Importance:The most recent US clinical practice guideline (CPG) for tinnitus was published in 2014. The US Department of Veterans Affairs (VA)/US Department of Defense Tinnitus Clinical Practice Guideline Work Group recently completed a new guideline. The work group consisted of experts across disciplines who were supported by the VA Office of Quality and Patient Safety and the Defense Health Agency Clinical Quality Improvement Program. This article summarizes the first VA/US Department of Defense CPG for tinnitus management. Methods and Observations:The guideline was based on a systematic review of clinical and epidemiological evidence. Rigorous methods determined the strength of the recommendations. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical associations between various care options and health outcomes while rating the quality of the evidence and strength of the recommendations for 20 questions focused on evaluating and managing care for adults with bothersome tinnitus. The guideline provides an evidence-based framework for evaluating and managing care for adults with bothersome tinnitus. Conclusions and Relevance:The CPG offers patients with tinnitus and clinicians an overview of evidence-based education and self-management, care options, and recommended outcome measures to monitor effectiveness and potentially improve patient health and well-being. Findings of a lack of sufficient evidence resulted from evaluating the quality of the body of evidence and emphasize the gaps in knowledge that need further study. Addressing these gaps may enable a comprehensive evaluation of the potential benefits and limitations of various tinnitus care options, ultimately improving patient care and clinical practice.

Abstract Introduction The VA Telesleep Enterprise Wide Initiative (EWI) operated from 2017 through 2023 and focused on increasing sleep medicine care to rural Veterans. Part of the Telesleep EWI was promotion of telehealth visits to improve access to sleep medicine care for rural Veterans. This report examines the significant growth of telesleep visits during the COVID-19 pandemic and the strong sustainment in Telesleep care in EWI sites post-pandemic. EWI sites participated in weekly clinical support meetings and best practices sharing to foster uptake and improvement of telesleep clinical work. Non EWI sites did not have access this support network. Methods Data regarding clinical visits for sleep medicine at a national level were obtained from the VA Corporate Data Warehouse by trained and experienced data analysts. Data from 2019 through fiscal year 2023 were obtained which spans the pre-pandemic to the post-pandemic time frame. The data were analyzed by medical center based on whether the site was part of the Telesleep EWI or not part of the EWI. In this report only rural Veterans were analyzed. Results From 2019 to 2023, for rural Veterans, the proportion of total sleep medicine visits performed using telehealth modalities increased from 25% to 56% for sites in the Telesleep EWI compared to 16% to 36% in the non EWI sites. Comparing Telesleep visits at the peak of pandemic in 2021-22 to post-pandemic 2023, Telesleep visits peaked at 61% and decreased to 56% in 2023 for the EWI sites and peaked at 52% and decreased to 36% in non EWI sites. Conclusion The COVID -19 pandemic resulted in rapid changes in healthcare delivery for many clinical services including sleep medicine. Post-COVID-19 many clinicians returned to previous care delivery models. In VA, where telesleep medicine virtual care was strongly supported in the EWI, sites showed greater sustainment of virtual care compared to non EWI sites. We speculate that ongoing support of clinicians through training and expert support in the EWI accounted for this better sustainment of virtual care. Support (if any) VA Office of Rural Health; VA Office of Connected Care; VA HSR&D Merit Review

OBJECTIVE:Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for tinnitus, although outcomes are highly variable. We previously described a multilocus sequential rTMS treatment protocol for tinnitus involving stimulation of both prefrontal and auditory targets. In this study, we report results using this approach in an open-label treatment study of tinnitus with and without comorbid major depressive disorder (MDD).MATERIALS AND METHODS:Forty patients with chronic tinnitus (mean age 56 years, ten female) and with (n = 17) or without (n = 23) MDD received multilocus rTMS administered sequentially to 1) left dorsolateral prefrontal cortex, followed by 2) auditory cortex (Heschel's gyrus). Patients completed weekly self-report ratings using the Tinnitus Functional Index (TFI) and Tinnitus Handicap Inventory, and patients with MDD completed the Inventory of Depressive Symptomatology Self-Report 30-item.RESULTS:Patients showed significant mean improvement in tinnitus at sessions 5 (mean TFI improvement 6.8 points ± 12.2, p = 0.002) and 10 (mean improvement 9.2 points ± 14.1, p = 0.002), with 48% of patients responding within ten treatment sessions. Responders were significantly older than nonresponders (61.5 ± 15 years vs 51.3 ± 16 years), and there was a trend toward decreased likelihood of response in subjects with comorbid MDD compared with subjects without comorbidity (odds ratio = 0.28, p = 0.06). Patients with comorbid MDD reported significantly less improvement after ten sessions than did those with tinnitus alone (4.3 ± 10.3 vs 14.7 ± 15.0 points, p = 0.04). Post hoc analyses suggested that the comorbid group achieved improvement comparable to that of the tinnitus-only group after 30 treatments.CONCLUSIONS:Patients showed significant improvement in tinnitus from multilocus sequential rTMS treatment, and those with tinnitus alone improved more quickly. Those with depression who continued rTMS through a full 30-session course further improved, indicating that tinnitus with comorbid MDD may respond with extended treatment.

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

Transcranial magnetic stimulation (TMS) has been investigated as a potential treatment for chronic tinnitus for 20 years. Numerous studies have reported that repetitive TMS (rTMS) has demonstrated efficacy for reducing the severity of tinnitus and its associated co-conditions such as depression, anxiety, and insomnia. However, some researchers have reported that active rTMS is no more effective than sham (placebo) rTMS as a tinnitus treatment method. There are numerous unresolved issues in this field that need to be addressed before rTMS can become a viable treatment for tinnitus. These issues include the type or brand of TMS system and its configuration; coil type, orientation, and placement method; scalp or neural target; laterality of rTMS application; dual site vs. single site stimulation; stimulation frequency and intensity; number of sessions; number of pulses per session; determination of the resting motor threshold (rMT); characteristics of the study population and their tinnitus; and outcome measures and follow-up assessments. To address and resolve these issues, large-scale, multi-site clinical trials of rTMS for tinnitus need to be conducted to determine which rTMS protocols are the most effective. In the absence of such investigations, the issues that need to be studied and addressed remain unresolved and continue to impede the clinical application of this treatment method.

BackgroundIn fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities.MethodsIn early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement.Results18 sites reported sustainment, while six were “on track.” Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.

Background:Methods for modulating the cerebellum with transcranial magnetic stimulation (TMS) are well established, and preliminary data from our group and others has shown evidence of transient improvements in balance after cerebellar repetitive transcranial magnetic stimulation (rTMS) in progressive suprancuclear palsy (PSP). This study examines extensive posturography measures before and after 10 sessions of cerebellar rTMS and sham TMS in PSP.Methods:Thirty subjects with PSP and postural instability will undergo cerebellar active and sham rTMS in a single-blind, crossover design with a randomized order of a 10-day intervention. Primary outcomes will be changes in sway area and medio-lateral range of sway with eyes open while standing on a stationary force-plate, and safety, tolerability, and blindedness. Secondary outcomes will include posturography and gait analysis with body-worn, triaxial inertial sensors, clinical balance scales and questionnaires, and a bedside test of vestibular function. Exploratory outcomes are changes in functional near infrared spectroscopy (fNIRS) signal over the prefrontal, supplementary motor, and primary motor cortices while standing and walking, and speech samples for future analysis.Discussion:The C-STIM crossover intervention study adds a longer duration of stimulation and extensive posturography measures to more finely measure the improvements in balance and exploratory functional near-infrared spectroscopy (fNIRS) over the prefronal, supplementary motor, and primary motor cortices during balance assessments before and after 10 sessions of cerebellar rTMS and 10 sessions of sham cerebellar TMS. This project will improve our understanding of the importance of the cerebellum for control of postural stability in PSP.

Background Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts’ intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers. Objective The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented. Design Retrospective, observational, utilizing administrative data. Subjects VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT). Main Measures Observed distance: distance between Veteran’s home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran’s home and nearest VA facility offering in-person equivalent of telehealth service. Key Results In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices. Conclusions Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

The Veterans Health Administration cares for many veterans with sleep disorders who live in rural areas. The Veterans Health Administration’s Office of Rural Health funded the TeleSleep Enterprise-Wide Initiative (EWI) to improve access to sleep care for rural veterans through creation of national telehealth networks. The TeleSleep EWI consists of (1) virtual synchronous care, (2) home sleep apnea testing, and (3) REVAMP (Remote Veterans Apnea Management Platform), a patient- and provider-facing web application that enabled veterans to actively engage with their sleep care and sleep care team. The TeleSleep EWI was designed as a hub-and-spoke model, where larger sites with established sleep centers care for smaller, rural sites with a shortage of providers. Structured formative evaluation for the TeleSleep EWI is supported by the Veterans Health Administration’s Quality Enhancement Research Initiative and was critical in assessing outcomes and effectiveness of the program. The TeleSleep EWI launched with 7 hubs and 34 spokes (2017) and rapidly expanded to 13 hubs and 63 spokes (2020). The TeleSleep EWI resulted in a significant increase in rural veterans accessing sleep care by utilizing home sleep apnea testing to establish a diagnosis of obstructive sleep apnea and virtual care for follow-up. Rates of virtual care utilization were greater in hubs and spokes participating in the TeleSleep EWI compared with non-EWI sleep programs. Additionally, veterans expressed satisfaction with their virtual care TeleSleep experiences. The TeleSleep EWI successfully increased sleep care access for rural veterans, promoted adoption of virtual care services, and resulted in high patient satisfaction.

PURPOSE:To describe and compare demographic characteristics and comorbidities of rural and urban Veterans diagnosed with sleep disorders, and to evaluate whether rurality is a disparity for sleep care among Veterans.METHODS:Numbers of Veterans with sleep disorders and comorbid conditions were determined using the Department of Veterans Affairs (VA's) Corporate Data Warehouse, a database that contains detailed clinical information for all Veterans who receive VA health care. Comparisons between urban and rural Veterans were conducted for fiscal years (FY) 2010-2021.FINDINGS:The prevalence of diagnosed sleep disorders was similar among rural and urban Veterans from FY2010 to 2021 and increased for both groups during this time period. The prevalence of chronic pulmonary disease, congestive heart failure, and diabetes mellitus was higher for rural Veterans with sleep disorders compared to their urban counterparts. From 2012 to 2021, the percentage of rural Veterans who received sleep care at VA facilities was lower than the percentage of urban Veterans who received VA sleep care during the same time span.CONCLUSIONS:Although rural Veterans exhibited a higher prevalence of 3 comorbid conditions associated with sleep disorders, the prevalence of sleep disorder diagnoses was similar between rural and urban Veterans. Therefore, it is possible that sleep disorders are underdiagnosed among rural Veterans. The fact that rural Veterans received VA sleep care at a lower rate compared to urban Veterans indicates that rurality is a disparity in access to care in this population. VA is addressing this disparity through a variety of programs, including telehealth initiatives.

PURPOSE Tinnitus is a highly prevalent condition that can severely reduce health functioning. In spite of extant clinical practice guidelines (CPGs), implementation of these CPGs is relatively uncommon. As a result, patients seeking professional services for tinnitus often have no assurance of receiving evidence-based care. The purpose of this tutorial was to clarify the evidence for sound therapy so that it may be included in future CPGs for tinnitus. METHOD "Best clinical evidence" is obtained from high-quality systematic reviews, which are generally considered the highest level of evidence. Our review of recent, comprehensive, high-quality systematic reviews of interventions for tinnitus concludes that cognitive behavioral therapy is the only effective intervention, though the strength of evidence was generally rated as low in these reviews. Although trials of sound therapy for tinnitus have been included in these reviews, they have been rated as having high risk of bias (RoB) and not included in syntheses or rated as insufficient strength of evidence. RESULTS Conclusions from these and other reviews have influenced recommendations made in CPGs for tinnitus. These conclusions, however, can make it appear that an intervention for tinnitus is not effective, even if the opposite is true. We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus. Ultimately, this process has resulted in many patients not receiving sound therapy, despite what should be sufficient evidence that this is an effective form of intervention. CONCLUSION If we rely on systematic reviews using contemporary RoB assessment criteria for studies published prior to these reporting guidelines, then we risk excluding important conclusions regarding interventions that could help patients in need.

Background Obstructive sleep apnea (OSA) is a very common and serious health condition which is highly prevalent among U.S. military Veterans. Because the demand for sleep medicine services often overwhelms the availability of such services, it is necessary to streamline diagnosis and treatment protocols. The goals of this study are to, (1) assess the efficacy of de-implementing the initial provider encounter for diagnosis and treatment of OSA; (2) determine the negative predictive value (NPV) of home sleep apnea testing (HSAT); (3) develop HSAT usage recommendations for various at-risk patient populations. Methods This is a large, pragmatic study that will take place in 3 VA sleep medicine programs: San Francisco, CA; Portland, OR; and Pittsburgh, PA. All Veterans referred for new sleep apnea evaluations at these sites will be included in this four-year study. Outcomes will include time from referral for OSA to sleep testing and treatment; positive airway pressure (PAP) treatment adherence measures; patient-reported clinical outcomes and measures of satisfaction; determination of the NPV of HSAT; HSAT usage recommendations for at-risk patient populations. Discussion The DREAM (Direct Referral for Apnea Monitoring) Project will inform sleep medicine providers and clinical organizations regarding strategies to streamline diagnosis and treatment protocols for OSA. Results of this study should have significant impact on clinical practices and professional guidelines. Trial registration The majority of this project is an observational study of clinical procedures. Therefore, clinical trial registration is not required.

Abstract Introduction Obstructive Sleep Apnea (OSA) is very prevalent in the Veterans Administrations (VA) clinical population, affecting about 24% of Veterans. Sleep medicine services in VA suffers from uneven distribution, which especially affects Veterans in rural populations, where care is often not available except by long distance travel. Travel burden is increasingly recognized as a burden on Veteran care that can be ameliorated by telemedicine. Little is known about travel burden and few attempts have been made to quantify it. We have attempted to quantify travel burden for rural Veterans using data from VA's Office of Rural Health supported Enterprise Wide Initiative for Telesleep Medicine. In this project we focus on travel from a Veteran's home to a facility-based sleep clinic visit (traditional face-face visit) vs. how much travel would be avoided if visits were performed using video-based telemedicine with the Veteran at his/her residence. Methods Purpose built geocoding software (validated in prior studies) was used to quantify the driving distance from the Veterans home zipcode to the zipcode of the facility where the visits would were performed. The data were taken from the VA's national corporate data warehouse (CDW). Over 4 million sleep encounters were coded. CPT4 codes were used to define the clinic visit encounters from 2016 through 2020. We set the travel range where telemedicine is reasonable based on distance at greater than 40 miles from the VA medical center which is how VA currently defines "distant travel". Results No. of Encounters (thous) 2016, 557; 2017, 623; 2018, 678; 2019, 667; 2020, 420Miles ObsTravel (mil) 2016, 38; 2017, 42; 2018, 45; 2019, 43; 2020, 27 Miles Travel if telemed used (mil) 2016, 25; 2017, 27; 2018, 29; 2019, 27: 2020, 17Difference (mil miles) 2016, 13; 2017, 15; 2018, 16; 2019, 16 2020, 10Between 10 and 16 million miles could be saved each year for sleep medicine visits if all travel > 40 miles was converted to video home visits. Conclusion Travel burden in this analysis, defined by miles driven to and from a sleep medicine encounter, could be dramatically reduced if telemedicine visits were used for sleep apnea evaluation and management. This reduction in travel equates to a reduction in automobile related use-costs, lower carbon footprint, fewer automobile crashes with injury and death. Assuming that clinical effectiveness of home telemedicine is comparable to traditional visits, these data support the vigorous adoption of telemedicine for sleep medicine services. Support (If Any) VA Office of Rural Health; Measurement QUERI, San Francisco VA Medical

Abstract Background The study examined follow-up rates for pursuing hearing health care (HHC) 6 to 8 months after participants self-administered one of three hearing screening methods: an automated method for testing of auditory sensitivity (AMTAS), a four-frequency pure-tone screener (FFS), or a digits-in-noise test (DIN), with and without the presentation of a 2-minute educational video about hearing. Purpose The study aims to determine if the type of self-administered hearing screening method (with or without an educational video) affects HHC follow-up rates. Research Design The study is a randomized controlled trial of three automated hearing screening methods, plus control group, with and without an educational video. The control group completed questionnaires and provided follow-up data but did not undergo a hearing screening test. Study Sample The study sample includes 1,665 participants (mean age 50.8 years; 935 males) at two VA Medical Centers and at university and community centers in Portland, OR; Bay Pines, FL; Minneapolis, MN; Mauston, WI; and Columbus, OH. Data Collection and Analysis HHC follow-up data at 6 to 8 months were obtained by contacting participants by phone or mail. Screening methods and participant characteristics were compared in relation to the probability of participants pursuing HHC during the follow-up period. Results The 2-minute educational video did not have a significant effect on HHC follow-up rates. When all participants who provided follow-up data are considered (n = 1012), the FFS was the only test that resulted in a significantly greater percentage of HHC follow-up (24.6%) compared with the control group (16.8%); p = 0.03. However, for participants who failed a hearing screening (n = 467), follow-up results for all screening methods were significantly greater than for controls. The FFS resulted in a greater probability for HHC follow-up overall than the other two screening methods. Moreover, veterans had higher follow-up rates for all screening methods than non-veterans. Conclusion The FFS resulted in a greater HHC follow-up rate compared with the other screening methods. This self-administered test may be more motivational for HHC follow-up because participants who fail the screening are aware of sounds they could not hear which does not occur with adaptive assessments like AMTAS or the DIN test. It is likely that access to and reduced personal cost of audiological services for veterans contributed to higher HHC follow-up rates in this group compared with non-veteran participants.

Abstract Introduction Rurality is a known contributor to health disparities, including Sleep medicine. Over 1 million (>350,000 rural, >650,000 non-rural) Veterans who received care from VHA in 2020 have obstructive sleep apnea (OSA). VHA’s Office of Rural Health (ORH) TeleSleep Program (FY17-20) aimed to increase access to sleep care for rural veterans by establishing telehealth services at 12 hubs and 63 spokes across the country. The TeleSleep program has three components: (1) Telemedicine; (2) Home Sleep Apnea Testing (HSAT); and (3) REVAMP (Remote Veterans Apnea Management Platform), a web-application for comprehensive sleep apnea care. Methods Each of the three TeleSleep components was evaluated independently using specific metrics. We report here on the impact of leveraging telemedicine to improve access to sleep care. Patient care encounters are defined by VA-specific stop codes and are thus identifiable as telehealth or in-person visits. Data used in the evaluation were obtained from the VA Corporate Data Warehouse. Results During FY20, 33,743 rural Veterans had 74,458 sleep encounters within the TeleSleep network. Visits included in-person care, virtual initial and follow up visits, electronic consultations, asynchronous telehealth (remote monitoring of PAP data and HSAT), remote PAP initiation by video or phone, and email exchanges between patients and providers. Between FY17-20, the number of rural Veterans seen for sleep-related disorders at TeleSleep sites tripled (from 10,702 to 33,743), and the number of encounters for sleep-related disorders more than doubled (from 32,894 to 74,458). In FY20, 72% (up from 53% in FY18) of rural Veterans at the TeleSleep hubs or spokes had at least one virtual sleep visit. This was significantly higher than non-TeleSleep VA sites where only 64% of rural Veterans had virtual visits (72% vs. 64%; p<0.001). In addition, the proportion of Veterans who had face-to-face only visits (28% at TeleSleep sites vs. 36% at non-TeleSleep sites; p<0.001) indicates that the TeleSleep program was highly successful in promoting virtual (instead of face-to-face) visits. Conclusion The ORH TeleSleep Program has improved access to comprehensive sleep care for rural Veterans by increasing the proportion and type of sleep visits conducted virtually vs. in person. Support (if any) Funding provided by VHA Office of Rural Health

Study Objective Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disorder affecting US military Veterans. The Remote Veterans Apnea Management Platform (REVAMP) is a web-based OSA management program created to improve access to care. REVAMP was launched within the Veterans Health Administration (VHA) in July 2017, with variable patient recruitment rates (from 0 to 573 patients per site) at the first 10 Veterans Affairs (VA) medical centers (Wave-1 sites). This study aimed to examine the contextual circumstances surrounding the implementation of REVAMP from the provider perspective to inform strategies to increase its uptake at future rollout sites. Methods A purposive sample of REVAMP site leaders from the Wave-1 sites was recruited with additional staff members being solicited as well. Semi-structured interviews were conducted. Two independent coders reviewed individual transcripts using content analysis to identify emerging themes. Results Fifteen individuals from Wave-1 sites were interviewed. Implementation of REVAMP was facilitated by the presence of leadership support, staff, and time dedicated to REVAMP, and perceived usefulness of REVAMP by staff as well as positive feedback from the Veterans using REVAMP. The difficulty of supporting Veteran creation of login credentials to the program and integrating REVAMP into the existing workflow were major barriers to its implementation. Conclusion Improving leadership engagement, simplifying the enrollment process, and enhancing the medical staff experience through shared best practice alerts were identified as actions needed to improve the penetration of REVAMP at future rollout sites.

Background Parkinson's disease (PD) patients are at increased risk for central auditory processing (CAP) deficits and cognitive dysfunction. However, behavioral assessments of CAP and cognitive processing used in a previous study by our research team found few significant differences in performance between early-stage PD patients and age-matched control subjects. The objective of this study is to use auditory event-related potentials (AERPs) to compare CAP and cognitive functions in a population of PD patients with a group of age-matched control subjects. Methods AERPs in response to tonal and speech stimuli were recorded from 35 adults who had a medical diagnosis of PD (23 males and 12 females; mean age = 66.9 ± s.d.11.2 years), and 35 age-matched control subjects who did not have PD or any other neurological disorders (31 males and 4 females; mean age = 65.4 ± s.d.12.3 years). Auditory stimuli included pure tones (500 and 1000 Hz) to elicit the P300 response and a dichotic digits paradigm to elicit the N200 processing negativity. Results Compared to control subjects, PD patients exhibited significantly longer latencies of P300 and N200 components and smaller amplitude N200 components. Latency and amplitude of the N200 component were significantly correlated with participants' age. N200 amplitude was correlated with results from the Rey Auditory Verbal Learning Test (RAVLT) of cognitive ability. Latency of the P300 and amplitude of the N200 components were significantly correlated with results from the Spatial Release From Masking (SRM) behavioral CAP assessment. Conclusions AERP assessments used in this study appear to be sensitive indicators of CAP and cognitive deficits exhibited by early-stage PD patients. While few significant differences in performance on behavioral CAP and cognitive tests were previously observed between this population of PD patients and age-matched control subjects, N200 and P300 components recorded in the present study revealed impaired neural processing by the PD group.

ObjectivesTranslingual neurostimulation (TLNS) studies indicate improved outcomes in neurodegenerative disease or spinal cord injury patients. This study was designed to assess the safety and efficacy of TLNS plus targeted physical therapy (PT) in people with a chronic balance deficit after mild-to-moderate traumatic brain injury (mmTBI).Materials and MethodsThis international, multicenter, randomized study enrolled 122 participants with a chronic balance deficit who had undergone PT following an mmTBI and had plateaued in recovery. Randomized participants received PT plus either high-frequency pulse (HFP; n = 59) or low-frequency pulse (LFP; n = 63) TLNS. The primary efficacy and safety endpoints were the proportion of sensory organization test (SOT) responders (SOT composite score improvement of ≥15 points) and fall frequency after five weeks of treatment, respectively.ResultsThe proportion of SOT responders was significant in the HFP + PT (71.2%) and LFP + PT (63.5%) groups compared with baseline (p < 0.0005). For the pooled population, the SOT responder rate was 67.2% (p < 0.00005), and there were clinically and statistically significant improvements in SOT composite scores after two and five weeks (p < 0.0005). Both groups had reductions in falls and headache disability index scores. Mean dynamic gait index scores in both groups also significantly increased from baseline at weeks 2 and 5.ConclusionsSignificant improvements in balance and gait, in addition to headaches, sleep quality, and fall frequency, were observed with TLNS plus targeted PT; in participants who had a chronic balance deficit following an mmTBI and had plateaued on prior conventional physiotherapy.

The prevalence of diagnosed sleep disorders among Veterans treated at Veterans Affairs (VA) medical facilities increased significantly during fiscal years (FY) 2012 through 2018. Specifically, the prevalence of sleep-related breathing disorders (SRBD) increased from 5.5% in FY2012 to 22.2% in FY2018, and the prevalence of insomnia diagnoses increased from 7.4% in FY2012 to 11.8% in FY2018. Consequently, Veterans' demand for sleep medicine services also increased significantly between FY2012-2018, with steady increases in the annual number of VA sleep clinic appointments during this period (<250,000 in FY 2012; >720,000 in FY2018). Common co-morbid conditions among Veterans diagnosed with sleep disorders include obesity, diabetes, congestive heart failure, depression, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). To address this healthcare crisis, the Veterans Health Administration (VHA) developed and/or implemented numerous innovations to improve the quality and accessibility of sleep care services for Veterans. These innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans’ access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and CBT-i Coach; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.