The Veterans Health Research Institute - NCIRE · Assistant Commandant, ... is provided at community-based outpatient clinics in Santa Rosa, Eureka, ... The Veterans Health Research

www.ncire.org

Presented by NCIRE – The Veterans Health Research Institute

In cooperation with the San Francisco VA Medical Center, the University of California, San Francisco, and the

United States Department of Defense

The Veterans Health Research Institute

ncIRe

Third Annual Conference

June 17, 2010

The Commandant’s BallroomMarines’ Memorial Club & Hotel

San Francisco, California

20 10BRAIN

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On behalf of NCIRE – The Veterans Health Research Institute and the San Francisco VA Medical Center, it is with great pleasure that

Since our inaugural meeting in 2008, this conference has grown into the premier summit of extraordinary leaders and advocates from many institutions and fields of expertise, each one devoted to finding new solutions to post-traumatic stress, traumatic brain injury, and related neurological and psychological wounds of war. As the research nexus between the San Francisco VA and the University of California, San Francisco, NCIRE is privileged to be part of a unique collaboration between the Department of Veterans Affairs, the Department of Defense, academia, industry, and individuals. Today’s meeting is part of an ongoing, ever-expanding conversation among those who are dedicated to improving the health of our men and women who have served in uniform and their families.

During what is clearly a challenging time for advancing health care and the research that underpins it, we are extremely grateful for your participation as we endeavor to meet the needs of those who have sacrificed so much on our behalf.

Thank you for attending The Brain at War 2010.

Sincerely,

NCIRE – The Veterans Health Research Institute The Brain at War

Welcome

we welcome you to the third annual meeting of The Brain at War conference.

Robert E. Obana Executive Director

NCIRE

Lawrence H. CarrollDirector

San Francisco VA Medical Center

Table of Contents

Program 3

The Origins of The Brain at War 6

NCIRE’s Research Collaborators 7

San Francisco VA Medical Center 7

The University of California, San Francisco 7

United States Department of Defense 8

Neuroscience Center of Excellence 10

Center for Imaging of Neurodegenerative Diseases 11

PTSD Linked with Almost Double Dementia Risk 13

Stress-Affected Brain Region is Smaller in Veterans with PTSD 14

Investigators: Norbert Schuff, PhD and Thomas C. Neylan, MD 14

NCIRE Board of Directors 15


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NCIREThe Veterans Health Research Institute

Table of Contents

ProgramContinental Breakfast 7:30 – 8:00 am

8:00 am – 8:10 am WelcomeMajor General J. Michael Myatt, USMC (Ret.)President and CEO, Marines’ Memorial Association

8:10 am – 8:30 am Opening Remarks

• Colonel Karl E. Friedl, PhD Director, US Army Telemedicine & Advanced Technology Research Center • Brigadier General Loree K. Sutton, MD Director, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and (DCoE)

8:30 am – 9:15 am Keynote Address

General James F. Amos Assistant Commandant, United States Marine Corps

Traumatic Brain Injury: Clinical applications of latest research; integrative/holistic medicine treatments; readjustment/reintegration; continuity of care

9:15 am – 10:15 am • James P. Kelly, MA, MD, FAAN Director, National Intrepid Center of Excellence, DCoE • Nisha Money, MD, MPH, ABHM

Global Health & Integrative Medicine Specialist, US Military

• Fred Tittle, MDiv, Chaplain - USMC (Ret.) • Staff Sergeant Jay Wilkerson, US Army (Ret.) • Daniel Lim, MD, PhD, SFVAMC and UCSF (Moderator)

Break 10:15 - 10:30 am


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PROGRAM ONE

Program

Warrior Care on the Battlefield: Strategies for resilience and stress management in theater

10:30 am – 12:00 pm • Deployment Anxiety Reduction Training (DART) - Captain Daniel B. Michel, PhD, and Major Jennifer J. Hatzfeld, PhD, RN, David Grant Medical Center, USAF; Gerard Choucroun, MSW, NCIRE, and Shannon McCaslin, PhD, UCSF, SFVAMC, NCIRE

• Trauma Resiliency Model for Veterans and Warriors (TRM, V, W) – Elaine Miller-Karas, LCSW, Co-Founder and Co-Director, Trauma Resource Institute • Major Paul E. Gonzales, US Army National Guard Captain Lance Friis, Behavioral Health Outreach Liaison, Northern California, California National Guard • Thomas Neylan, MD, SFVAMC and UCSF (Moderator)

Lunch 12:00 – 12:30 pm

SPECIAL GUEST SPEAKER

12:30 pm – 1:15 pm Heidi Kraft, PhD Deputy Director, US Navy Combat Stress Control Program

Women Warriors: The unique challenges experienced by women in uniform in Iraq and Afghanistan – and by women Veterans after their service

1:15 pm – 2:15 pm ! • Staff Sergeant Megan Krause, US Army Reserve• Captain Rebecca Murga, US Army Reserve, 63rd Regional Support Command• Elizabeth Yano, PhD, MSPH, VA Greater Los Angeles Healthcare System and UCLA• Shira Maguen, PhD, SFVAMC and UCSF

(Moderator)


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PROGRAM TWO

PROGRAM THREE

Program

Break 2:15 - 2:30 pm

Coming Home: Warriors, their families, and communities deal with the effects of multiple deployments and the challenges of readjustment and reintegration into civilian life

2:30 pm – 3:45 pm • Joseph Bobrow, PhD, Founder & President, Coming Home Project

• Mary Dudum, California Statewide Collaborative – East Bay • Julie Hughes, DCoE • Chris Loverro, OIF Veteran • Lieutenant Colonel David D. Rabb, LICSW, ACSW, US Army Reserve, Director, Psychological Health, 63rd Regional Support Command (Moderator)

Writers’ Roundtable: Journalists’ perspectives on combat stress, neurological/psychological wounds of war, readjustment, and related issues

3:45 pm – 4:45 pm • James Dao, New York Times military and veterans affairs correspondent• Kimberly Dozier, Associated Press reporter and author of

• John Koopman, author of McCoy’s Marines: • Paul A. Volberding, MD, Chairman of the Board, NCIRE, Chief of Medical Service, SFVAMC, Professor and Vice Chair of Medicine, UCSF Co-Director, UCSF-GIVI Center for AIDS Research (Moderator)

4:45 pm - 5:00 pm Closing Comments

• Colonel Karl. E. Friedl, PhD• Brigadier General Loree K. Sutton, MD• Paul Volberding, MD


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PROGRAM FOUR

PROGRAM FIVE

Breathing the Fire

Darkside to Baghdad

Program

The Origins of The Brain at War

In 2006, as part of its role as the leading Veterans health research institute in the United States, NCIRE established the Neuroscience Center of Excellence, a Department of Defense/VA/NCIRE collaborative research center dedicated to advanced medical research of high relevance to active military and Veterans. Basic, clinical, and translational research projects are targeted at the imaging, diagnosis, treatment, prevention, and management of neuropsychiatric and neurological disorders such as PTSD, TBI, and associated neurocognitive consequences of war. As our colleagues in the Department of Defense have noted, the Neuroscience Center of Excellence has become a national resource for research in these fields.

Another aspect of the Neuroscience Center of Excellence is thought leadership. In 2008, NCIRE convened a group of leading researchers, healthcare providers, military representatives, policy makers, and others to create an environment for discussion and debate on the current and emerging health needs facing our military troops and Veterans and their families. With the participation of Veterans and leaders from the Department of Veterans Affairs, Department of Defense, academia, and


6The Origins of The Brain at War

on the brain. The Brain at War has quickly become the premiere gathering of its kind, drawing experts from around the United States.

industry, The Brain at War serves to advance our understanding of, and responses to, the neurological and psychological consequences of combat

NCIRE’s Research Collaborators San Francisco VA Medical Center

The San Francisco VA Medical Center (SFVAMC) has been a leader in health care for over 75 years, and is known as one of the most integrated, state-of-the-art acute medical, neurological, surgical, and psychological health care systems. SFVAMC is home to the largest medical research program in the national VA system, with more than 200 research scientists and clinicians, all of whom are faculty members at the University of California, San Francisco School of Medicine. The Medical Center has 124 operating beds and a 120-bed Community Living Center. Primary and mental health care is provided at community-based outpatient clinics in Santa Rosa, Eureka, Ukiah, and San Bruno, with a specialized homeless Veterans clinic located in downtown San Francisco. SFVAMC has National Centers of Excellence for Epilepsy Treatment, Cardiac Surgery, Post-Traumatic Stress Disorder, HIV, and Renal Dialysis, plus many other nationally-recognized research and clinical programs. In 2007, the OEF/OIF Integrated Care Clinic was created specifically to meet the health care needs of the newest generation of Veterans.

The University of California, San Francisco

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. One of the world’s premier health sciences universities, UCSF is San Francisco’s second-largest


7NCIRE’s Research Collaborators

employer, with an annual budget of $2.5 billion. UCSF Medical Center and UCSF Children’s Hospital rank among the top 10 hospitals in the United States; the UCSF Schools of Dentistry, Medicine, Nursing, Pharmacy, and Graduate Division all rank among the nation’s most prestigious advanced study programs in the health sciences; and UCSF schools are among the top institutional recipients of NIH research funding. Four UCSF faculty have won Nobel prizes; 42 are members of the National Academy of Sciences; 71 are members of the Institute of Medicine; and 17 are Howard Hughes Medical Institute investigators.


The United States Department of Defense (DoD) is a Cabinet-level organization that includes the uniformed services of the United States (Army, Air Force, Navy, and Marine Corps) and 15 defense agencies. Its mission is to provide the military forces needed to deter war and to protect the security of our country. As part of this mission, the health and well-being of its service members is a top priority. NCIRE partners with several organizations within the DoD to conduct advanced research in military medicine and Veterans health, including:

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)

DCoE assesses, validates, oversees, and facilitates prevention, resilience, identification, treatment, outreach, rehabilitation, and reintegration programs for psychological health (PH) and traumatic brain injury (TBI) to ensure that the DoD meets the needs of the nation's military communities, warriors and families. DCoE partners with the Department of Veterans Affairs, and a national network of military and civilian agencies, community leaders, advocacy groups, clinical experts, and academic institutions to establish best practices and quality standards for the treatment of PH and TBI. Its work is carried out across these major areas: clinical care; education and training; prevention; research; and patient, family, and community outreach. In addition, DCoE is working to tear down the stigma that still deters some from seeking psychological health care with its Real Warriors Campaign.



Military Operational Medicine Research Program (MOMRP)

The MOMRP provides biomedical solutions that protect Soldiers and enhance their performance in operational and training environments that include multiple stressors. Its core biomedical research capabilities are organized into thirteen areas ranging from environmental medicine and bioenergetics, injury sciences, and systems hazards to neuropsychological stress and performance. The MOMRP conducts collaborative research with university and commercial laboratories and other federal agencies oriented toward solving critical problems facing the Army today and in the future. Service- and platform-specific issues are addressed through close coordination with Navy and Air Force counterparts.

Telemedicine and Advanced Technologies Research Center (TATRC)

The Telemedicine & Advanced Technology Research Center (TATRC) performs medical reconnaissance and special operations to address critical gaps that are underrepresented in DoD medical research programs. TATRC is an office of the headquarters of the US Army Medical Research and Materiel Command (USAMRMC). TATRC fosters research on health informatics, telemedicine/m-Health, medical training systems, and computational biology, and promotes and manages science and engineering in other key portfolios. Through an extensive network of partners, TATRC is focused at both ends of the research spectrum, exploring models of high risk and innovative research, and putting research findings into the hands of warfighters while looking toward wider civilian utility. TATRC augments core medical research programs through special funding and partnership opportunities.



Neuroscience Center

of Excellence


10Neuroscience Center of Excellence

The Neuroscience Center of Excellence is a unique research partnership between the US Army Telemedicine and Advanced Technology Research Center (TATRC), Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), SFVAMC, and NCIRE. The Center was established to bring the Department of Veterans Affairs (VA), Department of Defense (DoD), academic, and industry resources together to build on NCIRE’s core research strengths in neuroimaging, neurotrauma, neuro-rehabilitation, psychological health, sleep and human performance, and telemedicine.

At the heart of the program is the SFVAMC Center for Imaging of Neurodegenerative Diseases (CIND), the only imaging center in the VA system dedicated exclusively to brain imaging.

The Neuroscience Center’s goal is to bring experts in individual specialties into focused alliances to hasten the development of the clinical services most crucial to the health and well being of warriors. This research program benefits from a comprehensive view of the entire life course of the warrior, from preparation and training, pre-deployment, and management of mental and physical stressors in the combat theater to recognition and treatment of post-deployment health concerns.

The Neuroscience Center of Excellence has become an exemplar of seamless inter-agency cooperation and collaboration, and a model for NCIRE’s collaborative partnerships.

Center for Imaging

of Neurodegenerative

Diseases


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The Center for Imaging of Neurodegenerative Diseases (CIND) at the SFVAMC was inaugurated on May 12, 2006. Located in historic Building 13 on the SFVAMC campus, CIND is a collaborative effort between the VA, the Department of Defense, the University of California, San Francisco, the National Institutes of Health, and NCIRE, which administers much of the funding for CIND researchers.

The Director of CIND is Michael Weiner, MD, who is also a professor of radiology, medicine, psychiatry, and neurology at the University of California, San Francisco.

Center for Imaging of Neurodegenerative Diseases


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The mission of CIND to research the causes, prevention, early detection, progression, and monitoring of neurodegenerative diseases, and to develop effective treatments for Alzheimer's disease, post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), Gulf cWar illness, Parkinson's disease, epilepsy, HIV dementia and other dementias, and other neurological conditions.

Brain images are obtained with magnetic resonance imaging (MRI) and other non-invasive, non-radioactive imaging technologies. At the heart of the CIND equipment array is 4.0 Tesla MRI instrument, the only one of its kind in the VA system, which is several times more powerful than conventional MRI devices. The Center features a 1.5 Tesla MRI instrument as well. Plans for acquiring new, state-of-the-art 3.0 Tesla and 7.0 Tesla machines have been approved by the VA and are under way.

CIND has a staff of more than 60 physicians, researchers, physicists, computer scientists, radiologists, technicians, and support personnel. With more than 35 research grants, over a dozen research projects, and a number of clinical trials under way, they are one of the most established and respected research groups in the world focusing on magnetic resonance imaging of neurodegenerative diseases.

Center for Imaging of Neurodegenerative Diseases

June 7, 2010

PTSD Linked with Almost Double Dementia RiskInvestigator: Kristine Yaffe, MDJournal: Archives of General Psychiatry


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Older Veterans with post-traumatic stress disorder were almost twice as likely to develop dementia as Veterans without PTSD, in a study of more than 180,000 Veterans led by Kristine Yaffe, MD, chief of geriatric psychiatry at SFVAMC and associate chair of research for psychiatry and professor of psychiatry, neurology, and epid-emiology and biostatistics at UCSF. The results were published in the June, 2010 issue of “Archives of General Psychiatry.”

“These findings are important because PTSD has become a common consequence of combat and exposure to trauma,” says Dr. Yaffe.

Using data from the Department of Veterans Affairs, the study authors analyzed the 1997-2000 records of 53,155 Veterans with PTSD and 127,938 without PTSD, and then followed the Veterans from 2001 to 2007. None were diagnosed as demented when the study began. Their average age was 68.8 years, and 97 percent were male. By 2007, Veterans with PTSD had a dementia rate of 10.6 percent, while those without had a dementia rate of 6.6 percent. The

PTSD patients had a 1.77 times greater risk of developing dementia after adjustment for other health problems.

“It is critical that we identify and understand the mechanisms linking these two disorders,” says Dr. Yaffe. “By doing so, we may be able to find ways to reduce the risk.”

An analysis by the US Army Tele-medicine and Advanced Technology Research Center (TATRC), which funded the research, notes that the findings speak to the importance of screening PTSD patients for cognitive problems as well as identifying and treating PTSD as early as possible in order to mitigate potential future problems.

Co-authors of the study are Eric Vittinghoff, PhD, of UCSF; Karla Lindquist, MS, Deborah E. Barnes, PhD, Kenneth E. Covinsky, MD, Thomas Neylan, MD, and Molly Kluse, BA, of SFVAMC and UCSF; and Charles Marmar, MD, of SFVAMC and UCSF at the time of the study. TATRC funds supporting the research were administered by NCIRE under the Neuroscience Center of Excellence.

Collaborative Research Spotlight


http://www.ncire.org/researchers_by_name.php?bio=67




March 1, 2010

Stress-Affected Brain Region is Smaller in Veterans with PTSDInvestigators: Norbert Schuff, PhD and Thomas C. Neylan, MDJournal: Archives of General Psychiatry


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The CA3/dentate gyrus region of the hippocampus – an area known to be affected by stress – was significantly smaller in Veterans with post-traumatic stress disorder than in those without, according to a study led by Norbert Schuff, PhD, a senior research scientist at the SFVAMC Center for Imaging of Neurodegenerative Diseases and professor of radiology at UCSF.

Just as significantly, the CA1 region of the hippocampus, which shrinks as a part of normal aging, was not significantly smaller in the Veterans with PTSD, according to Schuff, who used magnetic resonance imaging to scan the brains of 40 Veterans – 20 with combat-related PTSD and 20 without.

The study appeared in the March, 2010 issue of “Archives of General Psychiatry.”

“This is the first time in human subjects that PTSD has been shown to be associated with changes in certain specific hippocampal regions and not in others,” says Schuff.

He cautions that while the results are highly suggestive, they cannot yet be used by clinicians to identify individuals with PTSD. He emphasizes that the findings also need to be replicated independently.

“This is an incremental step toward establishing a physical biomarker for PTSD,” adds study author Thomas C. Neylan, MD, director of the PTSD program at SFVAMC and a professor of psychiatry at UCSF.

Co-authors of the study are Zhen Wang, MD, of Shanghai Mental Health Center, Shanghai, China and UCSF; Susanne G. Mueller, MD; Maryann Lenoci, MA, of SFVAMC and UCSF; Diana Truran, MS, of SFVAMC; Charles R. Marmar, MD, of SFVAMC and UCSF at the time of the study; and Michael W. Weiner, MD, of SFVAMC and UCSF.

The research was supported by funds from the US Department of Veterans Affairs, the US Department of Defense, and the National Institutes of Health, some of which were administered by NCIRE.


NCIRE Board of Directors

Paul A. Volberding, MDChairman of the Board, NCIREChief of Medical Service, SFVAMCProfessor and Vice Chair of Medicine, UCSFCo-Director, UCSF-GIVI Center for AIDS Research

Judy Yee, MDVice Chair of the Board, NCIREChief of Radiology Service, SFVAMCProfessor and Vice Chair of Radiologyand Biomedical Imaging, UCSF

John W. Bitoff, Rear Admiral, US Navy (Ret.)Executive Director, Facilities Maintenance and OperationsSan Francisco Unified School District

Lawrence H. CarrollMedical Center Director, SFVAMC

Steve Countouriotis, Lieutenant Colonel, US Army Reserve (Ret.)Chief, Emergency ServicesCommand Security OfficerUS Department of Homeland SecurityUnited States Coast Guard

Andrew P. Grose, Brigadier General US Air Force (Ret.)Retired Nonprofit Executive

J. Michael Myatt, Major General, US Marine Corps (Ret.)President and CEOMarines' Memorial Association


15NCIRE Board of Directors

Board of Directors – continued

Walter S. Newman, Major, US Army (Ret.)Community Leader

C. Diana Nicoll, MD, PhD, MPAChief of Staff, SFVAMCActing ACOS for Research and Development, SFVAMCChief, Laboratory Service, SFVAMCAssociate Dean, School of Medicine, UCSFProfessor and Vice Chair of Laboratory Medicine, UCSF

Stephen Peary, JD, LLMGeneral CounselFPX, LLC

Mark Ratcliffe, MDChief of Surgical Service, SFVAMCProfessor and Vice Chair of Surgery, UCSF

Raymond A. Swanson, MDChief of Neurology and Rehabilitation Service, SFVAMCProfessor and Vice Chair of Neurology, UCSF

Sophia Vinogradov, MDInterim Chief of Mental Health Service, SFVAMCProfessor and Interim Vice Chair of Psychiatry, UCSF

Keith R. Yamamoto, PhDExecutive Vice Dean, School of Medicine, UCSFProfessor of Cellular and Molecular Pharmacology, UCSF


16NCIRE Board of Directors

Advisors and Advisory StaffJudi A. ChearyDirector of Public Affairs, SFVAMC

John A. Kerner, MD, US Army Medical Corps (Ret.)Professor of Obstetrics and Gynecology Emeritus, UCSF

Lloyd Holly Smith, MDAssociate Dean, School of Medicine, UCSF Professor of Medicine, UCSF

William Seaman, MDStaff Physician, SFVAMC Professor of Medicine Emeritus, UCSF

Marvin Sleisinger, MDStaff Physician, SFVAMCProfessor of Medicine Emeritus, UCSF

Suzanne Will, JDRegional Counsel, Department of Veterans Affairs

Officers and Senior ManagementRobert E. ObanaCEO and Executive Director

Stephen MorangeChief Financial Officer

Gerard ChoucrounManager of On-Line Services

Robin L. MorjikianDirector of Development

Janet YokoyamaDirector of Human Resources


17NCIRE Advisors and Advisory Staff / Officers and Senior Management


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Deloitte is proud to be a sponsor of NCIRE’s The Brain at War symposium.

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With gratitude for generous support provided by our sponsors

Sponsors

Additional support generously provided by the Wells Fargo Foundation

WE THANK YOU FOR YOURSERVICE AND SACRIFICE.

REAL SUPPORT. REAL ADVANTAGE.www.baesystems.com

NCIREv2.indd 1 6/9/2010 5:02:16 PM


19Sponsors

NCIRE – The Veterans Health Research Institute

Salutes Major General J. Michael Myatt, USMC (Ret.)

and the dedicated staff of

Marines’ Memorial Association

For their support of The Brain at War


20

www.ncire.org

Presented by NCIRE – The Veterans Health Research Institute

In cooperation with the San Francisco VA Medical Center, the University of California, San Francisco, and the


The Veterans Health Research Institute

ncIRe

Third Annual Conference

June 17, 2010

The Commandant’s BallroomMarines’ Memorial Club & Hotel

San Francisco, California

20 10BRAIN

WAR

TH

E

at

Documents

The Veterans Health Research Institute - NCIRE · Assistant Commandant, ... is provided at community-based outpatient clinics in Santa Rosa, Eureka, ... The Veterans Health Research