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Gaffey AE, Chang TE, Brandt CA, Haskell SG, Dhruva SS, Bastian LA, Levine A, Skanderson M, Burg MM. Blood Pressure Control and Maintenance in a Prospective Cohort of Younger Veterans: Roles of Sex, Race, Ethnicity, and Social Determinants of Health. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.22.24306203. [PMID: 38712220 PMCID: PMC11071551 DOI: 10.1101/2024.04.22.24306203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Proactive blood pressure (BP) management is particularly beneficial for younger Veterans, who have a greater prevalence and earlier onset of cardiovascular disease than non-Veterans. It is unknown what proportion of younger Veterans achieve and maintain BP control after hypertension onset and if BP control differs by demographics and social deprivation. Methods Electronic health records were merged from Veterans who enrolled in VA care 10/1/2001-9/30/2017 and met criteria for hypertension - first diagnosis or antihypertensive fill. BP control (140/90 mmHg), was estimated 1, 2, and 5 years post-hypertension documentation, and characterized by sex, race, and ethnicity. Adjusted logistic regressions assessed likelihood of BP control by these demographics and with the Social Deprivation Index (SDI). Results Overall, 17% patients met criteria for hypertension (n=198,367; 11% of women, median age 41). One year later, 59% of men and 65% of women achieved BP control. After adjustment, women had a 72% greater odds of BP control than men, with minimal change over 5 years. Black adults had a 22% lower odds of BP control than White adults. SDI did not significantly change these results. Conclusions In the largest study of hypertension in younger Veterans, 41% of men and 35% of women did not have BP control after 1 year, and BP control was consistently better for women through 5 years. Thus, the first year of hypertension management portends future, long-term BP control. As social deprivation did not affect BP control, the VA system may protect against disadvantages observed in the general U.S. population.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine)
| | - Tiffany E. Chang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, West Haven, CT
- Department of Biostatistics, Yale School of Medicine
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale School of Medicine
| | - Sanket S. Dhruva
- San Francisco Veterans Affairs Health Care System, San Francisco, CA
- Section of Cardiology, Department of Medicine, UCSF School of Medicine
| | - Lori A. Bastian
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale School of Medicine
| | | | | | - Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine)
- Department of Anesthesiology, Yale School of Medicine
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Kim K, Crook J, Lu CC, Nyman H, Abdelaziz A, LaFleur J. Epidemiology of Diabetic Kidney Disease among US Veterans. Diabetes Metab Syndr Obes 2024; 17:1585-1596. [PMID: 38616990 PMCID: PMC11011711 DOI: 10.2147/dmso.s450370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/15/2024] [Indexed: 04/16/2024] Open
Abstract
Rationale With a large number of patients and high mortality, diabetic kidney disease (DKD) imposes a significant burden on US health care. Although diabetes is the leading cause of chronic kidney disease and complications, the epidemiology of DKD in the contemporary US veteran population is generally unknown. Objective We aimed to estimate the rate of DKD progression and to measure the general epidemiology of DKD in the United States veteran population. Study Design We performed a retrospective observational research using electronic health-care records and administrative databases. Setting The DKD patient cohort was abstracted from the Veterans Health Administration health-record data from January 2016 to March 2022. Participants We defined DKD patients using the laboratory test data based on Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines. Analytic Approach Summary statistics include the five-year cumulative incidence of progression to an advanced stage from the DKD stage at the cohort entry date and prevalence at a series of single time points. Results A total of 685,288 patients (male [96%], mean age 62 years, Caucasian [64%], non-Hispanic [87%]) met our eligibility criteria. The 5-year cumulative incidence of progression to an advanced DKD stage or all-cause death from DKD stages G1 A2/A3, G2 A2/A3, G3a, and G3b were 52.0%, 47.4%, 50.5%, and 60.9%, respectively. In sum, 594,082 patients were classified as moderate or high risk as per KDIGO guidelines in 2021, and stages G3a and G3b accounted for 51.2% and 25.3%, respectively, of cases. Conclusion More than half of DKD patients underwent a stage progression or death within 5 years. A substantial number of DKD patients at an earlier stage might be left undetermined. The study findings warrant a revision of DKD patient identification and management in US veterans.
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Affiliation(s)
- Kibum Kim
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob Crook
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Chao-Chin Lu
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Heather Nyman
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Abdullah Abdelaziz
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, USA
| | - Joanne LaFleur
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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3
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Turnquist BE, MacIver PH, Katzel LI, Waldstein SR. Interactive Relations of Body Mass Index, Cardiorespiratory Fitness, and Sex to Cognitive Function in Older Adults. Arch Clin Neuropsychol 2024:acae018. [PMID: 38486431 DOI: 10.1093/arclin/acae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 01/29/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE The course of cognitive aging is influenced by multiple health factors. This cross-sectional study investigated the interactive relations between body mass index (BMI), maximum oxygen consumption (VO2max), and sex on neuropsychological outcomes in community-dwelling predominantly older adults. METHODS Participants were 164 healthy adults [M (SD) = 64.6 (12.5) years, 56% men, 87% white] who participated in an investigation of cardiovascular risk factors and brain health. Multivariable regression analysis, adjusted for age, education, ethnicity, smoking, alcohol consumption, and depression, examined the interactive relations of BMI, VO2max, and sex to multiple neuropsychological outcomes. RESULTS Significant BMI*VO2max*sex interactions for Grooved Pegboard dominant (p = .019) and nondominant (p = .005) hands revealed that men with lower VO2max (l/min) displayed worse performance with each hand as BMI increased (p's < .02). A significant BMI*sex interaction for Logical Memory-Delayed Recall (p = .036) (after adjustment for blood glucose) showed that men, but not women, with higher BMI demonstrated worse performance (p = .036). Lastly, significant main effects indicated that lower VO2max was related to poorer logical memory, and higher BMI was associated with poorer Trail Making B and Stroop interference scores (p's < .05). CONCLUSIONS Among men, higher cardiorespiratory fitness may protect against the negative impact of greater BMI on manual dexterity and motor speed, making VO2max a target for intervention. Higher BMI is further associated with poorer executive function and verbal memory (in men), and lower VO2max is associated with poorer verbal memory.
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Affiliation(s)
- B Eric Turnquist
- Department of Psychology, University of Maryland, Baltimore, MD, USA
- Department of Psychology, American University, Washington, DC, USA
| | - Peter H MacIver
- Department of Psychology, University of Maryland, Baltimore, MD, USA
| | - Leslie I Katzel
- Division of Gerontology, Geriatrics and Palliative Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Geriatric Research Education and Clinical Center, Baltimore VA Medical Center, Baltimore, MD, USA
| | - Shari R Waldstein
- Department of Psychology, University of Maryland, Baltimore, MD, USA
- Division of Gerontology, Geriatrics and Palliative Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Marmuse A, Billaud JB, Jacob S, Vigier C, Ramdani C, Trousselard M. 'Hidden' anger as a risk factor for operational health: An exploratory approach among French military personnel. MILITARY PSYCHOLOGY 2024:1-11. [PMID: 38436979 DOI: 10.1080/08995605.2024.2324645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
Military personnel are repeatedly exposed to multiple stressors, and are sometimes characterized by high levels of anger. Evidence suggests that this anger can become dysfunctional, and impact the health status of populations chronically exposed to stress. In particular, rumination (understood as perseverative thoughts about a past event), provides a theoretical framework for investigating how anger may impact stress regulation abilities in military personnel declared fit for deployment. This exploratory study aimed therefore to examine the impact of the anger profile on psychological suffering in terms of burnout and post-traumatic stress disorder (PTSD), along with the reactivity of the autonomic nervous system, measured as cardiac variability. One hundred and seventeen French soldiers were tested before deployment to Operation BARKHANE. Anger rumination, burnout, and PTSD symptoms were assessed using questionnaires, and cardiac variability was measured as the questionnaires were completed. The results revealed two profiles related to anger trait and anger rumination. Burnout and PTSD scores were higher among military personnel with high levels of anger trait and rumination, and this group also had lower parasympathetic activity and flexibility after completing the questionnaires. These results suggest that there may be a link between an angry profile and psychological suffering, notably burnout and PTSD. Rumination could be involved in this link, as it is associated with poor adaptation to stress in a military context. Prospective researches including post-deployment will establish whether this ruminative response can account for the relationship between problematic anger, stress regulatory capacities and psychological health in military populations.
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Affiliation(s)
- Anaïs Marmuse
- 9th Army Medical Center, Army Health Service, Draguignan, France
- INSPIIRE, University of Lorraine, Metz Cedex, France
| | - Jean-Baptiste Billaud
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Sandrine Jacob
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Cécile Vigier
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Céline Ramdani
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Marion Trousselard
- INSPIIRE, University of Lorraine, Metz Cedex, France
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
- French Military Health Service Academy, Paris, France
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Nackeeran S, Zucker I, Efimenko I, Weber A, Brown SC, Ramasamy R, Masterson T. Diagnosis and treatment patterns of Peyronie's disease among different racial, ethnic, and regional groups in the Veterans Affairs healthcare system. Int J Impot Res 2023; 35:706-711. [PMID: 36151319 DOI: 10.1038/s41443-022-00615-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/28/2022] [Accepted: 09/07/2022] [Indexed: 11/09/2022]
Abstract
Peyronie's Disease, which is known to have racial/ethnic disparities in the general population, has never been studied in the veteran population. We compared the diagnosis and treatment rates for Peyronie's Disease among United States veterans of various racial-ethnic backgrounds at Veterans Affairs medical centers, which are equal-access systems. We queried the Veterans Affair Informatics and Computing Infrastructure to identify 17,647 Peyronie's Disease patients in the United States by ICD-9 or ICD-10 code between 2015-2020. We assessed demographic characteristics, clinical characteristics, Veterans Affairs facility information, and treatment patterns. Racial-ethnic demographics of veterans with Peyronie's Disease were 71.4% White, 15.4% Black, 5.8% Hispanic, 1.6% Native American, 0.3% Asian, and 5.4% unknown. Treatment rate was 13.6% overall, 13.6% of Whites (ref), 14.3% of Blacks (p = 0.2985), 13.5% of Hispanics (p = 0.9205), 9.1% of Asians (p = 0.3319), 16.7% of Native Americans (p = 0.1406), and 9.6% of unknown (p = 0.0041). White patients were more likely to receive injectional therapy and less likely to undergo surgery than Black patients. Peyronie's Disease patients at Veterans Affairs facilities are treated at the same rate, indicating that equal-access healthcare systems may mitigate racial-ethnic disparities. Further research is necessary to account for differences in disease severity and Veterans Affairs surgeon availability.
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Affiliation(s)
- Sirpi Nackeeran
- University of Miami, Miller School of Medicine, Miami, FL, USA.
| | - Isaac Zucker
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Iakov Efimenko
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Alexander Weber
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Scott C Brown
- Department of Public Health Services, University of Miami, Miami, FL, USA
| | - Ranjith Ramasamy
- Desai Sethi Urology Institute, University of Miami, Miami, FL, USA
| | - Thomas Masterson
- Desai Sethi Urology Institute, University of Miami, Miami, FL, USA
- Department of Surgery, Bruce W. Carter VA Medical Center, Miami, FL, USA
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6
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Betancourt JA, Dolezel DM, Shanmugam R, Pacheco GJ, Stigler Granados P, Fulton LV. The Health Status of the US Veterans: A Longitudinal Analysis of Surveillance Data Prior to and during the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:2049. [PMID: 37510490 PMCID: PMC10378995 DOI: 10.3390/healthcare11142049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023] Open
Abstract
Chronic diseases affect a disproportionate number of United States (US) veterans, causing significant long-term health issues and affecting entitlement spending. This longitudinal study examined the health status of US veterans as compared to non-veterans pre- and post-COVID-19, utilizing the annual Center for Disease Control and Prevention (CDC) behavioral risk factor surveillance system (BRFSS) survey data. Age-adjusted descriptive point estimates were generated independently for 2003 through 2021, while complex weighted panel data were generated from 2011 and onward. General linear modeling revealed that the average US veteran reports a higher prevalence of disease conditions except for mental health disorders when compared to a non-veteran. These findings were consistent with both pre- and post-COVID-19; however, both groups reported a higher prevalence of mental health issues during the pandemic years. The findings suggest that there have been no improvements in reducing veteran comorbidities to non-veteran levels and that COVID-19 adversely affected the mental health of both populations.
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Affiliation(s)
- Jose A Betancourt
- School of Health Administration, Texas State University, San Marcos, TX 78666, USA
| | - Diane M Dolezel
- Department of Health Information Management, Texas State University, Round Rock, TX 78665, USA
| | - Ramalingam Shanmugam
- School of Health Administration, Texas State University, San Marcos, TX 78666, USA
| | - Gerardo J Pacheco
- School of Health Administration, Texas State University, San Marcos, TX 78666, USA
| | | | - Lawrence V Fulton
- Woods College of Advancing Studies, Boston College, Chestnut Hill, MA 02467, USA
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Raza Z, Hussain SF, Foster VS, Wall J, Coffey PJ, Martin JF, Gomes RSM. Exposure to war and conflict: The individual and inherited epigenetic effects on health, with a focus on post-traumatic stress disorder. FRONTIERS IN EPIDEMIOLOGY 2023; 3:1066158. [PMID: 38455905 PMCID: PMC10910933 DOI: 10.3389/fepid.2023.1066158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/03/2023] [Indexed: 03/09/2024]
Abstract
War and conflict are global phenomena, identified as stress-inducing triggers for epigenetic modifications. In this state-of-the-science narrative review based on systematic principles, we summarise existing data to explore the outcomes of these exposures especially in veterans and show that they may result in an increased likelihood of developing gastrointestinal, auditory, metabolic and circadian issues, as well as post-traumatic stress disorder (PTSD). We also note that, despite a potential "healthy soldier effect", both veterans and civilians with PTSD exhibit the altered DNA methylation status in hypothalamic-pituitary-adrenal (HPA) axis regulatory genes such as NR3C1. Genes associated with sleep (PAX8; LHX1) are seen to be differentially methylated in veterans. A limited number of studies also revealed hereditary effects of war exposure across groups: decreased cortisol levels and a heightened (sex-linked) mortality risk in offspring. Future large-scale studies further identifying the heritable risks of war, as well as any potential differences between military and civilian populations, would be valuable to inform future healthcare directives.
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Affiliation(s)
- Zara Raza
- Research & Innovation, Blind Veterans UK, London, United Kingdom
- BRAVO VICTOR, Research & Innovation, London, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | - Syeda F Hussain
- Research & Innovation, Blind Veterans UK, London, United Kingdom
- BRAVO VICTOR, Research & Innovation, London, United Kingdom
| | - Victoria S Foster
- Research & Innovation, Blind Veterans UK, London, United Kingdom
- BRAVO VICTOR, Research & Innovation, London, United Kingdom
- St George's Hospital Medical School, London, United Kingdom
| | - Joseph Wall
- Hull York Medical School, University of York, York, United Kingdom
- Haxby Group Hull, General Practice Surgery, Hull, United Kingdom
| | - Peter J Coffey
- Development, Ageing and Disease, UCL Institute of Ophthalmology, University College London, London, United Kingdom
| | - John F Martin
- Centre for Cardiovascular Biology and Medicine, University College London, London, United Kingdom
| | - Renata S M Gomes
- Research & Innovation, Blind Veterans UK, London, United Kingdom
- BRAVO VICTOR, Research & Innovation, London, United Kingdom
- Northern Hub for Veterans and Military Families Research, Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
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Obesity in Latinx and White U.S. military veterans: prevalence, physical health, and functioning. J Psychiatr Res 2022; 155:163-170. [PMID: 36030571 DOI: 10.1016/j.jpsychires.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE While Latinx Americans in the general population are more likely to have obesity than non-Hispanic Whites, limited research has examined ethnic differences in obesity and its correlates among military veterans. To address this gap, we examined the prevalence, physical health and functional correlates of obesity in a population-based sample of Latinx and White U.S. military veterans. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of veterans. Bivariate and multivariate analyses were conducted to evaluate the relation between obesity, and health and functioning measures in Latinx and White veterans. RESULTS The prevalence of obesity was significantly higher among Latinx veterans (weighted 43.6% vs. 35.5%; odds ratio (OR) = 1.4, 95% confidence interval (CI) = 1.10-1.81). While obesity was associated with a greater number of medical conditions, reduced functioning, higher somatic symptoms, and insomnia severity in both Latinx and White veterans, these differences were more pronounced in Latinx relative to White veterans, with higher rates of arthritis, liver disease, diabetes, high blood pressure and cholesterol, heart attack, stroke, migraine, and physical disability, and greater physical, mental, and psychosocial dysfunction. CONCLUSION Obesity is more prevalent in Latinx than in White U.S. veterans, and the associated elevated health and functional impairments are more pronounced in Latinx veterans. Characterization of co-occurring physical and functioning problems among Latinx and White veterans with obesity may help inform ethnically-sensitive obesity prevention and treatment efforts in this population.
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Sun L, Candelieri-Surette D, Anglin-Foote T, Lynch JA, Maxwell KN, D’Avella C, Singh A, Aakhus E, Cohen RB, Brody RM. Cetuximab-Based vs Carboplatin-Based Chemoradiotherapy for Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2022; 148:1022-1028. [PMID: 36136306 PMCID: PMC9501776 DOI: 10.1001/jamaoto.2022.2791] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/28/2022] [Indexed: 12/13/2022]
Abstract
Importance Cetuximab-based and carboplatin-based chemoradiotherapy (CRT) are often used for patients with locally advanced head and neck cancer who are ineligible for cisplatin. There are no prospective head-to-head data comparing cetuximab-based and carboplatin-based regimens for radiosensitization. Objective To compare survival with cetuximab-based and carboplatin-based CRT in locally advanced head and neck squamous cell carcinoma (HNSCC). Design, Setting, and Participants This cohort study included US veterans who received a diagnosis of HNSCC between January 2006 and December 2020 and were treated with systemic therapy and radiation. Data cutoff was March 1, 2022 and data analysis was conducted from April-May 2022. Exposures Cisplatin, cetuximab, or carboplatin-based systemic therapy as captured in VA medication data and cancer registry. Main Outcomes and Measures Overall survival by systemic therapy was estimated using Kaplan-Meier methods. We used propensity score and inverse probability weighting to achieve covariate balance between cetuximab-treated and carboplatin-treated patients and used Cox regression to estimate cause-specific hazard ratios of death associated with carboplatin vs cetuximab. We also performed subgroup analyses of patients with oropharynx vs nonoropharynx primary sites. Results A total of 8290 patients (median [IQR] age, 63 [58-68] years; 8201 men [98.9%]; 1225 [15.8%] Black or African American and 6424 [82.6%] White individuals) with nonmetastatic HNSCC were treated with CRT with cisplatin (5566 [67%]), carboplatin (1231 [15%]), or cetuximab (1493 [18%]). Compared with cisplatin-treated patients, patients treated with carboplatin and cetuximab were older with worse performance status scores and higher comorbidity burden. Median (IQR) overall survival was 74.4 (22.3-162.2) months in patients treated with cisplatin radiotherapy (RT), 43.4 (15.3-123.8) months in patients treated with carboplatin RT, and 31.1 (12.4-87.8) months in patients treated with cetuximab RT. After propensity score and inverse probability weighting, carboplatin was associated with improved overall survival compared with cetuximab (cause-specific hazard ratio, 0.85; 95% CI, 0.78-0.93; P = .001). This difference was prominent in the oropharynx subgroup. Conclusions and Relevance In this cohort study of a US veteran population with HNSCC undergoing treatment with CRT, almost a third of patients were ineligible to receive treatment with cisplatin and received cetuximab-based or carboplatin-based radiosensitization. After propensity score matching, carboplatin-based systemic therapy was associated with 15% improvement in overall survival compared with cetuximab, suggesting that carboplatin may be the preferred radiosensitizer, particularly in oropharynx cancers.
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Affiliation(s)
- Lova Sun
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Tori Anglin-Foote
- VA Salt Lake City Health Care System, University of Utah, Salt Lake City
| | - Julie A. Lynch
- VA Salt Lake City Health Care System, University of Utah, Salt Lake City
- Division of Epidemiology, School of Medicine, University of Utah, Salt Lake City
| | - Kara N. Maxwell
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Christopher D’Avella
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Aditi Singh
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Erin Aakhus
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Roger B. Cohen
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert M. Brody
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Otorhinolaryngology–Head & Neck Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Vallejo-Zamora JA, Vega-Cantu YI, Rodriguez C, Cordell GA, Rodriguez-Garcia A. Drug-Eluting, Bioresorbable Cardiovascular Stents─Challenges and Perspectives. ACS APPLIED BIO MATERIALS 2022; 5:4701-4717. [PMID: 36150217 DOI: 10.1021/acsabm.2c00551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Globally, the leading causes of natural death are attributed to coronary heart disease and type 1 and type 2 diabetes. High blood pressure levels, high cholesterol levels, smoking, and poor eating habits lead to the agglomeration of plaque in the arteries, reducing the blood flow. The implantation of devices used to unclog vessels, known as stents, sometimes results in a lack of irrigation due to the excessive proliferation of endothelial tissue within the blood vessels and is known as restenosis. The use of drug-eluting stents (DESs) to deliver antiproliferative drugs has led to the development of different encapsulation techniques. However, due to the potency of the drugs used in the initial stent designs, a chronic inflammatory reaction of the arterial wall known as thrombosis can cause a myocardial infarction (MI). One of the most promising drugs to reduce this risk is everolimus, which can be encapsulated in lipid systems for controlled release directly into the artery. This review aims to discuss the current status of stent design, fabrication, and functionalization. Variables such as the mechanical properties, metals and their alloys, drug encapsulation and controlled elution, and stent degradation are also addressed. Additionally, this review covers the use of polymeric surface coatings on stents and the recent advances in layer-by-layer coating and drug delivery. The advances in nanoencapsulation techniques such as liposomes and micro- and nanoemulsions and their functionalization in bioresorbable, drug-eluting stents are also highlighted.
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Affiliation(s)
- Julio A Vallejo-Zamora
- Tecnologico de Monterrey, Escuela de Ingeniería y Ciencias, Ave. Eugenio Garza Sada 2501, Monterrey, Nuevo León64849, Mexico
| | - Yadira I Vega-Cantu
- Tecnologico de Monterrey, Escuela de Ingeniería y Ciencias, Ave. Eugenio Garza Sada 2501, Monterrey, Nuevo León64849, Mexico
| | - Ciro Rodriguez
- Tecnologico de Monterrey, Escuela de Ingeniería y Ciencias, Ave. Eugenio Garza Sada 2501, Monterrey, Nuevo León64849, Mexico
- Laboratorio Nacional de Manufactura Aditiva y Digital (MADIT), Apodaca, Nuevo León66629, Mexico
| | - Geoffrey A Cordell
- Natural Products, Inc., Evanston, Illinois60201, United States
- College of Pharmacy, University of Florida, Gainesville, Florida32610, United States
| | - Aida Rodriguez-Garcia
- Tecnologico de Monterrey, Escuela de Ingeniería y Ciencias, Ave. Eugenio Garza Sada 2501, Monterrey, Nuevo León64849, Mexico
- Universidad Autónoma de Nuevo León, Facultad de Ciencias Biológicas, Instituto de Biotecnología, Ciudad Universitaria, Ave. Pedro de Alba S/N, San Nicolás de los Garza, Nuevo León66455, Mexico
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Gray KE, Rao M, Gunnink E, Eschenroeder L, Geyer JR, Nelson KM, Reddy A. Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017. J Gen Intern Med 2022; 37:3089-3096. [PMID: 35230624 PMCID: PMC8886698 DOI: 10.1007/s11606-022-07452-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 02/03/2022] [Indexed: 10/26/2022]
Abstract
BACKGROUND Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN Retrospective observational cohort study. PARTICIPANTS Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.
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Affiliation(s)
- Kristen E Gray
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA. .,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA. .,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Eric Gunnink
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lee Eschenroeder
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - John R Geyer
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Karin M Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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12
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Sun L, Brody R, Candelieri D, Anglin-Foote T, Lynch JA, Maxwell KN, Damrauer S, Ojerholm E, Lukens JN, Cohen RB, Getz KD, Hubbard RA, Ky B. Association Between Up-front Surgery and Risk of Stroke in US Veterans With Oropharyngeal Carcinoma. JAMA Otolaryngol Head Neck Surg 2022; 148:740-747. [PMID: 35737359 PMCID: PMC9227679 DOI: 10.1001/jamaoto.2022.1327] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Cardiovascular events are an important cause of morbidity in patients with oropharyngeal squamous cell carcinoma (OPSCC). Radiation and chemotherapy have been associated with increased risk of stroke; up-front surgery allows the opportunity for (chemo)radiotherapy de-escalation. Objective To evaluate whether up-front surgery was associated with decreased stroke risk compared to nonsurgical treatment for OPSCC. Design, Setting, and Participants This cohort study was conducted at the US Veterans Health Administration and examined US veterans diagnosed with nonmetastatic OPSCC from 2000 to 2020. Data cutoff was September 17, 2021, and data analysis was performed from October 2021 to February 2022. Exposures Up-front surgical treatment or definitive (chemo)radiotherapy as captured in cancer registry. Main Outcomes and Measures Cumulative incidence of stroke, accounting for death as a competing risk; and association between up-front surgery and stroke risk. After generating propensity scores for the probability of receiving surgical treatment and using inverse probability weighting (IPW) to construct balanced pseudo-populations, Cox regression was used to estimate a cause-specific hazard ratio (csHR) of stroke associated with surgical vs nonsurgical treatment. Results Of 10 436 patients, median (IQR) age was 61 (56-67) years; 10 329 (99%) were male; 1319 (13%) were Black, and 7823 (75%) were White; 2717 received up-front surgery, and 7719 received nonsurgical therapy with definitive (chemo)radiotherapy. The 10-year cumulative incidence of stroke was 12.5% (95% CI, 11.8%-13.3%) and death was 57.3% (95% CI, 56.2%-58.4%). Surgical patients who also received (chemo)radiotherapy had shorter radiation and chemotherapy courses than nonsurgical patients. After propensity score and IPW, the csHR of stroke for surgical treatment was 0.77 (95% CI, 0.66-0.91). This association was consistent across subgroups defined by age and baseline cardiovascular risk factors. Conclusions and Relevance In this cohort study, up-front surgical treatment was associated with a 23% reduced risk of stroke compared with definitive (chemo)radiotherapy. These findings present an important additional risk-benefit consideration to factor into treatment decisions and patient counseling and should motivate future studies to examine cardiovascular events in this high-risk population.
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Affiliation(s)
- Lova Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Corporal Michael Crescenz VA Medical Center, Philadelphia
| | - Robert Brody
- Corporal Michael Crescenz VA Medical Center, Philadelphia,Division of Otorhinolaryngology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Tori Anglin-Foote
- VA Salt Lake City Health Care System, University of Utah, Salt Lake City
| | - Julie A. Lynch
- VA Salt Lake City Health Care System, University of Utah, Salt Lake City
| | - Kara N. Maxwell
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Corporal Michael Crescenz VA Medical Center, Philadelphia,Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Scott Damrauer
- Corporal Michael Crescenz VA Medical Center, Philadelphia,Department of Genetics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Eric Ojerholm
- Corporal Michael Crescenz VA Medical Center, Philadelphia,Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - John N. Lukens
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Roger B. Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kelly D. Getz
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rebecca A. Hubbard
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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13
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Florez HJ, Ghosh A, Pop-Busui R, Hox SH, Underkofler C, McKee MD, Park J, Rhee MK, Killean T, Krause-Steinrauf H, Aroda VR, Wexler DJ. Differences in complications, cardiovascular risk factor, and diabetes management among participants enrolled at veterans affairs (VA) and non-VA medical centers in the glycemia reduction approaches in diabetes: A comparative effectiveness study (GRADE). Diabetes Res Clin Pract 2022; 184:109188. [PMID: 34971663 PMCID: PMC8917078 DOI: 10.1016/j.diabres.2021.109188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/14/2021] [Accepted: 12/23/2021] [Indexed: 02/03/2023]
Abstract
AIMS We evaluated differences in participants with type 2 diabetes (T2DM) enrolled in the GRADE study at VA vs non-VA sites, focusing on cardiovascular risk factors and rates of diabetes care target achievements. METHODS We compared baseline characteristics between participants at VA (n = 1216) and non-VA (n = 3831) sites, stratifying analyses by cardiovascular disease (CVD) history. RESULTS VA and non-VA participants had similar diabetes duration (4.0 years), HbA1c (7.5%), and BMI (34 kg/m2); however, VA participants had more individuals ≥ 65 years (37.3% vs 19.8%, p < 0.001), men (90.0% vs 55.2%, p < 0.001), hypertension (75.8% vs 63.6%, p < 0.001), hyperlipidemia (76.6% vs 64.6%, p < 0.001), current smokers (19.0% vs 12.1%, p < 0.001), nephropathy (20.4% vs 17.0%, p < 0.05), albuminuria (18.4% vs 15.1%, p < 0.05), and CVD (10.4% vs 5.2%, p < 0.001). In those without CVD, more VA participants were treated with lipid (70.8% vs 59.5%, p < 0.001) and blood pressure (74.9% vs 65.4%, p < 0.001) lowering medications, and had LDL-C < 70 mg/dl (32.9% vs 24.2%, p < 0.05). Among those with CVD, more VA participants had BP < 140/90 (80.2% vs 70.1%, p < 0.05) after adjusting for demographics. CONCLUSION GRADE participants at VA sites had more T2DM complications, greater CVD risk and were more likely to be treated with medications to reduce it, leading to more LDL-C at goal than non-VA participants, highlighting differences in diabetes populations and care.
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Affiliation(s)
- Hermes J Florez
- Medical University of South Carolina and Department of Veterans Affairs, Charleston, SC, United States
| | - Alokananda Ghosh
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Sophia H Hox
- Department of Veterans Affairs Pacific Islands Health Care System, Honolulu, HI, United States
| | - Chantal Underkofler
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - M Diane McKee
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Jean Park
- MedStar Health Research Institute, Hyattsville and Baltimore MD, United States
| | - Mary K Rhee
- Emory University School of Medicine, Department of Medicine, Division of Endocrinology, Metabolism and Lipids, and the Atlanta VA Health Care System, Decatur, GA, United States
| | - Tina Killean
- Obesity and Diabetes Clinical Research Section, NIDDK-Phoenix, Phoenix, AZ, United States
| | - Heidi Krause-Steinrauf
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD, United States
| | - Vanita R Aroda
- MedStar Health Research Institute, Hyattsville and Baltimore MD, United States; Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Deborah J Wexler
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA, United States.
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14
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Sapkota A, Neupane D, Shrestha AD, Adhikari TB, McLachlan CS, Shrestha N. Prevalence and associated factors of hypertension among veterans of the Indian Gorkha regiments living in Pokhara Metropolitan City, Nepal. BMC Health Serv Res 2021; 21:899. [PMID: 34470648 PMCID: PMC8408920 DOI: 10.1186/s12913-021-06907-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertension is a major preventable risk factor for cardiovascular disease. Occupational factors such as having served or serving in armed forces may be associated with hypertension. This study aimed to assess the prevalence and factors associated with hypertension among veterans of the Indian Gorkha army living in western Nepal. METHODS A community-based cross-sectional study was conducted among the veterans living in the Pokhara metropolitan city. Data on blood pressure (BP), anthropometric measurements, and behavioral factors were collected by face-to-face interviews using the World Health Organization's non-communicable disease risk factor surveillance (STEPS) tool. Hypertension was defined as systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP of ≥ 90 mm Hg or currently on antihypertensive medication. RESULTS The age-adjusted prevalence of hypertension was 66.2 % among the study participants (317). Mean systolic and diastolic blood pressure was 144.5 mmHg (± 18.3) and 89.3mmHg (± 16.0), respectively. Among the hypertensive participants, 67 % were aware of their disease, 90 % of them were under treatment, and 14 % of the individuals who received treatment had their hypertension under control. The proportion of smokers was 12.9 % and alcohol drinker was 86.1 %. One-fourth (25.9 %) of the participants had a family history of hypertension. Veterans aged 55-64 years had higher odds (AOR: 5.3; 95 % CI: 1.8-15.9; p = 0.003) of being associated with hypertension as compared to 35-44 years. Being a current alcohol drinker (AOR: 2.5; 95 % CI: 1.4-4.5; p = 0.003), overweight (AOR: 1.9; 95 % CI: 1.0-3.5; p = 0.04), obese (AOR: 3.1; 95 % CI: 1.1-8.3; p = 0.03) and family history of hypertension (AOR: 2.9; 95 % CI: 1.5-5.8; p = 0.002) were independently associated with hypertension. CONCLUSIONS Hypertension was prevalent in retired Nepal veterans. Hypertension was associated with a number of modifiable lifestyle and behavioral factors. Our findings suggest the need for screening, education and management of Nepal veterans for hypertension.
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Affiliation(s)
| | - Dinesh Neupane
- Nepal Development Society, Chitwan, Nepal
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Aamod Dhoj Shrestha
- Nepal Development Society, Chitwan, Nepal
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark
| | - Tara Ballav Adhikari
- Nepal Development Society, Chitwan, Nepal
- Department of Public Health, Section for Global Health, Aarhus University, Aarhus, Denmark
| | - Craig Steven McLachlan
- Health Faculty, Centre for Healthy Futures, Torrens University Australia, Adelaide, Australia
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15
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Angel CM, Woldetsadik MA, Armstrong NJ, Young BB, Linsner RK, Maury RV, Pinter JM. The Enriched Life Scale (ELS): Development, exploratory factor analysis, and preliminary construct validity for U.S. military veteran and civilian samples. Transl Behav Med 2021; 10:278-291. [PMID: 30590831 DOI: 10.1093/tbm/iby109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The U.S. military veteran serving nonprofit, Team Red, White & Blue (RWB), defined an "enriched life" as having physical, mental, and emotional health; supportive relationships; and a sense of purpose. Until now, no corresponding measure of an "enriched life" existed for the purposes of clinical assessment and research. The primary objective of this study was to explore the psychometric properties of the Enriched Life Scale (ELS) in veteran and civilian samples. Our secondary objective was to examine differences in ELS scores in subgroups of veterans who had combat deployments and service-related injuries. Veteran thought leaders working with social scientists developed the ELS and implemented exploratory factor analysis to determine the underlying dimensions of the "enriched life" construct. One thousand one hundred and eighty-seven veterans and 598 civilians participated in the study. This article describes the development of the ELS, reliability, exploratory factor analysis, and preliminary construct validity. The final ELS had 40 items and consisted of five constructs that were labeled "Genuine Relationships"; "Sense of Purpose"; "Engaged Citizenship"; "Mental Health"; and "Physical Health." Measures had high internal consistency (α = 0.82-0.94). Civilians scored higher than veterans on every ELS item, subscales, and total score, with small to large effect size differences noted between groups. In the veteran subsample, individuals with combat experience scored lower on every ELS subscale than those without combat experience (small effect sizes), as did veterans with service-related injuries in comparison to those without them (small to large effect sizes). This article establishes preliminary psychometric properties of the ELS-a promising instrument to measure an enriched life. Further study is currently underway to establish confirmatory factor analyses and explore extending its usage to diverse military and civilian samples.
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Affiliation(s)
- Caroline M Angel
- Team Red, White and Blue, Tampa, FL, USA.,Eagle Research and Innovation Center, Team Red, White and Blue, Tampa, FL, USA.,The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | | | - Nicholas J Armstrong
- The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Brandon B Young
- Team Red, White and Blue, Tampa, FL, USA.,Eagle Research and Innovation Center, Team Red, White and Blue, Tampa, FL, USA.,Tennyson Center for Children, Denver, CO, USA
| | - Rachel K Linsner
- The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Rosalinda V Maury
- The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
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16
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Betancourt JA, Granados PS, Pacheco GJ, Reagan J, Shanmugam R, Topinka JB, Beauvais BM, Ramamonjiarivelo ZH, Fulton LV. Exploring Health Outcomes for U.S. Veterans Compared to Non-Veterans from 2003 to 2019. Healthcare (Basel) 2021; 9:healthcare9050604. [PMID: 34070037 PMCID: PMC8158130 DOI: 10.3390/healthcare9050604] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/19/2021] [Accepted: 05/06/2021] [Indexed: 02/04/2023] Open
Abstract
The physical demands on U.S. service members have increased significantly over the past several decades as the number of military operations requiring overseas deployment have expanded in frequency, duration, and intensity. These elevated demands from military operations placed upon a small subset of the population may be resulting in a group of individuals more at-risk for a variety of debilitating health conditions. To better understand how the U.S Veterans health outcomes compared to non-Veterans, this study utilized the U.S. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) dataset to examine 10 different self-reported morbidities. Yearly age-adjusted, population estimates from 2003 to 2019 were used for Veteran vs. non-Veteran. Complex weights were used to evaluate the panel series for each morbidity overweight/obesity, heart disease, stroke, skin cancer, cancer, COPD, arthritis, mental health, kidney disease, and diabetes. General linear models (GLM’s) were created using 2019 data only to investigate any possible explanatory variables associated with these morbidities. The time series analysis showed that Veterans have disproportionately higher self-reported rates of each morbidity with the exception of mental health issues and heart disease. The GLM showed that when taking into account all the variables, Veterans disproportionately self-reported a higher amount of every morbidity with the exception of mental health. These data present an overall poor state of the health of the average U.S. Veteran. Our study findings suggest that when taken as a whole, these morbidities among Veterans could prompt the U.S. Department of Veteran Affairs (VA) to help develop more effective health interventions aimed at improving the overall health of the Veterans.
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17
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Normative Data for Blood Pressure in Croatian War Veterans: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084175. [PMID: 33920854 PMCID: PMC8071303 DOI: 10.3390/ijerph18084175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 12/04/2022]
Abstract
Purpose: The current study aimed to investigate the normative data for blood pressure. Materials and Methods: From 2017 to 2020, 2032 men and women classified as ‘war veterans’ were recruited (mean age ± standard deviation (SD): 60.97 ± 7.98 years; mean stature: 172.50 ± 9.10 cm; mean body mass: 90.25 ± 36.45 kg; mean body-mass index: 29.66 ± 5.59 kg/m2; 29.9% women). Their systolic and diastolic blood pressures were measured three times. The procedure was carried out according to the American Heart Organization. The sex-specific and age-specific normative data for the 5th, 25th, 50th (median), 75th, and 90th percentiles for systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (measured as SBP-DBP) and mid-BP (the average of SBP and DBP) were presented. Results: The men had higher SBP (p < 0.001), DBP (p < 0.001), pulse pressure (p < 0.001) and mid-BP (p < 0.001) compared to the women. The age-specific differences showed that older individuals had higher values of SBP (p < 0.001), pulse pressure (p < 0.001), and mid-BP (p < 0.001), while no significant differences for DBP (p = 0.496) were observed. Conclusions: This is the first study providing sex-specific and age-specific normative data for blood pressure in war veterans.
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18
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Lewinski AA, Bosworth HB, Goldstein KM, Gierisch JM, Jazowski S, McCant F, White-Clark C, Smith VA, Zullig LL. Improving cardiovascular outcomes by using team-supported, EHR-leveraged, active management: Disseminating a successful quality improvement project. Contemp Clin Trials Commun 2021; 21:100705. [PMID: 33644491 PMCID: PMC7887650 DOI: 10.1016/j.conctc.2021.100705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/24/2020] [Accepted: 01/01/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Uncontrolled blood pressure (BP) is common among Veterans. Rural Veterans are at risk for suboptimal care coordination as successful programs may be implemented at lower rates due to individual- and system-level factors. There is strong evidence to support the use of remotely delivered support and patient-generated data from home BP monitors and virtual BP visits to manage BP. OBJECTIVE The purpose of this project is to augment the current approach to addressing uncontrolled BP so that existing clinical staff can reach a larger patient population. METHODS Our project will address uncontrolled BP by leveraging team-based care, the Veteran's Health Administration Electronic Health Record, and patient-centered medical home data to address patient, provider, and system barriers to cardiovascular disease (CVD) preventive care. We will implement this project in cardiovascular disease practices in three rural Veterans Health Administration clinics. We will evaluate implementation processes as well as patient-level (e.g., clinical outcomes, referrals to specialty services) outcomes in a one-arm, pre-post design. DISCUSSION This manuscript describes our process in expanding the implementation of a successful project to improve BP control in high-risk, rural Veterans. Findings from our study will inform an understanding of both implementation and clinical effectiveness outcomes of a potentially scalable BP intervention in rural, community-based clinics. Appropriate management of Veterans with uncontrolled BP can reduce morbidity and mortality related to CVD. In turn, improvements in BP, can lead to improved quality metrics and potentially decrease costs for a healthcare system.
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Affiliation(s)
- Allison A. Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Karen M. Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M. Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Shelley Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leah L. Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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19
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Bendich I, Zhang N, Barry JJ, Ward DT, Whooley MA, Kuo AC. Antibiotic-Laden Bone Cement Use and Revision Risk After Primary Total Knee Arthroplasty in U.S. Veterans. J Bone Joint Surg Am 2020; 102:1939-1947. [PMID: 32890041 DOI: 10.2106/jbjs.20.00102] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND It is controversial whether the use of antibiotic-laden bone cement (ALBC) in primary total knee arthroplasty (TKA) affects periprosthetic joint infection (PJI) or revision rates. The impact of ALBC on outcomes of primary TKA have not been previously investigated in U.S. veterans, to our knowledge. The purposes of this study were to quantify utilization of ALBC among U.S. veterans undergoing primary TKA and to determine if ALBC usage is associated with differences in revision TKA rates. METHODS Patients who had TKA with cement from 2007 to 2015 at U.S. Veterans Health Administration (VHA) hospitals with at least 2 years of follow-up were retrospectively identified. Patients who received high-viscosity Palacos bone cement with or without gentamicin were selected as the final study cohort. Patient demographic and comorbidity data were collected. Revision TKA was the primary outcome. All-cause revisions and revisions for PJI were identified from both VHA and non-VHA hospitals. Unadjusted and adjusted regression analyses were performed to identify variables that were associated with increased revision rates. RESULTS The study included 15,972 patients who had primary TKA with Palacos bone cement at VHA hospitals from 2007 to 2015. Plain bone cement was used for 4,741 patients and ALBC was used for 11,231 patients. Utilization of ALBC increased from 50.6% in 2007 to 69.4% in 2015. At a mean follow-up of 5 years, TKAs with ALBC had a lower all-cause revision rate than those with plain bone cement (5.3% versus 6.7%; p = 0.0009) and a lower rate of revision for PJI (1.9% versus 2.6%; p = 0.005). On multivariable regression, ALBC use was associated with a lower risk of all-cause revision compared with plain bone cement (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68 to 0.92; p = 0.0019). Seventy-one primary TKAs needed to be implanted with ALBC to avoid 1 revision TKA. CONCLUSIONS The utilization of ALBC for primary TKAs performed at VHA hospitals has increased over time and was associated with a lower all-cause revision rate and a lower rate of revision for PJI. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ilya Bendich
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California
| | - Ning Zhang
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Veterans Affairs Quality Enhancement Research Initiative, San Francisco, California
| | - Jeffrey J Barry
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Derek T Ward
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Mary A Whooley
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Veterans Affairs Quality Enhancement Research Initiative, San Francisco, California
| | - Alfred C Kuo
- Departments of Orthopaedic Surgery (I.B., J.J.B., D.T.W., and A.C.K.), Medicine (N.Z. and M.A.W.), and Epidemiology and Biostatistics (M.A.W.), University of California, San Francisco, San Francisco, California.,Orthopedic Surgery Section, San Francisco Veterans Affairs Health Care System, San Francisco, California
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20
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Schindler DK, Lopez Mitnik GV, Soliván-Ortiz AM, Irwin SP, Boroumand S, Dye BA. Oral Health Status Among Adults With and Without Prior Active Duty Service in the U.S. Armed Forces, NHANES 2011-2014. Mil Med 2020; 186:e149-e159. [PMID: 33007064 DOI: 10.1093/milmed/usaa355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Many veterans qualify for health benefits but generally not dental care. This study examines differences in oral health status between veterans and nonveterans in the U.S. to determine how various factors, including socioeconomic, general health, and tobacco use, impact former service members' oral health. MATERIALS AND METHODS Data from 11,539 dentate adults participating in the National Health and Nutrition Examination Survey (2011-2014) were used. Outcome variables included decayed teeth (DT), missing teeth (MT), filled teeth (FT), caries experience (DMFT), and periodontitis (PD). Covariates included demographic and socioeconomic factors, deployment, smoking, depression, hypertension, hyperlipidemia, and diabetes. Logistic regression modelling was used to assess associations between these factors and oral health outcomes. RESULTS Veterans represent about 9% of the U.S. population. There was a higher prevalence of PD, MT, FT, and DMFT among veterans than nonveterans. Veterans were more likely to have PD (OR, 1.8; 95% CI, 1.3 to 2.5) and higher DMFT (OR, 2.9; 95% CI, 2.4 to 3.4); however, after controlling for other covariates, military service was only associated with FT (OR, 1.3; 95% CI, 1.1 to 1.6) and higher DMFT (OR, 1.6; 95% CI, 1.2 to 1.9). CONCLUSIONS Because veterans are more likely to originate from groups at a higher risk for poor oral health (older adults, smokers, males, diabetics), the prevalence of adverse oral health conditions are higher among veterans compared to nonveterans. Overall, military service is not associated with PD or untreated dental caries but is associated with indicators suggesting veterans have had more dental treatment (FT and DMFT). There is substantial unmet oral health care need primarily related to periodontitis among veterans.
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Affiliation(s)
- David K Schindler
- Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA.,National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA
| | - Gabriela V Lopez Mitnik
- National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA
| | - Aida M Soliván-Ortiz
- Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA
| | - Scott P Irwin
- Tri-Service Center for Oral Health Studies, Uniformed Services University-Southern Region, JBSA-Ft. Sam Houston, TX 78234, USA
| | - Shahdokht Boroumand
- National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA
| | - Bruce A Dye
- National Institutes of Health, National Institute of Dental and Craniofacial Research, Bethesda, MD 20892, USA
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21
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Connecting veterans with smoking cessation services in less than 3 minutes. J Am Assoc Nurse Pract 2020; 33:586-590. [PMID: 32590445 DOI: 10.1097/jxx.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/03/2020] [Indexed: 11/27/2022]
Abstract
ABSTRACT Veterans smoke disproportionately higher (nearly 1.3 times greater) than the general population and puts them at greater risk for tobacco-related illnesses. Annual screenings by the primary care providers are conducted at Veterans Health Administration (VHA) primary care clinics, but this practice may be inadequate to overcome the chronicity of smoking. The Ask, Advise, Refer strategy for smoking cessation was integrated in the workflow and implemented by the nursing staff at a VHA outpatient surgery clinic. Nurses established smoking status, advised smokers to quit, and for those interested, provided the smoker a list of resources Department of Veterans Affairs' approved smoking cessation options (telephone, text, and web-based interventions). All the smokers took a referral card containing a list of resources to help them quit smoking. During the follow-up phone calls after the clinic visit, 19% of patients reported using at least one of the resources listed on the card. Each clinical encounter should be viewed by health care providers as a window of opportunity to promote smoking cessation. The simplicity of the AAR strategy is effective in promoting smoking cessation especially in busy outpatient settings.
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22
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Jazowski SA, Bosworth HB, Goldstein KM, White-Clark C, McCant F, Gierisch JM, Zullig LL. Implementing a Population Health Management Intervention to Control Cardiovascular Disease Risk Factors. J Gen Intern Med 2020; 35:1931-1933. [PMID: 32016698 PMCID: PMC7280426 DOI: 10.1007/s11606-020-05679-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Shelley A Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA. .,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA. .,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA. .,School of Nursing, Duke University, Durham, NC, USA. .,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Courtney White-Clark
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Felicia McCant
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Jennifer M Gierisch
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
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23
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Impact of Cardiovascular Disease Risk Factors on Subfoveal Choroidal Thickness by Enhanced-depth Spectral Domain Optical Coherence Tomography. Optom Vis Sci 2020; 97:73-80. [PMID: 32011578 DOI: 10.1097/opx.0000000000001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
SIGNIFICANCE Risk stratification plays a large role in cardiovascular disease (CVD) management. Spectral-domain optical coherence tomography (SD-OCT) allows for noninvasive analysis of the ophthalmic vasculature, with potential for systemic disease surveillance. Subfoveal choroidal thickness (SFCT) may serve as a marker for CVD risk and play a role in risk stratification. PURPOSE This study aimed to explore the association of major CVD risk factors CVD on SFCT measured from SD-OCT images in a general population of U.S. veterans. METHODS One hundred fifty veterans were prospectively recruited at the Jamaica Plain VA Hospital (Boston, MA). A total of 143 participants were included in the final analysis. The SFCT was manually measured from Spectralis SD-OCT macular scans, and medical chart review was analyzed for CVD data. The SFCT measurements were correlated with CVD risk factors and CVD clinical makers while controlling for age and refractive error. Mean differences in SFCT between those with and without CVD risk factors were analyzed. RESULTS In multivariate analysis, diabetes diagnosis was independently associated with thinner subfoveal choroid (P = .001) and hypertension and hyperlipidemia with thicker subfoveal choroid (P = .006 and P = .05). After adjusting for age and refractive error, veterans with diabetes had thinner choroids than those without (P = .02), and veterans with hypertension and hyperlipidemia had thicker choroids than those without, although these differences did not reach statistical significance (P = .07 and P = .1). CONCLUSIONS Comorbid risk factors for CVD are independently associated with optical coherence tomography-derived measurements of subfoveal choroidal thickness in a vasculopathic population of U.S. veterans, and there are detectable differences in subfoveal choroidal thickness between groups with and without CVD risk factors. Larger studies with adequate controls and longitudinal design are necessary to assess the clinical role of SFCT measurements in CVD risk analysis.
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24
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Howard JT, Stewart IJ, Kolaja CA, Sosnov JA, Rull RP, Torres I, Janak JC, Walker LE, Trone DW, Armenta RF. Hypertension in military veterans is associated with combat exposure and combat injury. J Hypertens 2020; 38:1293-1301. [DOI: 10.1097/hjh.0000000000002364] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Georgantopoulos P, Eberth JM, Cai B, Emrich C, Rao G, Bennett CL, Haddock KS, Hébert JR. Patient- and area-level predictors of prostate cancer among South Carolina veterans: a spatial analysis. Cancer Causes Control 2020; 31:209-220. [DOI: 10.1007/s10552-019-01263-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/21/2019] [Indexed: 12/29/2022]
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26
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Engler RJM, Brede E, Villines T, Vernalis MN. Lipoprotein(a) Elevation: A New Diagnostic Code with Relevance to Service Members and Veterans. Fed Pract 2019; 36:S19-S31. [PMID: 31892786 PMCID: PMC6913584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Newly recognized as a clinical diagnosis, Lp(a) elevation is a major contributor to cardiovascular disease risk should be considered for patients with advanced premature atherosclerosis on imaging or a family history of premature cardiovascular disease, particularly when there are few traditional risk factors.
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Affiliation(s)
- Renata J M Engler
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Emily Brede
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Todd Villines
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
| | - Marina N Vernalis
- is a Professor of Medicine and Pediatrics and is an Adjunct Assistant Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. is a Professor of Medicine in the Cardiology Division at the University of Virginia Health System in Charlottesville, Virginia. is a Protocol Developer; Renata Engler is a Consultant of Cardiovascular Immunology, Diagnostic Laboratory Immunology, Allergy-Immunizations, Integrative Medicine and Research; and Marina Vernalis is Medical Director, Integrative Cardiac Health Project, Cardiology; all at the Henry M. Jackson Foundation, in Bethesda
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27
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Kotagal V, Albin RL, Müller MLTM, Bohnen NI. Cardiovascular Risk Factor Burden in Veterans and Non-Veterans with Parkinson Disease. JOURNAL OF PARKINSONS DISEASE 2019; 8:153-160. [PMID: 29480230 DOI: 10.3233/jpd-171271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Medical comorbidities, including cardiovascular risk factors such as hypertension and diabetes, influence disease progression in Parkinson disease (PD) and may be variably present in different clinical populations. OBJECTIVE/METHODS We conducted a retrospective nested case-control study of 29 Veterans with PD and 29 non-Veteran PD controls. The groups were matched for age, gender, and disease duration. Both groups underwent clinical and imaging testing as part of their participation in a larger cross-sectional PD observational study at our research center. Veterans were recruited primarily from movement disorders neurology clinics at the Ann Arbor Veterans Affairs (VA) Health System. Non-Veterans were recruited primarily from analogous clinics at the University of Michigan Health System. We explored differences in cardiovascular risks factor burden between the groups. RESULTS Veterans with PD showed higher scores on the simplified Framingham 10-year general cardiovascular disease risk calculator (FR score; 27.3% (11.5) vs. 20.7% (6.8); t = -2.66, p = 0.011) and fewer years of self-reported education (14.5 (2.5) vs. 16.7 (2.6); t = 3.33, p = 0.002). After adjusting for age, disease duration, education, and the use of antihypertensive medications, Veterans showed higher FR scores (t = 2.95, p = 0.005) and a higher intra-subject ratio of FR score to age-and-gender normalized FR score (t = 2.49, p = 0.016), representing an elevated component of modifiable cardiovascular risk factor burden. CONCLUSION Cardiovascular comorbidities are common in Veterans with PD and may be more severe than in non-Veteran PD populations. These findings merit replication in other representative cohorts. Veterans may be a preferred population for clinical trials evaluating cardiovascular risk factor management on PD progression.
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Affiliation(s)
- Vikas Kotagal
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Neurology Service and GRECC, VAAAHS, Ann Arbor, MI, USA
| | - Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Neurology Service and GRECC, VAAAHS, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA
| | - Martijn L T M Müller
- University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Nicolaas I Bohnen
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Neurology Service and GRECC, VAAAHS, Ann Arbor, MI, USA.,University of Michigan Morris K. Udall Center of Excellence for Parkinson's Disease Research, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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28
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Hall PS, O'Donnell CI, Mathew V, Garcia S, Bavry AA, Banerjee S, Jneid H, Denktas AE, Giacomini JC, Grossman PM, Aggarwal K, Zimmet JM, Tseng EE, Gozdecki L, Burke L, Bertog SC, Buchbinder M, Plomondon ME, Waldo SW, Shunk KA. Outcomes of Veterans Undergoing TAVR Within Veterans Affairs Medical Centers: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. JACC Cardiovasc Interv 2019; 12:2186-2194. [PMID: 31473239 DOI: 10.1016/j.jcin.2019.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/22/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days. BACKGROUND Veterans with severe aortic stenosis frequently undergo TAVR at VA medical centers. METHODS Consecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization. RESULTS Nine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63). CONCLUSIONS Veterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.
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Affiliation(s)
- Philip S Hall
- University of North Carolina Rex Healthcare, Raleigh, North Carolina
| | - Colin I O'Donnell
- University of Colorado and Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Verghese Mathew
- Loyola University Stritch College of Medicine, Maywod, Illinois
| | - Santiago Garcia
- University of Minnesota and VA Medical Center, Minneapolis, Minnesota; Valve Science Center, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Anthony A Bavry
- University of Florida and VA Medical Center, Gainesville, Florida
| | - Subhash Banerjee
- University of Texas, Southwestern and North Texas VA Medical Center, Dallas, Texas
| | - Hani Jneid
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Ali E Denktas
- Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas
| | - John C Giacomini
- Stanford University and VA Medical Center, Palo Alto, California
| | - Paul M Grossman
- University of Michigan and VA Medical Center, Ann Arbor, Michigan
| | - Kul Aggarwal
- University of Missouri and Harry S. Truman Memorial Veterans Hospital, Columbia, Missouri
| | - Jeffrey M Zimmet
- University of California and Veterans Affairs Medical Center, San Francisco, California
| | - Elaine E Tseng
- University of California and Veterans Affairs Medical Center, San Francisco, California
| | - Leo Gozdecki
- Loyola University Stritch College of Medicine, Maywod, Illinois
| | - Lucas Burke
- Loyola University Stritch College of Medicine, Maywod, Illinois
| | - Stefan C Bertog
- Valve Science Center, Minneapolis Heart Institute, Minneapolis, Minnesota
| | | | - Mary E Plomondon
- University of Colorado and Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Stephen W Waldo
- University of Colorado and Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Kendrick A Shunk
- University of California and Veterans Affairs Medical Center, San Francisco, California.
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29
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Findley PA, Strong JD. Operation Veterans to Social Workers: A Military Social Work Certificate Program. SOCIAL WORK IN PUBLIC HEALTH 2019; 34:616-627. [PMID: 31345140 DOI: 10.1080/19371918.2019.1635949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Service members, Veterans, and their families have special needs for mental health services, but the nation lacks a sufficient pool of social workers competent in military culture. Noting the need for military cultural competency and an increasing number of student Veterans, a graduate school of social work created a military social work training program embedded in an existing MSW program. Operation Veterans to Social Workers (OVSW) were designed to increase culturally competent mental health services to this population by recruiting Veteran MSW students into a Military Social Work certificate program that included a specialized field placement with a trauma-informed clinical focus.
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Affiliation(s)
- Patricia A Findley
- School of Social Work, Rutgers University , New Brunswick , New Jersey , USA
| | - Jessica D Strong
- School of Social Work, University of North Carolina Wilmington , Wilmington , North Carolina , USA
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30
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Walker LE, Poltavskiy E, Janak JC, Beyer CA, Stewart IJ, Howard JT. US Military Service and Racial/Ethnic Differences in Cardiovascular Disease: An Analysis of the 2011-2016 Behavioral Risk Factor Surveillance System. Ethn Dis 2019; 29:451-462. [PMID: 31367165 DOI: 10.18865/ed.29.3.451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To determine: 1) rates of cardiovascular disease (CVD) among individuals with and without prior US military service; and 2) variation in CVD outcomes by race/ethnicity. Methods We performed a cross-sectional study of the 2011-2016 Behavioral Risk Factor Surveillance System during 2018-2019. Groups with (n=369,844) and without (n=2,491,784) prior service were compared overall, and by race/ethnicity. CVD odds were compared using logistic regression. Rate-difference decomposition was used to estimate relative contributions of covariates to differences in CVD prevalence. Results CVD was associated with military service (OR=1.34; P<.001). Among non-Hispanic Blacks, prior service was associated with a lower odds of CVD (OR=.69; P<.001), fully attenuating the net difference in CVD between individuals with and without prior service. Non-Hispanic Whites who served had the highest odds of CVD, while Hispanics with prior service had the same odds of CVD as non-Hispanic Whites without prior service. After age, smoking and body mass index status were the largest contributors to CVD differences by race/ethnicity. Conclusions Results from this study support an association between prior military service and CVD and highlight differences in this association by race/ethnicity. Knowledge of modifiable health behaviors that contribute to differences in CVD outcomes could be used to guide prevention efforts.
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Affiliation(s)
| | | | - Jud C Janak
- Defense Health Agency, Combat Support Operations, Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, TX
| | - Carl A Beyer
- David Grant USAF Medical Center, Travis AFB, CA.,Department of Surgery, University of California Davis Medical Center, Sacramento, CA
| | - Ian J Stewart
- David Grant USAF Medical Center, Travis AFB, CA.,Uniformed Services University of Health Sciences, Bethesda, MD
| | - Jeffrey T Howard
- Defense Health Agency, Combat Support Operations, Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, TX.,University of Texas at San Antonio, San Antonio, TX
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Shrestha A, Ho TE, Vie LL, Labarthe DR, Scheier LM, Lester PB, Seligman MEP. Comparison of Cardiovascular Health Between US Army and Civilians. J Am Heart Assoc 2019; 8:e009056. [PMID: 31164033 PMCID: PMC6645626 DOI: 10.1161/jaha.118.009056] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Cardiovascular conditions are common in US Army and civilian populations. The recently developed concept of ideal cardiovascular health provides a new approach to evaluating population cardiovascular status. Methods and Results We defined a cohort of 263 430 active duty Army personnel, aged 17 to 64 years, who completed a 2012 physical examination and a corresponding subset of the noninstitutionalized, civilian US population, who participated in the National Health and Nutrition Examination Survey (NHANES) 2011 to 2012 cycle. We compared 4 cardiovascular health metrics (current smoking, body mass index, blood pressure, and diabetic status) between Army and civilian groups overall, and separately by sex, race/ethnicity, and age. The Army population was younger, was less often women or Hispanic, and had less post–high school education than the NHANES population. Smoking rates were ≈20% in the Army and NHANES groups, but <15% among Army women and Hispanics. Overall, one third of the Army and NHANES groups and NHANES women, but nearly half of Army women, demonstrated ideal body mass index. Ideal blood pressure was strikingly less prevalent in the Army than NHANES participants (30% versus 55%). Diabetes mellitus was rare in both groups. Conclusions Ideal cardiovascular health was less prevalent in the Army than NHANES group, despite exclusion of the least healthy recruits. Prevalence of ideal body mass index and blood pressure was low in both the Army and NHANES groups, even at early adult ages. This finding reveals the need for policy changes to promote, preserve, and improve ideal cardiovascular health in both the Army and the US population as a whole.
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Affiliation(s)
- Alice Shrestha
- 1 Department of Psychology University of Pennsylvania Philadelphia PA.,2 Research Facilitation Laboratory Army Analytics Group Monterey CA
| | - Tiffany E Ho
- 1 Department of Psychology University of Pennsylvania Philadelphia PA.,2 Research Facilitation Laboratory Army Analytics Group Monterey CA
| | - Loryana L Vie
- 1 Department of Psychology University of Pennsylvania Philadelphia PA.,2 Research Facilitation Laboratory Army Analytics Group Monterey CA
| | | | - Lawrence M Scheier
- 1 Department of Psychology University of Pennsylvania Philadelphia PA.,2 Research Facilitation Laboratory Army Analytics Group Monterey CA
| | - Paul B Lester
- 2 Research Facilitation Laboratory Army Analytics Group Monterey CA
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Tran HA, O'Connell JB, Lee UK, Polanco JC, Chang TI, Friedlander AH. Relationship between symptomatic lower limb peripheral artery disease and calcified carotid artery plaque detected on panoramic images of neurologically asymptomatic males. Dentomaxillofac Radiol 2019; 48:20180432. [PMID: 30875245 DOI: 10.1259/dmfr.20180432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Males with peripheral arterial disease (PAD) are at high risk of ischaemic stroke given that atherogenic risk factors for both diseases are similar. We hypothesized that neurologically asymptomatic males diagnosed with PAD would demonstrate calcified carotid artery plaques (CCAP) on panoramic images (PI) significantly more often than similarly aged males not having PAD. METHODS Investigators implemented a retrospective cross-sectional study. Subjects were male patients over age 50 diagnosed with PAD by ankle-brachial systolic pressure index results of ≤ 0.9. Controls negative for PAD had an ankle-brachial systolic pressure index > 0.9. Predictor variable was a diagnosis of PAD and outcome variable was presence of CCAP. Prevalence of CCAP amongst the PAD+ patients was compared to prevalence of CCAP among PAD- patients. Descriptive and bivariate statistics were computed and p-value was set at 0.05. RESULTS Final sample size consisted of 234 males (mean age 72.68 ± 9.09); 116 subjects and 118 controls. Among the PAD+ cohort, CCAP+ prevalence rate (57.76%) was significantly (p = 0.001) greater than the CCAP+ rate (36.44%) of the PAD- (control). There was no significant difference in atherogenic "risk factors" in the PAD+ cohort between CCAP+ and CCAP- subjects. CONCLUSION We demonstrated that CCAP, a "risk factor" for future stroke and "risk indicator" of future myocardial infarction is seen significantly more often detected on the PIs of older male patients with PAD than among those without. Dentists treating patients with PAD must be uniquely vigilant for the presence of CCAPs on their patients' PI.
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Affiliation(s)
- Hoang-Anh Tran
- 1 Departments of Dentistry and Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System and UCLA Dental School , Los Angeles, CA , USA
| | - Jessica B O'Connell
- 2 Departments of Vascular Surgery, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , Los Angeles, CA , USA
| | - Urie K Lee
- 1 Departments of Dentistry and Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System and UCLA Dental School , Los Angeles, CA , USA
| | - John C Polanco
- 3 Clinical Research Department (CINBIOCLI), Jose Maria Cabral y Baez Regional University Hospital , Santiago de los Caballeros , Dominican Republic
| | - Tina I Chang
- 1 Departments of Dentistry and Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System and UCLA Dental School , Los Angeles, CA , USA
| | - Arthur H Friedlander
- 1 Departments of Dentistry and Oral and Maxillofacial Surgery, Veterans Affairs Greater Los Angeles Healthcare System and UCLA Dental School , Los Angeles, CA , USA
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Trammell AW, Shah AJ, Phillips LS, Michael Hart C. Mortality in US veterans with pulmonary hypertension: a retrospective analysis of survival by subtype and baseline factors. Pulm Circ 2019; 9:2045894019825763. [PMID: 30638433 DOI: 10.1177/2045894019825763] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Pulmonary hypertension (PH) occurs when the pulmonary vasculature is itself diseased or becomes affected secondarily by comorbid conditions, commonly left heart or lung disease. The high prevalence of chronic cardiopulmonary conditions among patients served by Veterans Health Administration (VHA) suggests this population may be particularly susceptible to PH. We sought to identify clinical features and outcomes in veterans diagnosed with PH. We utilized the VHA Corporate Data Warehouse to identify veterans diagnosed between January 1, 2003 and September 30, 2015, assess relevant patient characteristics and their survival time. The effects of PH subtype and baseline factors on outcome were estimated by Cox modeling. There were 110,564 veterans diagnosed with PH during the study period. These veterans were predominantly male, had median age 70.2, and had a high burden of comorbid conditions. PH was frequently due to left heart and/or lung disease. Average survival after PH diagnosis was 3.88 years. Compared with other types, PH due to left heart disease, lung disease or both had shorter survival. This large retrospective study of veterans demonstrates the significance of PH due to left heart and/or lung disease which was common and had high risk of death. Multi-comorbidity was common and added to risk. These findings underscore the need for risk assessment tools for subjects with non-Group 1 PH and novel management strategies to improve their outcome. This study details the largest retrospective cohort assembled for evaluation of secondary PH and allows hypothesis-generating inquiries into these common conditions that are rarely prospectively studied.
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Affiliation(s)
- Aaron W Trammell
- 1 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- 2 Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Amit J Shah
- 2 Atlanta VA Medical Center, Decatur, Georgia, USA
- 3 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lawrence S Phillips
- 2 Atlanta VA Medical Center, Decatur, Georgia, USA
- 4 Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Hart
- 1 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- 2 Atlanta VA Medical Center, Decatur, Georgia, USA
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Manley NA, Hicken BL, Rupper RW. Veterans Caregiving for Others: Caregiving as a Factor in the Health of America's Military Veterans. Mil Med 2019; 184:e162-e168. [PMID: 29901741 DOI: 10.1093/milmed/usy131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/14/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Natalie A Manley
- Division of Geriatrics, University of Nebraska Medical Center, 986155 Nebraska Medical Center, Omaha, NE
| | - Bret L Hicken
- George E. Wahlen Department of Veteran Affairs Medical Center, VA Building #2, GRECC 182, 500 S. Foothill Dr., SLC, UT
| | - Randall W Rupper
- George E. Wahlen Department of Veteran Affairs Medical Center, VA Building #2, GRECC 182, 500 S. Foothill Dr., SLC, UT
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Oddone EZ, Gierisch JM, Sanders LL, Fagerlin A, Sparks J, McCant F, May C, Olsen MK, Damschroder LJ. A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial. J Gen Intern Med 2018; 33:1487-1494. [PMID: 29736750 PMCID: PMC6108991 DOI: 10.1007/s11606-018-4398-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/17/2017] [Accepted: 03/01/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. OBJECTIVE To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone. DESIGN Two-arm randomized trial at three sites. SETTING Primary care clinics at Veterans Affairs facilities. PARTICIPANTS Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker). INTERVENTION Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors. MEASUREMENTS Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS). RESULTS Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33). CONCLUSIONS Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS. GOV IDENTIFIER NCT01828567.
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Affiliation(s)
- Eugene Z Oddone
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Jennifer M Gierisch
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Linda L Sanders
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Angela Fagerlin
- VA Salt Lake City Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Jordan Sparks
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Felicia McCant
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Carrie May
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Angel CM, Smith BP, Pinter JM, Young BB, Armstrong NJ, Quinn JP, Brostek DF, Goodrich DE, Hoerster KD, Erwin MS. Team Red, White & Blue: a community-based model for harnessing positive social networks to enhance enrichment outcomes in military veterans reintegrating to civilian life. Transl Behav Med 2018; 8:554-564. [PMID: 30016524 PMCID: PMC6065538 DOI: 10.1093/tbm/iby050] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Military service assimilates individuals into a socially cohesive force to address dangerous and traumatic situations that have no counterpart in civilian life. Upon leaving active duty, many veterans experience a “reverse culture shock” when trying to reintegrate into civilian institutions and cultivate supportive social networks. Poor social reintegration is associated with greater morbidity and premature mortality in part due to adoption of risky health behaviors, social isolation, and inadequate engagement in health care services. Although institutions like the Veterans Health Administration (VA) do much to address the complex psychosocial and health care needs of veterans and their families with evidence-based care, only 61% of Operations Enduring and Iraqi Freedom (OEF/OIF) Veterans are enrolled in VA care and there are numerous perceived barriers to care for enrollees. To address this gap, a community-based nonprofit organization, Team Red, White & Blue (RWB), was created to help veterans establish health-enriching social connections with communities through the consistent provision of inclusive and locally tailored physical, social, and service activities. This article provides an overview of the development and refinement of a theory-based framework for veteran health called the Enrichment Equation, comprised of three core constructs: health, people, and purpose. By operationalizing programming activities and roles, we describe how theoretical components were translated into a social networking implementation package that enabled rapid national spread of Team RWB. We conclude with future opportunities to partner with researchers and other organizations to understand program impact, and to identify effective intervention components that could be adapted for similar vulnerable groups.
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Affiliation(s)
- Caroline M Angel
- Team Red, White & Blue, Tampa, FL, USA.,Eagle Research and Innovation Center, Team Red, White & Blue, Tampa, FL, USA.,The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Blayne P Smith
- Team Red, White & Blue, Tampa, FL, USA.,Go Ruck, Jacksonville, FL, USA
| | | | - Brandon B Young
- Team Red, White & Blue, Tampa, FL, USA.,Tennyson Center for Children, Denver, CO, USA
| | - Nicholas J Armstrong
- The Institute for Veterans and Military Families, Syracuse University, Syracuse, NY, USA
| | - Joseph P Quinn
- Team Red, White & Blue, Tampa, FL, USA.,Headstrong Project, New York, NY, USA
| | | | - David E Goodrich
- Center for Evaluation and Implementation Resources and Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Katherine D Hoerster
- Seattle Division Mental Health Service, VA Puget Sound Healthcare System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Michael S Erwin
- Team Red, White & Blue, Tampa, FL, USA.,The Positivity Project, Pinehurst, NC, USA
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Bosworth HB, Olsen MK, McCant F, Stechuchak KM, Danus S, Crowley MJ, Goldstein KM, Zullig LL, Oddone EZ. Telemedicine cardiovascular risk reduction in veterans: The CITIES trial. Am Heart J 2018; 199:122-129. [PMID: 29754649 DOI: 10.1016/j.ahj.2018.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/05/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Comprehensive programs addressing tailored patient self-management and pharmacotherapy may reduce barriers to cardiovascular disease (CVD) risk reduction. METHODS This is a 2-arm (clinical pharmacist specialist-delivered, telehealth intervention and education control) randomized controlled trial including Veterans with poorly controlled hypertension and/or hypercholesterolemia. Primary outcome was Framingham CVD risk score at 6 and 12 months, with systolic blood pressure; diastolic blood pressure; total cholesterol; low-density lipoprotein; high-density lipoprotein; body mass index; and, for those with diabetes, HbA1c as secondary outcomes. RESULTS Among 428 Veterans, 50% were African American, 85% were men, and 33% had limited health literacy. Relative to the education control group, the clinical pharmacist specialist-delivered intervention did not show a reduction in CVD risk score at 6 months (-1.8, 95% CI -3.9 to 0.3; P = .10) or 12 months (-0.3, 95% CI -2.4 to 1.7; P = .74). No differences were seen in systolic blood pressure, diastolic blood pressure, or low-density lipoprotein at 6 or 12 months. We did observe a significant decline in total cholesterol at 6 months (-7.0, 95% CI -13.4 to -0.6; P = .03) in the intervention relative to education control group. Among patients in the intervention group, 34% received at least 5 of the 12 planned intervention calls and were considered "compliers." A sensitivity analysis of the "complier average causal effect" of intervention compared to control showed a mean difference in CVD risk score reduction of 5.7 (95% CI -12.0 to 0.7) at 6 months and -1.7 (95% CI -7.6 to 4.8) at 12 months. CONCLUSIONS Despite increased access to pharmacist resources, we did not observe significant improvements in CVD risk for patients randomized to the intervention compared to education control over 12 months. However, the intervention may have positive impact among those who actively participate, particularly in the short term.
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Preoperative factors associated with worsening in health-related quality of life following coronary artery bypass grafting in the Randomized On/Off Bypass (ROOBY) trial. Am Heart J 2018; 198:33-38. [PMID: 29653645 DOI: 10.1016/j.ahj.2017.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/17/2017] [Indexed: 11/21/2022]
Abstract
For advanced coronary disease, coronary artery bypass graft (CABG) surgery generally improves patients' symptoms and long-term survival. Unfortunately, some patients experience worse health-related quality of life (HRQL) after CABG. The objective of this study is to report the frequency and risk factors associated with 1-year post-CABG HRQL deterioration. METHODS From 2002 to 2007, 2203 "Randomized On/Off Bypass" (ROOBY) trial patients randomly received either off-pump or on-pump CABG at 18 VA medical centers. Subjects completed both baseline and 1-year Seattle Angina Questionnaire (SAQ) and the Veterans Rand 36 (VR-36) questionnaires to assess HRQL. Using previously published criteria, the rates of clinically significant changes were determined for the SAQ [angina frequency (AF), physical limitation (PL), and quality of life (QoL)] and VR36 [mental component score (MCS) and physical component score (PCS)] subscales. Multivariate regression models were then used to identify pre-CABG patient characteristics associated with worsened 1-year HRQL status for each subscale. RESULTS Over 80% of patients had an improvement or no change in SAQ and VR-36 subscale scores 1 year after CABG. The HRQL scale-specific deterioration rates were 4.5% SAQ-AF, 16.8% SAQ-PL, 4.9% SAQ-QoL, 19.4% VR36-MCS, and 13.5% VR36-PCS. Predictors of 1-year HRQL deterioration were diabetes and smoking for the SAQ-AF; diabetes, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD) for SAQ-PL; COPD and depression for the SAQ-QoL; diabetes for VR36-PCS, and history of stroke and depression for VR36-MCS. The baseline score was an independent predictor for worsening in all the subscales studied. CONCLUSIONS Among VA patients, less than 20% experienced worse HRQL 1 year after CABG. For patients with low symptom burden at baseline, diabetes, smoking, depression, PVD, COPD, and a prior stroke, clinicians should be more cautious in pre-CABG counseling as to their anticipated HRQL improvements.
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Patel YA, Gifford EJ, Glass LM, McNeil R, Turner MJ, Han B, Provenzale D, Choi SS, Moylan CA, Hunt CM. Risk factors for biopsy-proven advanced non-alcoholic fatty liver disease in the Veterans Health Administration. Aliment Pharmacol Ther 2018; 47:268-278. [PMID: 29115682 PMCID: PMC5861349 DOI: 10.1111/apt.14411] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/26/2017] [Accepted: 10/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND With its increasing incidence, nonalcoholic fatty liver disease (NAFLD) is of particular concern in the Veterans Health Administration (VHA). AIMS To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes. METHODS In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver. RESULTS Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis (NASH) without fibrosis (n = 68), NAFLD/NASH stage 1-3 fibrosis (n = 82), and NAFLD/NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma (HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese (BMI>35 kg/m2 ). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes (OR 11.8, P < .001) and BMI (OR 1.4, P < .001) were the most significant predictors of advanced fibrosis. CONCLUSIONS In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity.
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Richardson CR, Goodrich DE, Larkin AR, Ronis D, Holleman RG, Damschroder LJ, Lowery JC. A Comparative Effectiveness Trial of Three Walking Self-monitoring Strategies. TRANSLATIONAL JOURNAL OF THE AMERICAN COLLEGE OF SPORTS MEDICINE 2017; 1:133-142. [PMID: 28529971 PMCID: PMC5435380 DOI: 10.1249/tjx.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Walking programs improve health outcomes in adults at risk for cardiovascular disease (CVD), and self-monitoring strategies can improve adherence to such programs. The objective of this study was to determine whether a 6-month Internet-based walking program using Web-enhanced pedometers results in more weight loss than walking programs based on time or simple pedometer step count goals in adults with or at risk for CVD. This was a multisite, randomized controlled trial of 255 male veterans who were ambulatory, insufficiently active, and with body mass index (BMI) ≥28, and who reported CVD risk factors ≥1 risk factors. Participants were randomized to one of three self-monitoring strategies to increase walking: 1) time-based walking goals; 2) simple pedometer-based walking goals; and 3) Web-enhanced pedometer feedback goals with Internet-mediated feedback. All participants also attended five individual weight loss sessions with a dietitian. The main outcome measure was change in weight at 6 months (kg), and the secondary outcomes were change in accelerometer-measured physical activity (min) and change in health-related quality of life at 6 months. The 255 participants had a mean age of 56.3 yr (SD = 10.0), BMI = 36.3 (SD = 5.3), with a mean value of 5.2 (SD = 2.3) medical comorbidities. Dropouts were distributed evenly across the three groups, and 72% of participants completed the program. At 6 months, participants in the Web-enhanced pedometer arm lost significantly more weight (−1.9 kg, 95% CI, −2.7 to −1.1) than those in the time-based group (−0.7 kg, 95% CI, −1.5 to 0.0; P = 0.04) and simple pedometer group (−0.6 kg, 95% CI, −1.4 to 0.2; P = 0.02). In conclusion, Internet-enhanced pedometers result in greater weight loss in veterans than in walking programs using time-based walking goals or simple pedometers.
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Affiliation(s)
- Caroline R Richardson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.,The Department of Family Medicine, University of Michigan Health System, Ann Arbor, MI
| | - David E Goodrich
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Angela R Larkin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - David Ronis
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Robert G Holleman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Julie C Lowery
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Renn BN, Thakur A, Trahan LH, Stanley MA, Dubbert P, Evans-Hudnall G. Leveraging Spousal Support to Improve Health Promotion in Serious Mental Illness. Clin Case Stud 2016. [DOI: 10.1177/1534650116678481] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.
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Affiliation(s)
- Brenna N. Renn
- Baylor College of Medicine, Houston, TX, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
| | - Aishwarya Thakur
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
- Rice University, Houston, TX, USA
| | | | - Melinda A. Stanley
- Baylor College of Medicine, Houston, TX, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
| | - Patricia Dubbert
- VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
- University of Arkansas for Medical Sciences, Little Rock, USA
| | - Gina Evans-Hudnall
- Baylor College of Medicine, Houston, TX, USA
- VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
- VA South Central Mental Illness Research, Education and Clinical Center (A Virtual Center), Houston, TX, USA
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Haibach JP, Haibach MA, Hall KS, Masheb RM, Little MA, Shepardson RL, Dobmeyer AC, Funderburk JS, Hunter CL, Dundon M, Hausmann LR, Trynosky SK, Goodrich DE, Kilbourne AM, Knight SJ, Talcott GW, Goldstein MG. Military and veteran health behavior research and practice: challenges and opportunities. J Behav Med 2016; 40:175-193. [DOI: 10.1007/s10865-016-9794-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 09/09/2016] [Indexed: 12/01/2022]
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Moazen-Zadeh E, Khoshdel A, Avakh F, Rahmani A. Increased blood pressures in veterans with post traumatic stress disorder. Int J Psychiatry Med 2016. [PMID: 28629292 DOI: 10.1177/0091217417696734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective Veterans of war affected by posttraumatic stress disorder (PTSD) are at increased risk for cardiovascular diseases. We aimed to compare brachial and central blood pressures between veterans with PTSD and controls. Method In this case-control study on veterans of Iran-Iraq war, 50 veterans with PTSD and 50 veterans as controls were selected from an outpatient clinic and matched for age ±3 years. Exclusion criteria were malignancies, severe anatomical defects such as amputated extremities, history of PTSD before serving in war, comorbid psychiatric disorders other than anxiety or depressive disorders. Detailed history was taken concerning medical and social aspects. Beck Depression Inventory was used for depressive symptoms. Brachial blood pressures were measured using both auscultatory and oscillometric devices. Measures of central hemodynamics were estimated accordingly. Data on lipid profile were collected either through medical records or newly required lab tests. Results Brachial systolic, diastolic, and pulse pressures as well as estimated central systolic and diastolic pressures were significantly higher in the PTSD group. Beck Depression Inventory scores, frequency of diabetes mellitus, and hypertension were significantly higher in the PTSD group. PTSD status was an independent predictor of both brachial and central systolic and diastolic pressures. Conclusions We demonstrated increased measures of blood pressure in veterans with PTSD independent of depression and other risk factors. Further research is warranted to confirm our results.
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Affiliation(s)
- Ehsan Moazen-Zadeh
- 1 Modern Epidemiology Research Center, Aja University of Medical Sciences, Tehran, Iran
- 2 Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
- 3 Mental Health Research Center, Tehran Institute of Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshdel
- 1 Modern Epidemiology Research Center, Aja University of Medical Sciences, Tehran, Iran
| | - Farhad Avakh
- 4 Faculty of Aerospace and Diving Medicine, Aja University of Medical Sciences, Tehran, Iran
| | - Arash Rahmani
- 3 Mental Health Research Center, Tehran Institute of Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
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