veteran and we can show the cause and the case it will help the Veteran, we have license to do it."
One of the lab's top projects is to develop same-day custom orthotics to protect the feet of diabetics.
Eventually, doctors will be able to scan a patient's foot and feed specific measurements into the 3D printer, which will then build the unique orthotic, adding one thin layer at a time.
"It allows you to create objects and shapes that normally you can't make. It also allows you to create very customized things at a fraction of the cost," Ripley said.
They are also using 3D printing to help plan surgeries. By printing a model of an organ or body part that is identical to a patient, surgeons go into the operating room knowing exactly what they're going to see.
"You save that patient two hours under anesthesia, which means a better outcome. You might have saved them blood loss," Ripley said. "You save the fatigue on your surgeon."
It also saves money by cutting out OR time.
They wanted to use the same 3D tech to build an attachment that would fit perfectly onto Crouch's hand, doing the job of his thumb.
They enlisted the engineers of tomorrow: high schoolers and college students in a national competition.
Without ever seeing Crouch in person, the students competing at 2018 SkillsUSA Additive Manufacturing used a digital file to know the shape and size of Bob's hand, then they designed and printed around a hundred possible devices with various knobs and extensions to make gaming easier.
Crouch was emotional just thinking about their hard work.
"They don't even know me. I'm just an old Vet that's been trying to keep himself occupied and have some fun and everything, and they're trying to help me," he said.
And they're using technology Crouch couldn't have imagined when he served in Vietnam 45 years ago.
"I just kinda think it's maybe another way for someone to say, thanks you old Vet for doing what you did, you know?" Crouch said.
A couple years ago, Seattle was one of just three VA hospitals with a 3D engineering lab. Now there are 20, with plans to create more. From an occupational therapist point of view, Matthews-Brownell says it's the future.
"I find it to be a game changer in technology," she said. When she went through her training, "we had wood shop and sewing machines. I think 3D printers will be the new wood shop."
Interest in medical marijuana has increased in recent years. But does it actually help with pain and other conditions? According to a literature review commissioned by the VA Quality Enhancement Research Initiative (QUERI), evidence is lacking on the effects of medical marijuana for many types of chronic pain and for PTSD.
Researchers from the VA Portland Health Care System and Oregon Health and Science University searched multiple databases for studies on marijuana use for treating chronic pain or PTSD, and for studies on the potential harms of marijuana use. They included studies on a wide variety of cannabis plant preparations, including marijuana cigarettes and plant extracts. Studies on synthetic cannabis were excluded.
After reviewing more than 13,000 publications, the researchers identified 75 relating to pain or potential harms. They found limited evidence that marijuana use might alleviate neuropathic pain in some patients, and that it might reduce spasticity associated with multiple sclerosis.
There was insufficient evidence on the benefits of marijuana for all other pain types.
The body of evidence was limited by the number and size of studies, the inconsistency of results across studies, methodologic flaws of many available studies, and the lack of information on the long-term effects in chronic pain populations.
Very few studies on cannabis for PTSD
The researchers found insufficient evidence to assess the effects of marijuana on PTSD. Very few studies and no randomized controlled trials have been conducted on this topic. Three observational studies found that the marijuana use was not associated with PTSD symptom improvement.
In the largest of these studies, active marijuana use was associated with greater PTSD symptom severity. However, it is impossible to know from existing studies whether marijuana directly causes improvements or worsening in PTSD symptoms, say the researchers.
They also noted that there are multiple randomized controlled trials investigating the effectiveness of marijuana for treating PTSD currently underway. Evidence from these trials will likely be available in the next few years.
Lack of evidence 'surprising'
According to Dr. Devan Kansagara, senior author on the project, the lack of evidence was surprising: "We thought we would find more substantial evidence of beneficial effects, given how medical marijuana is widely used."
Additionally, his team found limited but consistent evidence that active marijuana use in general populations was associated with an increased risk of psychotic symptoms and psychotic spectrum disorders, adverse cognitive effects, and motor vehicle accidents. There was insufficient evidence to determine the long-term effects of marijuana use on cardiovascular health, on pulmonary health in older patients, and on the risk of many types of cancer.
The review also found almost no information about the long-term health effects of marijuana in older, sicker patients. The researchers cautioned that it is difficult to apply existing evidence to real-world clinical practice because dosage is often inaccurate and inconsistent in products available to patients through dispensaries. Moreover, many trials tested products that included equal and low levels of THC (the chemical associated with euphoria and possibly pain control) and CBD (a chemical that does not produce euphoria, but is thought to possibly help with pain control). In most dispensary products, the dosage of THC is far higher.
Medical marijuana use increasing despite lack of evidence
As of this study, 29 states—plus Washington, D.C., Guam, and Puerto Rico—had legalized marijuana for medical purposes. Between 45 and 80 percent of those who seek medical marijuana do so for pain management, and up to 39 percent of patients on long-term opioid therapy for pain also use marijuana. More than a third of patients seeking medical marijuana list PTSD as the primary reason for their request.
As the researchers explain, marijuana is becoming commonly available through state-sanctioned dispensaries, despite limited research on benefits and harms. The popular press has reported many stories about people gaining relief by using marijuana as a coping strategy for pain and PTSD.
According to the researchers, more information is needed on the clinical effects marijuana, including studies comparing marijuana with other pharmacologic treatments and comparing different cannabis preparations. They explain that, while strong evidence of the benefits of medical marijuana has not been found, "clinicians will still need to engage in evidence-based discussions with patients managing chronic pain who are using or requesting the use of cannabis." At this point, any methodologically strong research would add to the strength of the available evidence, they say.
VA and federal position on marijuana
Current federal law prohibits the use or dispensing of marijuana. As a federal agency, VA follows this prohibition, even where individual state laws permit marijuana use. As such, VA does not prescribe medical marijuana to any of its patients.
Patients participating in state medical marijuana programs are not denied VA services, but VA doctors cannot complete forms giving recommendations or opinions about a patient's need for prescription marijuana. VA providers may need to consider patients' marijuana use in the context of substance use disorder programs, or to avoid health complications or possible drug interactions.
Although marijuana is illegal under federal law, the Controlled Substances Act allows for research into the potential medical uses of controlled substances. Such research must be approved by the Drug Enforcement Agency, Food and Drug Administration, National Institute of Drug Abuse, and scientific merit review boards.
VA is not currently conducting any research on the topic, but VA leadership has expressed interest in learning from ongoing research outside the agency. Kansagara agrees that more research will help shed more light on the actual benefits and risks. "We don't have enough information to confidently answer [whether doctors should recommend cannabis] one way or the other," he says. "We certainly need better research."
In a May 31, 2017, White House press briefing, VA Secretary Dr. David J. Shulkin summed up VA's position on medical marijuana: "Federal law does not prevent us at VA to look at [medical marijuana] as an option for Veterans. I believe that everything that could help Veterans should be debated by Congress and by medical experts, and we will implement that law. ...And we're interested in looking at [existing medical marijuana research] and learning from that. But until the time that federal law changes, we are not able to prescribe medical marijuana."