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Martin SI, Bennett AS, Elliott L, Gorgens KA. Overdose Risk and Brain Injury (Traumatic Brain Injury/Acquired Brain Injury), A Commentary. Subst Use Misuse 2024:1-4. [PMID: 38803022 DOI: 10.1080/10826084.2024.2359722] [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] [Indexed: 05/29/2024]
Abstract
OBJECTIVE This commentary seeks to evaluate existing knowledge about the relationship between brain injury (BI) and overdose (OD), to unify distant bodies of literature, and to enhance prevention and treatment for opioid OD among individuals with BI. BACKGROUND There is a hidden epidemic of undiagnosed BI in the United States. Due to lack of screening, the vast majority of BI sufferers do not know they have a BI. Not only are those with BI at elevated risk for opioid use, misuse, and opioid use disorder, but also they are at elevated risk for OD. Conversely, those with OUD and those who experienced an OD, are more likely to sustain BI. Key Findings/Conclusions: The existing literature suggests that primary strategies to reduce ABI (Acquired Brain Injury)/TBI (Traumatic Brain Injury) harms involve addressing: screening, stigma, racial disparities, and popular misconceptions about OD. The association between TBI and OD is an underexamined public health issue, exacerbated by the bidirectional nature of the relationship. Not only is TBI a risk factor for opioid OD; opioid OD was also found to be a major cause of ABI, which can have lifelong effects similar to Alzheimer's disease. Screening tools for BI were underutilized and inconsistently implemented across reviewed studies. Enhanced screening population wide is a promising intervention, complemented with expanded treatment and research. Black individuals face worse outcomes in BI and treatment outcomes. Anti-racist strategies must fight inequity while addressing social and structural drivers of overdose and BI within the opioid and opioid overdose crises.
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Affiliation(s)
- Samuel I Martin
- Research Associate, School of Global Public Health, New York University, Doctoral Candidate, Graduate School of Professional Psychology, University of Denver
| | - Alex S Bennett
- Research Associate Professor, Center for Drug Use and HIV/HCV Research, School of Global Public Health, New York University
| | - Luther Elliott
- Associate Research Scientist, School of Global Public Health, New York University
| | - Kim A Gorgens
- Professor, Graduate School of Professional Psychology, University of Denver
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Grover LE, Williamson C, Burdett H, Palmer L, Fear NT. Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol 2024:10.1007/s00127-024-02685-3. [PMID: 38771350 DOI: 10.1007/s00127-024-02685-3] [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: 11/01/2023] [Accepted: 05/03/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE Combat deployment increases exposure to potentially traumatic events. Perceived social support (PSS) may promote health and recovery from combat trauma. This systematic review and meta-analysis aimed to synthesize studies investigating the level of PSS and associated factors among (ex-)military personnel who served in the Iraq/Afghanistan conflicts. METHODS Five electronic databases were searched in August 2023 and searches were restricted to the beginning of the Iraq/Afghanistan conflicts in 2001. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A quality assessment was carried out, and a meta-analysis and narrative synthesis were performed. RESULTS In total, 35 papers consisting of 19,073 participants were included. Of these, 31 studies were conducted in the United States (US) and 23 were cross-sectional. The pooled mean PSS score was 54.40 (95% CI: 51.78 to 57.01). Samples with probable post-traumatic stress disorder had a lower mean PSS score (44.40, 95% CI: 39.10 to 49.70). Approximately half of the included studies (n = 19) investigated mental health in relation to PSS, whilst only four explored physical health. The most frequently reported risk factors for low PSS included post-traumatic stress disorder, depression and anxiety, whilst post-traumatic growth and unit support were protective factors. CONCLUSION Higher levels of PSS were generally associated with more positive psychosocial and mental health-related outcomes following deployment. PSS should be targeted in psychosocial interventions and education programmes. Future research should investigate PSS in (ex-)military personnel across other countries and cultures, based on the lack of studies that focused on PSS in countries outside of the US.
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Affiliation(s)
- Laura E Grover
- King's College London, King's Centre for Military Health Research, London, SE5 9RJ, UK.
| | - Charlotte Williamson
- King's College London, King's Centre for Military Health Research, London, SE5 9RJ, UK
| | - Howard Burdett
- King's College London, King's Centre for Military Health Research, London, SE5 9RJ, UK
| | - Laura Palmer
- King's College London, King's Centre for Military Health Research, London, SE5 9RJ, UK
| | - Nicola T Fear
- King's College London, King's Centre for Military Health Research, London, SE5 9RJ, UK
- Academic Department of Military Mental Health, King's College London, London, SE5 9RJ, UK
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Brostow DP, Donovan M, Penzenik M, Stamper CE, Spark T, Lowry CA, Ishaq SL, Hoisington AJ, Brenner LA. Food desert residence has limited impact on veteran fecal microbiome composition: a U.S. Veteran Microbiome Project study. mSystems 2023; 8:e0071723. [PMID: 37874170 PMCID: PMC10734509 DOI: 10.1128/msystems.00717-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/11/2023] [Indexed: 10/25/2023] Open
Abstract
IMPORTANCE Social and economic inequities can have a profound impact on human health. The inequities could result in alterations to the gut microbiome, an important factor that may have profound abilities to alter health outcomes. Moreover, the strong correlations between social and economic inequities have been long understood. However, to date, limited research regarding the microbiome and mental health within the context of socioeconomic inequities exists. One particular inequity that may influence both mental health and the gut microbiome is living in a food desert. Persons living in food deserts may lack access to sufficient and/or nutritious food and often experience other inequities, such as increased exposure to air pollution and poor access to healthcare. Together, these factors may confer a unique risk for microbial perturbation. Indeed, external factors beyond a food desert might compound over time to have a lasting effect on an individual's gut microbiome. Therefore, adoption of a life-course approach is expected to increase the ecological validity of research related to social inequities, the gut microbiome, and physical and mental health.
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Affiliation(s)
- Diana P. Brostow
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Military and Veteran Microbiome Consortium for Research and Education, Aurora, Colorado, USA
| | - Meghan Donovan
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
| | - Molly Penzenik
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher E. Stamper
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Military and Veteran Microbiome Consortium for Research and Education, Aurora, Colorado, USA
| | - Talia Spark
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
| | - Christopher A. Lowry
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Military and Veteran Microbiome Consortium for Research and Education, Aurora, Colorado, USA
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
- Center for Neuroscience and Center for Microbial Exploration, University of Colorado Boulder, Boulder, Colorado, USA
- Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Suzanne L. Ishaq
- School of Food and Agriculture, University of Maine, Orono, Maine, USA
| | - Andrew J. Hoisington
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Military and Veteran Microbiome Consortium for Research and Education, Aurora, Colorado, USA
- Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Systems Engineering & Management, Air Force Institute of Technology, Wright-Patterson AFB, Dayton, Ohio, USA
| | - Lisa A. Brenner
- VA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, Colorado, USA
- Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Military and Veteran Microbiome Consortium for Research and Education, Aurora, Colorado, USA
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Skop KM, Bajor L, Sevigny M, Swank C, Tallavajhula S, Nakase-Richardson R, Miles SR. Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury. PM R 2023; 15:1524-1535. [PMID: 37490363 DOI: 10.1002/pmrj.13044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/09/2023] [Accepted: 07/14/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction. OBJECTIVE To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity. DESIGN Multicenter cohort study; cross-sectional sample. SETTING In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study. INTERVENTION Not applicable. METHODS A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD). MAIN OUTCOME MEASURES Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI). RESULTS One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001). CONCLUSION Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).
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Affiliation(s)
- Karen M Skop
- Physical Medicine and Rehabilitation Services, Department of Physical Therapy, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, University of South Florida, School of Physical Therapy, Tampa, Florida, USA
| | - Laura Bajor
- Mental Health and Behavioral Sciences Service, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
- Harvard South Shore Psychiatry Training Program, Brockton, Massachusetts, USA
| | - Mitch Sevigny
- Research Department, Craig Hospital, Englewood, Colorado, USA
| | - Chad Swank
- Baylor Scott & White Research Institute for Rehabilitation, Dallas, Texas, USA
- Baylor Scott White Research Institute, Dallas, Texas, USA
| | - Sudha Tallavajhula
- University of Texas McGovern Medical School, Houston, Texas, USA
- TIRR Memorial Hermann Neurological Sleep Disorders Center, Houston, Texas, USA
| | - Risa Nakase-Richardson
- Mental Health and Behavioral Sciences and Defense and Veterans' Brain Injury Center, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Morsani College of Medicine, Pulmonary and Sleep Medicine Division, University of South Florida, Tampa, Florida, USA
| | - Shannon R Miles
- Mental Health and Behavioral Sciences Service, James A Haley Veterans' Hospital, Tampa, Florida, USA
- Department of Psychiatry & Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Yang Z, Mitra A, Liu W, Berlowitz D, Yu H. TransformEHR: transformer-based encoder-decoder generative model to enhance prediction of disease outcomes using electronic health records. Nat Commun 2023; 14:7857. [PMID: 38030638 PMCID: PMC10687211 DOI: 10.1038/s41467-023-43715-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
Deep learning transformer-based models using longitudinal electronic health records (EHRs) have shown a great success in prediction of clinical diseases or outcomes. Pretraining on a large dataset can help such models map the input space better and boost their performance on relevant tasks through finetuning with limited data. In this study, we present TransformEHR, a generative encoder-decoder model with transformer that is pretrained using a new pretraining objective-predicting all diseases and outcomes of a patient at a future visit from previous visits. TransformEHR's encoder-decoder framework, paired with the novel pretraining objective, helps it achieve the new state-of-the-art performance on multiple clinical prediction tasks. Comparing with the previous model, TransformEHR improves area under the precision-recall curve by 2% (p < 0.001) for pancreatic cancer onset and by 24% (p = 0.007) for intentional self-harm in patients with post-traumatic stress disorder. The high performance in predicting intentional self-harm shows the potential of TransformEHR in building effective clinical intervention systems. TransformEHR is also generalizable and can be easily finetuned for clinical prediction tasks with limited data.
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Affiliation(s)
- Zhichao Yang
- College of Information and Computer Science, University of Massachusetts Amherst, Amherst, MA, USA
| | - Avijit Mitra
- College of Information and Computer Science, University of Massachusetts Amherst, Amherst, MA, USA
| | - Weisong Liu
- School of Computer & Information Sciences, University of Massachusetts Lowell, Lowell, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
| | - Dan Berlowitz
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA
- Department of Public Health, University of Massachusetts Lowell, Lowell, MA, USA
| | - Hong Yu
- College of Information and Computer Science, University of Massachusetts Amherst, Amherst, MA, USA.
- School of Computer & Information Sciences, University of Massachusetts Lowell, Lowell, MA, USA.
- Center for Healthcare Organization and Implementation Research, VA Bedford Health Care System, Bedford, MA, USA.
- Center for Biomedical and Health Research in Data Sciences, University of Massachusetts Lowell, Lowell, MA, USA.
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Keller AV, Muller-Cohn CM, Austin TA, Jak AJ, Twamley EW. Neuropsychological functioning, neurobehavioral symptoms, and community reintegration in unstably housed veterans with mental health conditions. Clin Neuropsychol 2023; 37:1728-1744. [PMID: 36772819 PMCID: PMC10415532 DOI: 10.1080/13854046.2023.2176364] [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: 08/09/2022] [Accepted: 01/30/2023] [Indexed: 02/12/2023]
Abstract
Objective: Returning Veterans often have conditions (e.g. posttraumatic stress disorder [PTSD], depression, and history of traumatic brain injury [TBI]) associated with cognitive dysfunction and problems with work, school, housing, and relationships. Rehabilitative efforts in Veterans aim to promote community reintegration, or successful adjustment in one's home, community, and desired social roles. We examined associations between neuropsychological performance, neurobehavioral symptoms, and community reintegration in Veterans. Method: 89 Iraq/Afghanistan Veterans at risk for homelessness and receiving residential mental healthcare completed a neuropsychological assessment and the Community Reintegration for Service Members-Computer Adaptive Test (CRIS-CAT). Neuropsychological components were derived using Principal Component Analysis. Bivariate Pearson correlations between neuropsychological variables, neurobehavioral symptoms, and CRIS-CAT scales (Extent of Participation, Perceived Limitations, and Satisfaction) were used to determine significant correlates of community reintegration. Regression models were used to examine associations between bivariate-significant neuropsychological components, neurobehavioral symptoms, and CRIS-CAT scales. Results: Bivariate analyses revealed that better community reintegration was associated with better performance in attention/executive functioning and fewer neurobehavioral symptoms. Three regression models examining predictors of variance in Extent of Participation, Perceived Limitations, and Satisfaction in community reintegration were statistically significant overall, with only fewer affective symptoms emerging as significantly and uniquely associated with greater participation and greater satisfaction in community functioning. Conclusions: Veterans with fewer affective symptoms reported greater participation and satisfaction with community functioning. Future longitudinal research examining associations between neurobehavioral symptoms, cognition, and risk factors of poorer community reintegration in unstably housed Veterans is warranted.
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Affiliation(s)
- Amber V. Keller
- SDSU/UC San Diego Joint Doctoral Program in Clinical Psychology
- Research Service, VA San Diego Healthcare System
| | - Chantal M. Muller-Cohn
- Research Service, VA San Diego Healthcare System
- California School of Professional Psychology, Alliant International University
| | - Tara A. Austin
- The VISN 17 Center of Excellence for Research on Returning War Veterans
| | - Amy J. Jak
- Mental Health Service, VA San Diego Healthcare System
- Department of Psychiatry, University of California San Diego
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
| | - Elizabeth W. Twamley
- Research Service, VA San Diego Healthcare System
- Department of Psychiatry, University of California San Diego
- Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System
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Kinney AR, Yan XD, Schneider AL, Rickles E, King SE, O'Donnell F, Forster JE, Brenner LA. Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics. Arch Phys Med Rehabil 2023; 104:1802-1811. [PMID: 37116557 DOI: 10.1016/j.apmr.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics. DESIGN In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics. SETTING Outpatient setting in the VHA. PARTICIPANTS 8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684). INTERVENTIONS None. MAIN OUTCOME MEASURE(S) OT utilization was measured within a year of M2PI administration using VHA administrative data. RESULTS Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904). CONCLUSIONS Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.
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Affiliation(s)
- Adam R Kinney
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO.
| | - Xiang-Dong Yan
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Alexandra L Schneider
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Emma Rickles
- University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Samuel E King
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO
| | - Frederica O'Donnell
- Department of Rehabilitation and Prosthetic Services, Veterans Health Administration, Washington, DC
| | - Jeri E Forster
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Department of Physical Medicine and Rehabilitation, Aurora, CO
| | - Lisa A Brenner
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Aurora, CO; University of Colorado, Anschutz Medical Campus, Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Aurora, CO
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Rawat BPS, Reisman J, Pogoda TK, Liu W, Rongali S, Aseltine RH, Chen K, Tsai J, Berlowitz D, Yu H, Carlson KF. Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017. JMIR Public Health Surveill 2023; 9:e42803. [PMID: 37486751 PMCID: PMC10407646 DOI: 10.2196/42803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/06/2023] [Accepted: 04/12/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD. OBJECTIVE Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017. METHODS All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores. RESULTS About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization. CONCLUSIONS Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.
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Affiliation(s)
- Bhanu Pratap Singh Rawat
- Manning College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States
| | - Joel Reisman
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Bedford, MA, United States
| | - Terri K Pogoda
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, United States
- Boston University School of Public Health, Boston, MA, United States
| | - Weisong Liu
- Center of Biomedical and Health Research in Data Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Subendhu Rongali
- Manning College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States
| | - Robert H Aseltine
- Division of Behavioral Sciences and Community Health, UConn Health, Farmington, CT, United States
| | - Kun Chen
- Department of Statistics, University of Connecticut, Storrs, CT, United States
| | - Jack Tsai
- Center of Biomedical and Health Research in Data Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Dan Berlowitz
- Center of Biomedical and Health Research in Data Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Hong Yu
- Manning College of Information and Computer Sciences, University of Massachusetts Amherst, Amherst, MA, United States
- Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, United States
- Center of Biomedical and Health Research in Data Sciences, University of Massachusetts Lowell, Lowell, MA, United States
| | - Kathleen F Carlson
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, United States
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, United States
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Kornblith E, Schweizer S, Abrams G, Gardner R, Barnes D, Yaffe K, Novakovic-Agopian T. Telehealth delivery of group-format cognitive rehabilitation to older veterans with TBI: a mixed-methods pilot study. APPLIED NEUROPSYCHOLOGY. ADULT 2023:1-13. [PMID: 37044120 DOI: 10.1080/23279095.2023.2199160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Traumatic brain injury (TBI) is common among Veterans and may interact with aging, increasing risk for negative cognitive, emotional, and functional outcomes. However, no accessible (i.e., in-home) group interventions for TBI targeted to older adults exist. Goal Oriented Attentional Self-Regulation (GOALS) is a manualized, group cognitive rehabilitation training that improves executive function and emotional regulation among Veterans with TBI and healthy older adults. Our objectives were to adapt GOALS for delivery to older Veterans via in-home video telehealth (IVT) and evaluate feasibility and participant-rated acceptability of the telehealth GOALS intervention (TeleGOALS). Six Veterans 69+, with multiple TBIs completed the 10-session intervention in groups of 2. One participant withdrew, and another completed the remaining sessions alone (total n enrolled = 8). Required adaptations were noted; questionnaire responses were quantified; and feedback was analyzed and coded to identify themes. Quantitative and qualitative methods were used to examine feasibility (i.e., recruitment and retention) and participant-rated acceptability. Minimal adaptations were required for IVT delivery. Key themes emerged: (a) the importance of telehealth logistics, (b) facilitators' roles in prioritizing interpersonal connection, and (c) telehealth's capability to create opportunities for community reintegration. Thematic saturation (the point at which feedback from respondents is consistent and no further adaptations are required) was achieved. Participants stated they would likely recommend TeleGOALS to other Veterans. Although further study with a larger, more diverse sample is required, the adapted TeleGOALS intervention appears highly feasible and acceptable for older Veterans with TBI able and willing to participate in a group-format IVT intervention.
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Affiliation(s)
- Erica Kornblith
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
| | - Sara Schweizer
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Gary Abrams
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
| | - Raquel Gardner
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
| | - Deborah Barnes
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, CA, USA
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
- Department of Neurology, UCSF, San Francisco, CA, USA
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, CA, USA
| | - Tatjana Novakovic-Agopian
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Psychiatry, University of California San Francisco (UCSF), San Francisco, CA, USA
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Holliday R, Smith AA, Kinney AR, Forster JE, Bahraini N, Monteith LL, Brenner LA. Research Letter: Traumatic Brain Injury Among Veterans Accessing VA Justice-Related Services. J Head Trauma Rehabil 2023; 38:184-190. [PMID: 36727701 DOI: 10.1097/htr.0000000000000822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (ie, justice-involved Veterans) remains limited. The sequelae of TBI can impact justice-involved Veterans' engagement in Department of Veterans Affairs (VA) justice-related services (ie, Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting psychosocial functioning. As such, further understanding of TBI risk among justice-involved Veterans has the potential to inform the need for tailored screening and interventional efforts within VA justice-related service settings. We sought to better understand relative risk for TBI diagnosis among male and female Veteran recipients and nonrecipients of VA justice-related services. SETTING Electronic medical record data for Veterans accessing VA services from 2005 to 2018. PARTICIPANTS 1517 447 (12.48% justice-involved) male and 126 237 (8.89% justice-involved) female Veterans. DESIGN A cross-sectional examination of national VA electronic medical record data. Sex-stratified analyses were conducted to examine relative risk of TBI diagnosis based on use of VA justice-related services. MAIN MEASURES Documented TBI diagnosis was the main outcome. Covariates included VA service use, age, race, and ethnicity. RESULTS Both male and female Veterans using VA justice-related services were more likely to have a documented TBI diagnosis in their electronic VA medical record. Associations were attenuated, yet maintained significance, in all adjusted and sensitivity models. CONCLUSIONS Given potential risk for TBI, enhancing and tailoring care for justice-involved Veterans may be critical to facilitating rehabilitation and reducing recidivism. Examination of existing services within justice-related settings and methods of augmenting care is an important next step.
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Affiliation(s)
- Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, Colorado (Drs Holliday, Kinney, Forster, Bahraini, Monteith, and Brenner and Ms Smith); Department of Psychiatry (Drs Holliday and Monteith), Department of Physical Medicine and Rehabilitation (Dr Forster), Departments of Physical Medicine and Rehabilitation, Psychiatry (Drs Bahraini), Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology (Dr Brenner), University of Colorado Anschutz Medical Campus, Aurora; and VA National Center on Homelessness Among Veterans, Washington, District of Columbia (Dr Holliday)
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11
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O’Neil J, Barnes K, Morgan Donnelly E, Sheehy L, Sveistrup H. Identification and description of telerehabilitation assessments for individuals with neurological conditions: A scoping review. Digit Health 2023; 9:20552076231183233. [PMID: 37377560 PMCID: PMC10291871 DOI: 10.1177/20552076231183233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Background The clinical adoption of telerehabilitation accelerated rapidly over the last few years, creating opportunities for clinicians and researchers to explore the use of digital technologies and telerehabilitation in the assessment of deficits related to neurological conditions. The objectives of this scoping review were to identify outcome measures used to remotely assess the motor function and participation in people with neurological conditions and report, when available, the psychometric data of these remote outcome measures. Methods MEDLINE (Ovid), CINAHL, PubMed, PsychINFO, EMBASE, and Cochrane databases were searched between December 13, 2020, and January 4, 2021, for studies investigating the use of remote assessments to evaluate motor function and participation in people with neurological conditions. An updated search was completed on May 9, 2022, using the same databases and search terms. Two reviewers independently screened each title and abstract, followed by full-text screening. Data extraction was completed using a pre-piloted data extraction sheet where outcome measures were reported as per the International Classification of Functioning, Disability and Health. Results Fifty studies were included in this review. Eighteen studies targeted outcomes related to body structures and 32 targeted those related to activity limitation and participation restriction. Seventeen studies reported psychometric data; of these, most included reliability and validity data. Conclusion Clinical assessments of motor function of people living with neurological conditions can be completed in a telerehabilitation or remote context using validated and reliable remote assessment measures.
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Affiliation(s)
- Jennifer O’Neil
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Keely Barnes
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Lisa Sheehy
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Heidi Sveistrup
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
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12
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Merritt VC, Crocker LD, Sakamoto MS, Chanfreau-Coffinier C, Delano-Wood L. Psychiatric symptoms influence social support in VA Million Veteran Program enrollees screening positive for traumatic brain injury. Soc Sci Med 2022; 312:115372. [PMID: 36162363 DOI: 10.1016/j.socscimed.2022.115372] [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: 02/08/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine measures of social support and associations with neurobehavioral, psychiatric, and cognitive symptoms in Veterans who underwent the Veterans Health Administration's Traumatic Brain Injury (TBI) Screening and Evaluation Program. SETTING Nationally representative sample of U.S. Veterans enrolled in the Veterans Affairs Million Veteran Program. PARTICIPANTS Veterans (N = 9,837) were classified into the following three diagnostic groups based on results from the TBI Screening and Evaluation Program: (1) negative TBI screen (Screen-; n = 6,523), (2) positive TBI screen but no TBI diagnosis (Screen+/TBI-; n = 1,308), or (3) positive TBI screen and TBI diagnosis (Screen+/TBI+; n = 2,006). DESIGN Epidemiological cross-sectional study. MAIN MEASURES Medical Outcomes Study Social Support Survey Instrument (MOS-SSSI), with subscales representing emotional, tangible, and affectionate support and positive social interaction; Neurobehavioral Symptom Inventory (NSI); PTSD Checklist (PCL); Patient Health Questionnaire-4 (PHQ-4); and Medical Outcomes Study Cognitive Functioning-Revised Scale (MOS-Cog-R). RESULTS ANCOVAs showed significant associations between diagnostic group and all aspects of social support. Pairwise comparisons revealed that Veterans in the two Screen+ groups (Screen+/TBI+ and Screen+/TBI-) reported comparable levels of social support, but that both Screen+ groups reported significantly lower levels of social support compared to the Screen- group. Among the Screen+ groups, adjusted linear regression models controlling for age, sex, and race/ethnicity showed significant associations between social support indices and all symptom measures, such that lower levels of social support were associated with more severe neurobehavioral and psychiatric symptoms and worse cognitive functioning. Finally, mediation analyses showed that psychiatric symptoms mediated the association between TBI screen group and social support. CONCLUSIONS Our results are clinically informative and suggest (1) that the relationship between TBI screen status and social support is influenced by psychiatric symptoms and (2) that implementing distress reduction techniques before social support interventions may be most beneficial for Veterans screening positive for TBI.
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Affiliation(s)
- Victoria C Merritt
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States; Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, United States.
| | - Laura D Crocker
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States; Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, United States
| | - McKenna S Sakamoto
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States
| | - Catherine Chanfreau-Coffinier
- VA Informatics and Computing Infrastructure (VINCI), VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Lisa Delano-Wood
- Research & Psychology Services, VA San Diego Healthcare System (VASDHS), San Diego, CA, United States; Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, United States; Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, United States
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13
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Kinney AR, Yan XD, Schneider AL, King S, Forster JE, Bahraini N, Brenner LA. Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury. FRONTIERS IN REHABILITATION SCIENCES 2022; 3:964420. [PMID: 36311204 PMCID: PMC9597091 DOI: 10.3389/fresc.2022.964420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/14/2022] [Indexed: 11/05/2022]
Abstract
Background Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI. Materials and Methods This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression). Results 87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37). Discussion Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.
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Affiliation(s)
- Adam R. Kinney
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States,Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States,Correspondence: Adam R. Kinney
| | - Xiang-Dong Yan
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States
| | - Alexandra L. Schneider
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States
| | - Samuel King
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States
| | - Jeri E. Forster
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States,Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Nazanin Bahraini
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States,Departments of Physical Medicine and Rehabilitation and Psychiatry, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lisa A. Brenner
- Department of Veterans Affairs (VA) Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Aurora, CO, United States,Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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14
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Rao WW, Li M, Su Y, Caron J, Xiang YT, Meng X. How psychosocial stress profile influences the subsequent occurrence of neuropsychiatric comorbidities: A longitudinal population-based cohort study. J Affect Disord 2022; 311:294-302. [PMID: 35588911 DOI: 10.1016/j.jad.2022.05.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/31/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The role of psychosocial stressors in psychiatric disorders and executive dysfunction has been reported, separately. The literature has also suggested the involvement of social support and coping strategies in these relationships. However, there is a lack of research conducted to examine the relationships among multiple stressors and neuropsychiatric comorbidities while considering the presence of social support and coping strategies. This study aims to articulate the roles of multiple psychosocial stressors, social support, and coping strategies in the subsequent occurrence of neuropsychiatric comorbidities. METHODS Data analyzed were from the 6th data collection of a large-scale, longitudinal population-based cohort from Southwest Montreal in Canada. The cumulative effects of multiple stressors were separately examined by a composite score and latent profile analysis. Multinomial logistic regression models were used to test the relationship between cumulative stressors and neuropsychiatric comorbidities. RESULTS A total of 210 participants were included in the analyses. The LPA identified a 2-class model for psychosocial stressors (low and high) and executive function (executive dysfunction and no executive dysfunction), respectively. There were 11.8% of participants with neuropsychiatric comorbidities. Both the composite stress score (RR = 1.08, 95%CI = 1.01-1.15) and latent stress groups (RR = 3.65, 95%CI = 1.15-11.57) were associated with neuropsychiatric comorbidities after adjusting for social support and coping strategies. The risk of developing neuropsychiatric comorbidities decreased when the level of social support was high (P < 0.05). CONCLUSIONS Exposures to multiple stressors increased the risk of subsequent neuropsychiatric comorbidities, but the risk can be modified by a higher level of social support.
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Affiliation(s)
- Wen-Wang Rao
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Douglas Research Centre, Montreal, Quebec, Canada
| | - Muzi Li
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Douglas Research Centre, Montreal, Quebec, Canada
| | - Yingying Su
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Douglas Research Centre, Montreal, Quebec, Canada
| | - Jean Caron
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Douglas Research Centre, Montreal, Quebec, Canada
| | - Yu-Tao Xiang
- Unit of Psychiatry, Department of Public Health and Medicinal Administration, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao SAR, China; Centre for Cognitive and Brain Sciences, University of Macau, Macao SAR, China; Institute of Advanced Studies in Humanities and Social Sciences, University of Macau, Macao SAR, China
| | - Xiangfei Meng
- Department of Psychiatry, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada; Douglas Research Centre, Montreal, Quebec, Canada.
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15
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Lama S, Damkliang J, Kitrungrote L. Predictive factors for community integration among Nepalese persons after traumatic brain injury. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086221088104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Various factors affect the community integration (CI) of persons experiencing traumatic brain injury (TBI). To ensure positive outcomes in terms of life at home, social activities, and productive work among persons suffering TBI, it is necessary to understand the factors that facilitate or impede CI. Purpose To compare CI by looking at demographic and clinical characteristics and determine significant predictors of CI among TBI Nepalese persons. Methods 120 participants were selected using a stratified random sampling technique. A questionnaire was used to identify the participants’ demographic and clinical characteristics, and the Community Integration Questionnaire was used to measure CI. Univariate and multivariate analyses were performed for demographic and clinical factors associated with community integration. Results Using univariate analysis, male, employed, living with family, and independence in performing activities of daily living had significantly higher CI scores than female (t = −4.18, p<.000), unemployed (t = −10.52, p<.000), living with friends (t = −3.30, p<.001), and those with moderate to slight dependence (t = −2.83, p<.005). The multivariate analysis revealed that employment status, living with family, and length of hospital stay were significant predictors of CI among TBI Nepalese persons. Conclusion Employment status, living with family, and length of hospital stay were significant predictors of CI. These findings suggest that rehabilitation efforts should focus on minimizing hospital stay and promoting both productive and social activities among people surviving TBI.
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Merritt VC, Brickell TA, Bailie JM, Hungerford L, Lippa SM, French LM, Lange RT. Low resilience following traumatic brain injury is strongly associated with poor neurobehavioral functioning in U.S. military service members and veterans. Brain Inj 2022; 36:339-352. [PMID: 35171749 DOI: 10.1080/02699052.2022.2034183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE The purpose of this study was to examine the relationship between resilience and self-reported neurobehavioral functioning following traumatic brain injury (TBI) in U.S. military service members and veterans (SMVs). A secondary objective was to examine the interaction between resilience and posttraumatic stress disorder (PTSD) on neurobehavioral functioning. METHOD Participants included 795 SMVs classified into four groups: Uncomplicated Mild TBI (MTBI; n=300); Complicated Mild, Moderate, Severe, or Penetrating TBI (STBI, n 162); Injured Controls (IC, n=185); and Non-injured Controls (NIC, n=148). Two independent cohorts were evaluated - those assessed within 1-year of injury and those assessed 10-years post-injury. SMVs completed self-report measures including the PTSD Checklist-Civilian version, Neurobehavioral Symptom Inventory, and TBI-Quality of Life. RESULTS Results showed that (1) lower resilience was strongly associated with poorer neurobehavioral functioning across all groups at 1-year and 10-years post-injury, and (2) PTSD and resilience had a robust influence on neurobehavioral functioning at both time periods post-injury, such that SMVs with PTSD and low resilience displayed the poorest neurobehavioral functioning. CONCLUSION Results suggest that regardless of injury group and time since injury, resilience and PTSD strongly influence neurobehavioral functioning following TBI among SMVs. Future research evaluating interventions designed to enhance resilience in this population is indicated.
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Affiliation(s)
- Victoria C Merritt
- Research Service, VA San Diego Healthcare System, San Diego, CA, USA.,Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Contractor, General Dynamics Information Technology, Falls Church, VA, USA
| | - Jason M Bailie
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Contractor, General Dynamics Information Technology, Falls Church, VA, USA.,Naval Hospital Camp Pendleton, Oceanside, CA, Oceanside, CA, USA
| | - Lars Hungerford
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Contractor, General Dynamics Information Technology, Falls Church, VA, USA.,Naval Medical Center San Diego, San Diego, CA, USA
| | - Sara M Lippa
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Rael T Lange
- Traumatic Brain Injury Center of Excellence, Silver Spring, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA.,National Intrepid Center of Excellence, Bethesda, MD, USA.,Contractor, General Dynamics Information Technology, Falls Church, VA, USA.,University of British Columbia, Vancouver, BCCanada
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Changes in the health and broader well-being of U.S. veterans in the first three years after leaving military service: Overall trends and group differences. Soc Sci Med 2022; 294:114702. [PMID: 35051742 DOI: 10.1016/j.socscimed.2022.114702] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/30/2021] [Accepted: 01/04/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Scholars have theorized that the initial period after military discharge may be a particularly vulnerable time for veterans. Yet, several recent studies raise the prospect that risk for poor adjustment may actually increase rather than decrease over time. The current study examined whether the U.S. military veteran population experiences improvements or declines in their health and broader well-being during the first three years after leaving military service and documented differences based on gender, military rank, and warzone deployment history. METHODS A population-based sample of 3733 newly separated veterans completed a survey within three months of separation (Fall 2016), followed by five additional surveys at six-month intervals. Weighted multilevel logistic regressions were conducted to examine changes in the proportion of veterans reporting good health and broader well-being over time. RESULTS Most aspects of veterans' health and broader well-being worsened over time, with a noteworthy increase in reporting of mental health conditions and a decline in veterans' community involvement. Declines in the proportion of veterans reporting good health and well-being were most notable for women, with smaller differences observed for other subgroups. CONCLUSIONS The finding that veterans experienced worsening health and broader well-being over time highlights the need for enhanced prevention and early intervention efforts to mitigate these declines. Findings also point to the importance of attending to the unique readjustment concerns of female veterans and other at-risk subgroups.
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Fahey AM, Bain KM, Critchfield EA. "I Couldn't Be Better": Assessing Self-Awareness With the Mayo-Portland Adaptability Inventory-4 Following TBI. J Head Trauma Rehabil 2021; 36:E373-E380. [PMID: 33782347 DOI: 10.1097/htr.0000000000000670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION/OBJECTIVE To describe level of awareness, as assessed by the Mayo-Portland Adaptability Inventory-4 (MPAI-4), across physical, cognitive, functional, and emotional domains in individuals with mild, moderate, and severe traumatic brain injury (TBI) participating in a residential rehabilitation program. In addition, this study aimed to examine the relationship between time since injury and awareness. A novel way the MPAI-4 can be used to measure self-awareness is also presented. METHOD Retrospective analysis of existing data. The MPAI-4 was completed by the patient on admission, as well as by provider consensus within 2 weeks of admission. Level of awareness was determined by discrepancy scores, computed as MPAI-4 provider consensus score minus self-report MPAI-4 score, for the total score and for each index score: Ability, Adjustment, and Participation. PARTICIPANTS A total of 101 military veterans and active duty service members admitted to a Veterans Affairs community reintegration rehabilitation program. RESULTS Discrepancies between patient and provider reports of functioning were found among all severities of TBI across the MPAI-4 total score and index domains measuring Ability, Adjustment, and Participation. Interestingly, those with mild TBI endorsed greater impairments than their providers, while those with moderate and severe TBI reported less impairment on the MPAI-4 than providers. The effect of time varied across domains, and those who were more than 1 year postinjury displayed greater self-awareness. CONCLUSION This study highlights the importance of measuring awareness of functional ability over time and across TBI severity and introduces a novel method for doing so, using the MPAI-4 for comparison between staff and patient reports.
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Affiliation(s)
- Amber M Fahey
- Psychology Service, South Texas Veterans Health Care System, San Antonio
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Uzdavines A, Gonzalez RD, Price A, Broadway D, Smith TL, Rodrigues M, Woods K, Zimmerman MB, Jorge R, Dindo L. Acceptance and Commitment Training for Veterans with polytrauma: A randomized controlled trial protocol. Contemp Clin Trials 2021; 111:106601. [PMID: 34687944 DOI: 10.1016/j.cct.2021.106601] [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: 07/13/2021] [Revised: 09/20/2021] [Accepted: 10/17/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination - referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response. METHODS This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic. RESULTS The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months. CONCLUSION Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.
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Affiliation(s)
- Alex Uzdavines
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America
| | - Raquel D Gonzalez
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - Alexandra Price
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Dakota Broadway
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - Tracey L Smith
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America
| | - Merlyn Rodrigues
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Ken Woods
- South Central Mental Illness Research, Education, and Clinical Center, Michael E. DeBakey VA Medical Center, Houston, TX, United States of America
| | - M Bridget Zimmerman
- College of Public Health, University of Iowa, Iowa City, IA, United States of America
| | - Ricardo Jorge
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America
| | - Lilian Dindo
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America; Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States of America.
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20
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Troyanskaya M, Pastorek NJ, Walder A, Wilde EA, Kennedy JE, Levin HS, Scheibel RS. Role of deployment-related mTBI and resilience in perceived participation limitations among Veterans. MILITARY PSYCHOLOGY 2021. [DOI: 10.1080/08995605.2021.1962191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Maya Troyanskaya
- Michael E. DeBakey Veterans Affairs Medical Center Houston, Houston, Texas, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine Houston, Houston, Texas, USA
| | - Nicholas J. Pastorek
- Michael E. DeBakey Veterans Affairs Medical Center Houston, Houston, Texas, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine Houston, Houston, Texas, USA
| | - Annette Walder
- Michael E. DeBakey Veterans Affairs Medical Center Houston, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine Houston, Houston, Texas, USA
| | - Elisabeth A. Wilde
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine Houston, Houston, Texas, USA
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
- George E. Wahlen Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Jan E. Kennedy
- DefenseTX And Veterans Brain Injury Center, Brooke Army Medical Center Ft Sam Houston, San Antonio, Texas, USA
- General Dynamics Information Technology Falls Church, Falls Church, Virginia, USA
| | - Harvey S. Levin
- Michael E. DeBakey Veterans Affairs Medical Center Houston, Houston, Texas, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine Houston, Houston, Texas, USA
- Department of Neurology, Baylor College of Medicine Houston, Houston, Texas, USA
- Department of Neurosurgery, Baylor College of Medicine Houston, Houston, Texas, USA
- Department of Pediatrics, Baylor College of Medicine Houston, Houston, Texas, USA
| | - Randall S. Scheibel
- Michael E. DeBakey Veterans Affairs Medical Center Houston, Houston, Texas, USA
- H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine Houston, Houston, Texas, USA
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21
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Pugh MJ, Kennedy E, Gugger JJ, Mayo J, Tate D, Swan A, Kean J, Altalib H, Gowda S, Towne A, Hinds S, Van Cott A, Lopez MR, Jaramillo CA, Eapen BC, McCafferty RR, Salinsky M, Cramer J, McMillan KK, Kalvesmaki A, Diaz-Arrastia R. The Military Injuries: Understanding Post-Traumatic Epilepsy Study: Understanding Relationships among Lifetime Traumatic Brain Injury History, Epilepsy, and Quality of Life. J Neurotrauma 2021; 38:2841-2850. [PMID: 34353118 PMCID: PMC8820288 DOI: 10.1089/neu.2021.0015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Understanding risk for epilepsy among persons who sustain a mild (mTBI) traumatic brain injury (TBI) is crucial for effective intervention and prevention. However, mTBI is frequently undocumented or poorly documented in health records. Further, health records are non-continuous, such as when persons move through health systems (e.g., from Department of Defense to Veterans Affairs [VA] or between jobs in the civilian sector), making population-based assessments of this relationship challenging. Here, we introduce the MINUTE (Military INjuries-Understanding post-Traumatic Epilepsy) study, which integrates data from the Veterans Health Administration with self-report survey data for post-9/11 veterans (n = 2603) with histories of TBI, epilepsy and controls without a history of TBI or epilepsy. This article describes the MINUTE study design, implementation, hypotheses, and initial results across four groups of interest for neurotrauma: 1) control; 2) epilepsy; 3) TBI; and 4) post-traumatic epilepsy (PTE). Using combined survey and health record data, we test hypotheses examining lifetime history of TBI and the differential impacts of TBI, epilepsy, and PTE on quality of life. The MINUTE study revealed high rates of undocumented lifetime TBIs among veterans with epilepsy who had no evidence of TBI in VA medical records. Further, worse physical functioning and health-related quality of life were found for persons with epilepsy + TBI compared to those with either epilepsy or TBI alone. This effect was not fully explained by TBI severity. These insights provide valuable opportunities to optimize the resilience, delivery of health services, and community reintegration of veterans with TBI and complex comorbidity.
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Affiliation(s)
- Mary Jo Pugh
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eamonn Kennedy
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - James J. Gugger
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jamie Mayo
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - David Tate
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alicia Swan
- Department of Psychology, University of Texas San Antonio, San Antonio, Texas, USA
| | - Jacob Kean
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hamada Altalib
- Epilepsy Center of Excellence VA Connecticut Health Care System, West Haven, Connecticut, USA; Departments of Neurology and Psychiatry, Yale University School of Medicine, West Haven, Connecticut, USA
| | - Shaila Gowda
- Department of Neurology, Baylor School of Medicine, Houston, Texas, USA
| | - Alan Towne
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA; Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Sidney Hinds
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Anne Van Cott
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA; Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maria R. Lopez
- Miami VA Health Care System, Miami, Florida, USA; Department of Neurology, University of Miami School of Medicine, Miami, Florida, USA
| | - Carlos A. Jaramillo
- Polytrauma Rehabilitation Center, South Texas Veterans Healthcare System, San Antonio, Texas, USA
| | - Blessen C. Eapen
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA; University of California Los Angeles, Los Angeles, California, USA
| | | | - Martin Salinsky
- VA Portland Healthcare System, Portland, Oregon, USA; Oregon Health & Sciences University, Portland, Oregon, USA
| | - Joyce Cramer
- Department of Neurology, Baylor School of Medicine, Houston, Texas, USA
- Cramer Consulting, Houston, Texas, USA
| | | | - Andrea Kalvesmaki
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Haarbauer-Krupa J, Pugh MJ, Prager EM, Harmon N, Wolfe J, Yaffe K. Epidemiology of Chronic Effects of Traumatic Brain Injury. J Neurotrauma 2021; 38:3235-3247. [PMID: 33947273 PMCID: PMC9122127 DOI: 10.1089/neu.2021.0062] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the person and their family. Factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the person’s age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, sex, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of persons and potentially impact differential disease progression, we can guide investigators and clinicians toward more-precise patient diagnosis, along with tailored management, and improve clinical trial designs, data evaluation, and patient selection criteria.
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Affiliation(s)
- Juliet Haarbauer-Krupa
- Division of Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mary Jo Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | | | - Kristine Yaffe
- Department of Neurology, University of California San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Departments of Epidemiology/Biostatistics and Psychiatry, University of California San Francisco, San Francisco, California, USA
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23
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Race NS, Andrews KD, Lungwitz EA, Vega Alvarez SM, Warner TR, Acosta G, Cao J, Lu KH, Liu Z, Dietrich AD, Majumdar S, Shekhar A, Truitt WA, Shi R. Psychosocial impairment following mild blast-induced traumatic brain injury in rats. Behav Brain Res 2021; 412:113405. [PMID: 34097900 DOI: 10.1016/j.bbr.2021.113405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) is associated with increased risk for mental health disorders, impacting post-injury quality of life and societal reintegration. TBI is also associated with deficits in psychosocial processing, defined as the cognitive integration of social and emotional behaviors, however little is known about how these deficits manifest and their contributions to post-TBI mental health. In this pre-clinical investigation using rats, a single mild blast TBI (mbTBI) induced impairment of psychosocial processing in the absence of confounding physical polytrauma, post-injury motor deficits, affective abnormalities, or deficits in non-social behavior. Impairment severity correlated with acute upregulations of a known oxidative stress metabolite, 3-hydroxypropylmercapturic acid (3-HPMA), in urine. Resting state fMRI alterations in the acute post-injury period implicated key brain regions known to regulate psychosocial behavior, including orbitofrontal cortex (OFC), which is congruent with our previous report of elevated acrolein, a marker of neurotrauma and 3-HPMA precursor, in this region following mbTBI. OFC of mbTBI-exposed rats demonstrated elevated mRNA expression of metabotropic glutamate receptors 1 and 5 (mGluR1/5) and injection of mGluR1/5-selective agonist in OFC of uninjured rats approximated mbTBI-induced psychosocial processing impairment, demonstrating a novel role for OFC in this psychosocial behavior. Furthermore, OFC may serve as a hotspot for TBI-induced disruption of psychosocial processing and subsequent mental health disorders.
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Affiliation(s)
- Nicholas S Race
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; Medical Scientist Training Program, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katharine D Andrews
- Medical Scientist Training Program, Indiana University School of Medicine, Indianapolis, IN, USA; Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Program in Medical Neuroscience, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Elizabeth A Lungwitz
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Program in Medical Neuroscience, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sasha M Vega Alvarez
- PULSe Interdisciplinary Life Science Program, Purdue University, West Lafayette, IN, USA
| | - Timothy R Warner
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Anatomy, Cellular Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Glen Acosta
- Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA
| | - Jiayue Cao
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA
| | - Kun-Han Lu
- Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA; School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, USA
| | - Zhongming Liu
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA; School of Electrical and Computer Engineering, Purdue University, West Lafayette, IN, USA
| | - Amy D Dietrich
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Anatomy, Cellular Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sreeparna Majumdar
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Program in Medical Neuroscience, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Anantha Shekhar
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana Clinical and Translational Sciences Institute, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William A Truitt
- Paul and Carole Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Anatomy, Cellular Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Riyi Shi
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN, USA; PULSe Interdisciplinary Life Science Program, Purdue University, West Lafayette, IN, USA; Department of Basic Medical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN, USA; Purdue Institute for Integrative Neuroscience, Purdue University, West Lafayette, IN, USA; Center for Paralysis Research, West Lafayette, IN, USA.
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24
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Pugh MJ, Kennedy E, Prager EM, Humpherys J, Dams-O'Connor K, Hack D, McCafferty MK, Wolfe J, Yaffe K, McCrea M, Ferguson AR, Lancashire L, Ghajar J, Lumba-Brown A. Phenotyping the Spectrum of Traumatic Brain Injury: A Review and Pathway to Standardization. J Neurotrauma 2021; 38:3222-3234. [PMID: 33858210 PMCID: PMC8917880 DOI: 10.1089/neu.2021.0059] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
It is widely appreciated that the spectrum of traumatic brain injury (TBI), mild through severe, contains distinct clinical presentations, variably referred to as subtypes, phenotypes, and/or clinical profiles. As part of the Brain Trauma Blueprint TBI State of the Science, we review the current literature on TBI phenotyping with an emphasis on unsupervised methodological approaches, and describe five phenotypes that appear similar across reports. However, we also find the literature contains divergent analysis strategies, inclusion criteria, findings, and use of terms. Further, whereas some studies delineate phenotypes within a specific severity of TBI, others derive phenotypes across the full spectrum of severity. Together, these facts confound direct synthesis of the findings. To overcome this, we introduce PhenoBench, a freely available code repository for the standardization and evaluation of raw phenotyping data. With this review and toolset, we provide a pathway toward robust, data-driven phenotypes that can capture the heterogeneity of TBI, enabling reproducible insights and targeted care.
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Affiliation(s)
- Mary Jo Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eamonn Kennedy
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jeffrey Humpherys
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kristen Dams-O'Connor
- Department of Rehabilitation and Human Performance, Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dallas Hack
- Cohen Veterans Bioscience, New York, New York, USA
| | - Mary Katherine McCafferty
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City, Salt Lake City, Utah, USA.,Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Kristine Yaffe
- Department of Neurology, University of California San Francisco, California, USA.,Department of Psychiatry, University of California San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee Wisconsin, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California San Francisco, California, USA.,San Francisco Veterans Affairs Health System, San Francisco, California, USA
| | | | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.,Brain Performance Center, Stanford University School of Medicine, Stanford, California, USA
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA.,Brain Performance Center, Stanford University School of Medicine, Stanford, California, USA
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25
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Park CL, Sacco SJ, Finkelstein-Fox L, Sinnott SM, Scoglio AAJ, Lee SY, Gnall KE, Mazure C, Shirk SD, Hoff RA, Kraus SW. Post-9/11 military veterans' adjustment to civilian life over time following separation from service. J Clin Psychol 2021; 77:2077-2095. [PMID: 33871869 DOI: 10.1002/jclp.23144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/18/2021] [Accepted: 03/25/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVES US military veterans face many challenges in transitioning to civilian life; little information is available regarding veterans' reintegration experiences over time. The current study characterized veterans' postdeployment stressful life events and concurrent psychosocial wellbeing over one year and determined how stressors and wellbeing differ by demographic factors. METHODS Recent Post-911 veterans (n = 402) were assessed approximately every three months for 1 year. Participants were 60% men, primarily White (78%), and 12% Latinx; the average age was 36 years. RESULTS The frequency of stressful events decreased over time but was higher for men and minority-race veterans (independent of time since separation). Veterans reported high mean levels of posttraumatic stress disorder, anxiety, and insomnia symptoms, which improved slightly over time. Minority-race and Latinx veterans had higher symptom levels and slower rates of symptom reduction. CONCLUSION Veterans remain distressed in their overall transition to civilian life. Interventions to promote resilience and help veterans manage readjustment to civilian life appear urgently needed.
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Affiliation(s)
- Crystal L Park
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Shane J Sacco
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Lucy Finkelstein-Fox
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Sinead M Sinnott
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Arielle A J Scoglio
- Institute for Health Equity and Social Justice Research, Northeastern University, Boston, Massachusetts, USA
| | - Sharon Y Lee
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Katherine E Gnall
- Department of Psychological Sciences, University of Connecticut, Storrs, Connecticut, USA
| | - Carolyn Mazure
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Steven D Shirk
- Division of Addiction, VISN1 New England MIRECC, Edith Nourse Rogers Memorial Veterans Hospital and University of Massachusetts Medical School, Bedford, Massachusetts, USA
| | - Rani A Hoff
- Northeast Program Evaluation Center (NEPEC), VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Shane W Kraus
- Department of Psychology, University of Nevada, Las Vegas, Nevada, USA
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26
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The Enduring Health Consequences of Combat Trauma: a Legacy of Chronic Disease. J Gen Intern Med 2021; 36:713-721. [PMID: 32959346 PMCID: PMC7947104 DOI: 10.1007/s11606-020-06195-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/27/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND A better understanding of the long-term health effects of combat injury is important for the management of veterans' health in the Department of Defense (DoD) and Veterans Affairs (VA) health care systems and may have implications for primary care management of civilian trauma patients. OBJECTIVE To determine the impact of traumatic injury on the subsequent development of hypertension (HTN), diabetes mellitus (DM), and coronary artery disease (CAD) after adjustment for sociodemographic, health behavior, and mental health factors. DESIGN Retrospective cohort study of current and former US military personnel with data obtained from both the DoD and VA health care systems. PARTICIPANTS Combat injured (n = 8727) service members between 1 February 2002 and 14 June 2016 randomly selected from the DoD Trauma Registry matched 1:1 based on year of birth, sex, and branch of service to subjects that deployed to a combat zone but were not injured. MAIN MEASURES Traumatic injury, stratified by severity, compared with no documented injury. Diagnoses of HTN, DM, and CAD defined by International Classification of Diseases 9th or 10th Revision Clinical Modification codes. KEY RESULTS After adjustment, severe traumatic injury was significantly associated with HTN (HR 2.78, 95% CI 2.18-3.55), DM (HR 4.45, 95% CI 2.15-9.18), and CAD (HR 4.87, 95% CI 2.11-11.25), compared with no injury. Less severe injury was associated with HTN (HR 1.14, 95% CI 1.05-1.24) and CAD (HR 1.62, 95% CI 1.11-2.37). CONCLUSIONS Severe traumatic injury is associated with the subsequent development of HTN, DM, and CAD. These findings have profound implications for the primary care of injured service members in both the DoD/VA health systems and may be applicable to civilian trauma patients as well. Further exploration of pathophysiologic, health behavior, and mental health changes after trauma is warranted to guide future intervention strategies.
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27
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Hosting Community Events for Veterans and Planning for Invisible Disabilities. Arch Phys Med Rehabil 2021; 102:2275-2277. [PMID: 33648720 DOI: 10.1016/j.apmr.2020.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
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28
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Vogt D, King MW, Borowski S, Finley EP, Perkins DF, Copeland LA. Identifying factors that contribute to military veterans' post-military well-being. Appl Psychol Health Well Being 2021; 13:341-356. [PMID: 33595207 DOI: 10.1111/aphw.12252] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
Prior research has examined the independent effects of demographic and military characteristics, trauma history, and coping resources on military veterans' health. However, there is limited knowledge of how these factors intersect with one another and with veterans' health to impact their broader well-being as they readjust to civilian life. Data for this study were drawn from a longitudinal investigation of the health and broader well-being of U.S. veterans (N = 7150) who had recently left military service. Machine learning analyses (random forests of regression trees) were used to examine how factors assessed shortly after military separation were associated with veterans' well-being approximately a year later. Veterans who endorsed the combination of low depression, high social support, and high psychological resilience were most likely to report high well-being a year later. Neither demographic and military characteristics nor trauma history emerged as strong predictors of veterans' well-being when considered in the context of other factors. Although most predictors were similar for women and men, depression was a stronger predictor of women's well-being. Results highlight the importance of screening for and intervening with veterans who report high depression, low social support, and low psychological resilience when leaving military service. These findings can inform efforts to promote veterans' post-military well-being.
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Affiliation(s)
- Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD (116B-3), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Matthew W King
- Women's Health Sciences Division, National Center for PTSD (116B-3), VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shelby Borowski
- Women's Health Sciences Division, National Center for PTSD (116B-3), VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Erin P Finley
- Veterans Evidence-Based Research Dissemination and Implementation Center, South Texas Veterans Healthcare System, San Antonio, Texas, USA.,Departments of Medicine and Psychiatry, UT Health San Antonio, San Antonio, Texas, USA
| | - Daniel F Perkins
- Clearinghouse for Military Family Readiness, Pennsylvania State University, State College, Pennsylvania, USA.,Department of Agricultural Economics, Sociology, and Education, Pennsylvania State University, State College, Pennsylvania, USA.,Social Science Research Institute, Pennsylvania State University, State College, Pennsylvania, USA
| | - Laurel A Copeland
- VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Bouldin ED, Swan AA, Norman RS, Tate DF, Tumminello C, Amuan ME, Eapen BC, Wang CP, Trevino A, Pugh MJ. Health Phenotypes and Neurobehavioral Symptom Severity Among Post-9/11 Veterans With Mild Traumatic Brain Injury: A Chronic Effects of Neurotrauma Consortium Study. J Head Trauma Rehabil 2021; 36:10-19. [PMID: 32472834 PMCID: PMC10649312 DOI: 10.1097/htr.0000000000000574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate whether neurobehavioral symptoms differ between groups of veterans with mild traumatic brain injury (mTBI) classified by health characteristics. PARTICIPANTS A total of 71 934 post-9/11 veterans with mTBI from the Chronic Effects of Neurotrauma Consortium Epidemiology warfighter cohort. DESIGN Cross-sectional analysis of retrospective cohort. MAIN MEASURES Health phenotypes identified using latent class analysis of health and function over 5 years. Symptom severity measured using Neurobehavioral Symptom Inventory; domains included vestibular, somatic, cognitive, and affective. RESULTS Veterans classified as moderately healthy had the lowest symptom burden while the polytrauma phenotype group had the highest. After accounting for sociodemographic and injury characteristics, polytrauma phenotype veterans had about 3 times the odds of reporting severe symptoms in each domain compared with moderately healthy veterans. Those veterans who were initially moderately healthy but whose health declined over time had about twice the odds of severe symptoms as consistently healthier Veterans. The strongest associations were in the affective domain. Compared with the moderately healthy group, veterans in other phenotypes were more likely to report symptoms substantially interfered with their daily lives (odds ratio range: 1.3-2.8). CONCLUSION Symptom severity and interference varied by phenotype, including between veterans with stable and declining health. Ameliorating severe symptoms, particularly in the affective domain, could improve health trajectories following mTBI.
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Affiliation(s)
- Erin D Bouldin
- Department of Health and Exercise Science, Appalachian State University, Boone, North Carolina (Dr Bouldin); Department of Psychology, University of Texas at San Antonio (Dr Swan); Speech-Language Pathology Program, School of Health Professions, University of Texas Health Science Center at San Antonio (Dr Norman); George E. Whalen VA Medical Center, Salt Lake City, Utah (Dr Tate); Departments of Neurology (Dr Tate) and Internal Medicine (Dr Pugh), University of Utah School of Medicine, Salt Lake City; Lees-McRae College, Banner Elk, North Carolina (Ms Tumminello); VA Salt Lake City Health Care System, Informatics, Decision-Enhancement, and Analytic Sciences Center, Salt Lake City, Utah (Mss Amuan and Trevino and Dr Pugh); Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Health Care System, and Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California (Dr Eapen); and Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio (Dr Wang)
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30
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Fortenbaugh FC, Fonda JR, Fortier CB, Amick MM, Milberg WP, McGlinchey RE. The Impact of Common Psychiatric and Behavioral Comorbidities on Functional Disability Across Time and Individuals in Post-9/11 Veterans. J Trauma Stress 2020; 33:750-761. [PMID: 32339323 PMCID: PMC7731589 DOI: 10.1002/jts.22501] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 09/06/2019] [Accepted: 09/12/2019] [Indexed: 01/13/2023]
Abstract
Returning veterans often face multiple concurrent psychiatric and behavioral conditions that negatively impact reintegration into civilian life and are associated with functional disability. Understanding how conditions interact to negatively impact functioning is an important step toward developing holistic treatment approaches optimized for this population. This study utilized a cross-sectional and prospective longitudinal cohort design, applying regression algorithms to understand the relative contribution of common clinical issues to functional disability in U.S. veterans who served after the September 11, 2001 (9/11), terror attacks. Community-dwelling post-9/11 veterans (N = 397) completed detailed assessments, including common clinical condition diagnoses, combat experience, and demographics, which were used to predict functional disability (World Health Organization Disability Assessment Schedule); 205 participants were reassessed approximately 1-2 years after enrollment. Regression analyses showed a strong association between the predictor variables and functional disability, f 2 = 1.488. Validation analyses showed a high prediction ability of functional disability to independent samples, r = .719, and across time in the same individuals, r = .780. The strongest predictors included current posttraumatic stress disorder, depressive disorder, sleep disturbance, and pain diagnoses. These results demonstrate the importance of considering multiple common co-occurring conditions when assessing functional disability in post-9/11 veterans and suggest that certain syndromes contribute the most unique information to predicting functional disability with high confidence. As most U.S. veterans utilize private healthcare systems, these results have clinical utility for both Veterans Affairs and civilian healthcare practitioners in assessing and monitoring functional disability in post-9/11 veterans over time.
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Affiliation(s)
- Francesca C. Fortenbaugh
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer R. Fonda
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Catherine B. Fortier
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa M. Amick
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - William P. Milberg
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Regina E. McGlinchey
- Translational Research Center for TBI and Stress Disorders (TRACTS) and Geriatric Research, Education and Clinical Center (GRECC), VA Boston Healthcare System, Boston, Massachusetts, USA,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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31
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Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions. J Head Trauma Rehabil 2020; 34:158-166. [PMID: 31058758 DOI: 10.1097/htr.0000000000000493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE/PURPOSE Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes. METHODS Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA "Community Reintegration in the Polytrauma System of Care" meeting. CONCLUSIONS To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.
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Developing a Therapeutic Approach Toward Active Engagement for Veterans With Mild Traumatic Brain Injury. J Head Trauma Rehabil 2020; 34:141-149. [PMID: 31058756 DOI: 10.1097/htr.0000000000000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Treatment of chronic mild traumatic brain injury (mTBI) or postdeployment syndrome can be challenging to frontline providers who care for our nation's war heroes. There is ample guidance available for symptom-based interventions, but relatively little information regarding the structure and language of the clinical encounter. Dynamic patient education centered upon relatable language, accessible analogies, and brain health can move the visit beyond historical diagnostics into a shared understanding of postdeployment barriers to reintegration. OBJECTIVE We aim to describe a practical, education-based clinical approach for chronic mTBI or postdeployment syndrome (mTBI/PDS). The foundation of this method is gathering the veteran's narrative, validating and normalizing his or her experience, highlighting neurobehavioral changes from combat that may represent barriers to full community reintegration, and transitioning to an emphasis on overall brain health. CONCLUSION The chronic mTBI or PDS clinical encounter can be enhanced by empowering the patient with relatable terms and concepts to describe his or her reintegration challenges and emphasizing factors of brain health. This approach can provide the patient with a base of understanding regarding his or her current symptoms, promote focus on factors for cognitive health, and orient the clinical encounter toward improved community reintegration and long-term cognitive wellness.
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Cogan AM, Smith B, Bender Pape TL, Mallinson T, Eapen BC, Scholten J. Self-reported Participation Restrictions Among Male and Female Veterans With Traumatic Brain Injury in Veterans Health Administration Outpatient Polytrauma Programs. Arch Phys Med Rehabil 2020; 101:2071-2079. [PMID: 32795563 DOI: 10.1016/j.apmr.2020.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex. DESIGN Retrospective cross-sectional design. SETTING National VA Polytrauma System of Care outpatient settings. PARTICIPANTS Veterans with a confirmed TBI event (N=6065). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE(S) Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis. RESULTS The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item. CONCLUSIONS There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.
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Affiliation(s)
- Alison M Cogan
- Physical Medicine and Rehabilitation Service, Washington DC VA Medical Center, Washington, DC.
| | - Bridget Smith
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr VA Hospital, US Department of Veterans Affairs, Hines, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Theresa L Bender Pape
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr VA Hospital, US Department of Veterans Affairs, Hines, Illinois; Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Trudy Mallinson
- School of Medicine and Health Sciences, George Washington University, Washington, DC
| | - Blessen C Eapen
- Physical Medicine and Rehabilitation Service, VA Greater Los Angeles Health Care System, Los Angeles, California
| | - Joel Scholten
- Physical Medicine and Rehabilitation Service, Washington DC VA Medical Center, Washington, DC
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Merritt VC, Jurick SM, Crocker LD, Keller AV, Hoffman SN, Jak AJ. Factors associated with employment and work perception in combat-exposed veterans. Rehabil Psychol 2020; 65:279-290. [PMID: 32297778 PMCID: PMC8409174 DOI: 10.1037/rep0000323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE/OBJECTIVE The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no). RESULTS A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability. CONCLUSIONS/IMPLICATIONS Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | - Sarah M. Jurick
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | - Laura D. Crocker
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
| | | | | | - Amy J. Jak
- VA San Diego Healthcare System (VASDHS), San Diego, CA, USA
- Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA, USA
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USA
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Faruqui SHA, Alaeddini A, Chang MC, Shirinkam S, Jaramillo C, NajafiRad P, Wang J, Pugh MJ. Summarizing Complex Graphical Models of Multiple Chronic Conditions Using the Second Eigenvalue of Graph Laplacian: Algorithm Development and Validation. JMIR Med Inform 2020; 8:e16372. [PMID: 32554376 PMCID: PMC7330739 DOI: 10.2196/16372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/06/2020] [Accepted: 03/22/2020] [Indexed: 01/16/2023] Open
Abstract
Background It is important but challenging to understand the interactions of multiple chronic conditions (MCC) and how they develop over time in patients and populations. Clinical data on MCC can now be represented using graphical models to study their interaction and identify the path toward the development of MCC. However, the current graphical models representing MCC are often complex and difficult to analyze. Therefore, it is necessary to develop improved methods for generating these models. Objective This study aimed to summarize the complex graphical models of MCC interactions to improve comprehension and aid analysis. Methods We examined the emergence of 5 chronic medical conditions (ie, traumatic brain injury [TBI], posttraumatic stress disorder [PTSD], depression [Depr], substance abuse [SuAb], and back pain [BaPa]) over 5 years among 257,633 veteran patients. We developed 3 algorithms that utilize the second eigenvalue of the graph Laplacian to summarize the complex graphical models of MCC by removing less significant edges. The first algorithm learns a sparse probabilistic graphical model of MCC interactions directly from the data. The second algorithm summarizes an existing probabilistic graphical model of MCC interactions when a supporting data set is available. The third algorithm, which is a variation of the second algorithm, summarizes the existing graphical model of MCC interactions with no supporting data. Finally, we examined the coappearance of the 100 most common terms in the literature of MCC to validate the performance of the proposed model. Results The proposed summarization algorithms demonstrate considerable performance in extracting major connections among MCC without reducing the predictive accuracy of the resulting graphical models. For the model learned directly from the data, the area under the curve (AUC) performance for predicting TBI, PTSD, BaPa, SuAb, and Depr, respectively, during the next 4 years is as follows—year 2: 79.91%, 84.04%, 78.83%, 82.50%, and 81.47%; year 3: 76.23%, 80.61%, 73.51%, 79.84%, and 77.13%; year 4: 72.38%, 78.22%, 72.96%, 77.92%, and 72.65%; and year 5: 69.51%, 76.15%, 73.04%, 76.72%, and 69.99%, respectively. This demonstrates an overall 12.07% increase in the cumulative sum of AUC in comparison with the classic multilevel temporal Bayesian network. Conclusions Using graph summarization can improve the interpretability and the predictive power of the complex graphical models of MCC.
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Affiliation(s)
- Syed Hasib Akhter Faruqui
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Adel Alaeddini
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Mike C Chang
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Sara Shirinkam
- Department of Mathematics and Statistics, University of the Incarnate Word, San Antonio, TX, United States
| | - Carlos Jaramillo
- South Texas Veterans Health Care System, San Antonio, TX, United States
| | - Peyman NajafiRad
- Department of Information Systems and Cyber Security, The University of Texas at San Antonio, San Antonio, TX, United States
| | - Jing Wang
- School of Nursing, UT Health San Antonio, San Antonio, TX, United States
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System, Salt Lake City, UT, United States
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36
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Sagiraju HKR, Živković S, VanCott AC, Patwa H, Gimeno Ruiz de Porras D, Amuan ME, Pugh MJV. Amyotrophic Lateral Sclerosis Among Veterans Deployed in Support of Post-9/11 U.S. Conflicts. Mil Med 2019; 185:e501-e509. [PMID: 31642489 PMCID: PMC8921606 DOI: 10.1093/milmed/usz350] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a recognized military service-connected condition. Prior prevalence studies of ALS among U.S. war Veterans were not able to address concerns related to neurodegenerative sequelae of traumatic brain injury (TBI) and disregarded risk heterogeneity from occupational categories within service branches. MATERIALS AND METHODS We identified the prevalence of definite and possible ALS and cumulative incidence of definite ALS among Post-9/11 U.S. Veterans deployed in support of Post-9/11 conflicts (mean age 36.3) who received care in the Veterans Health Administration during fiscal years 2002-2015. Using a case-control study design, we also evaluated the association of TBI and major military occupation groups with ALS adjusting for demographics and comorbidities. RESULTS The prevalence of ALS was 19.7 per 100,000 over 14 years. Both prevalence and cumulative incidence of definite ALS were significantly higher among Air Force personnel compared to other service branches and among tactical operation officers and health care workers compared to general and administrative officers. Neither TBI nor younger age (<45 years) was associated with ALS. Depression, cardiac disease, cerebrovascular disease, high blood pressure, and obstructive sleep apnea were clinical comorbidities significantly associated with ALS in this population of Veterans. CONCLUSION This study among a cohort of relatively young Veterans showed a high ALS prevalence, suggesting an early onset of ALS among deployed military service members. The higher prevalence among some military specific occupations highlights the need to determine which occupational exposures specific to these occupations (particularly, Air Force personnel, tactical operations officers, and health care workers) might be associated with early onset ALS.
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Affiliation(s)
- Hari Krishna Raju Sagiraju
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT 84148,Division of Epidemiology, University of Utah, 383 Colorow Dr, Suite203, Salt Lake City, UT 84108
| | - Sasa Živković
- Department of Neurology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213
| | - Anne C VanCott
- Department of Neurology, University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213,Department of Neurology, VA Pittsburgh Health Care System, 4100 Allequippa St, Pittsburgh, PA 15213
| | - Huned Patwa
- VA Neurology Service, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT 06516
| | - David Gimeno Ruiz de Porras
- Department of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas Health Science Center at Houston, School of Public Health in San Antonio, 7411 John Smith Dr #1100, San Antonio, TX 78229
| | - Megan E Amuan
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT 84148
| | - Mary Jo V Pugh
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Drive Bldg. 182, Salt Lake City, UT 84148,Division of Epidemiology, University of Utah, 383 Colorow Dr, Suite203, Salt Lake City, UT 84108
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37
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Pugh MJ, Swan AA, Amuan ME, Eapen BC, Jaramillo CA, Delgado R, Tate DF, Yaffe K, Wang CP. Deployment, suicide, and overdose among comorbidity phenotypes following mild traumatic brain injury: A retrospective cohort study from the Chronic Effects of Neurotrauma Consortium. PLoS One 2019; 14:e0222674. [PMID: 31539410 PMCID: PMC6754132 DOI: 10.1371/journal.pone.0222674] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/03/2019] [Indexed: 12/02/2022] Open
Abstract
Mild traumatic brain injury in the Veteran population is frequently comorbid with pain, post-traumatic stress disorder, and/or depression. However, not everyone exposed to mild traumatic brain injury experiences these comorbidities and it is unclear what factors contribute to this variability. The objective of this study was to identify comorbidity phenotypes among Post-9/11 deployed Veterans with no or mild traumatic brain injury and examine the association of comorbidity phenotypes with adverse outcomes. We found that Veterans with mild traumatic brain injury (n = 93,003) and no brain injury (n = 434,378) were mean age of 32.0 (SD 9.21) on entering Department of Veterans Health Administration care, were predominantly Caucasian non-Hispanic (64.69%), and served in the Army (61.31%). Latent class analysis revealed five phenotypes in each subcohort; Moderately Healthy and Mental Health phenotypes were common to both. The Healthy phenotype was found only in no brain injury. Unique phenotypes in mild traumatic brain injury included Moderately Healthy+Decline, Polytrauma, and Polytrauma+Improvement. There was substantial variation in adverse outcomes. The Polytrauma+Improvement phenotype had the lowest likelihood of adverse outcomes. There were no differences between Moderately Healthy+Decline and Polytrauma phenotypes. Phenotypes of comorbidity vary significantly by traumatic brain injury status including divergence in phenotypes (and outcomes) over time in the mild traumatic brain injury subcohort. Understanding risk factors for the divergence between Polytrauma vs. Polytrauma+Improvement and Moderately Healthy vs. Moderately Healthy+Decline, will improve our ability to proactively mitigate risk, better understand the early patterns of comorbidity that are associated with neurodegenerative sequelae following mild traumatic brain injury, and plan more patient-centered care.
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Affiliation(s)
- Mary Jo Pugh
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States of America
- Department of Internal Medicine, University of Utah, School of Medicine, Salt Lake City, Utah, United States of America
| | - Alicia A. Swan
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas, United States of America
| | - Megan E. Amuan
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center, Salt Lake City, Utah, United States of America
| | - Blessen C. Eapen
- Department of Physical Medicine and Rehabilitation, VA Greater Los Angeles Health Care System, Los Angeles, California, United States of America
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Carlos A. Jaramillo
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Roxana Delgado
- Polytrauma Rehabilitation Center, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - David F. Tate
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, Missouri, United States of America
| | - Kristine Yaffe
- Department of Psychiatry, Neurology & Epidemiology, University of California, San Francisco, San Francisco, California, United States of America
| | - Chen-Pin Wang
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at San Antonio, San Antonio, Texas, United States of America
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Kinney AR, Eakman AM, Lassell R, Wood W. Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review. Mil Med Res 2019; 6:28. [PMID: 31462305 PMCID: PMC6714435 DOI: 10.1186/s40779-019-0217-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Evidence-based treatments for service-related health conditions such as posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) are not effective for all veterans. Equine-assisted interventions are emerging as an additional treatment modality, but little is known regarding the safe and effective delivery of these interventions. This study aimed to describe the following features of the body of literature concerning equine-assisted interventions among veterans: 1) veterans who have participated in equine-assisted interventions; 2) specific characteristics of equine-assisted interventions in veterans; and 3) the specific characteristics of research on equine-assisted interventions in veterans. METHODS We conducted a systematic mapping review of peer-reviewed literature reporting on equine-assisted interventions among veterans between 1980 and 2017. Searches of nine databases yielded 3336 unique records, six of which met the inclusion criteria and were reviewed. Data relevant to the study aims were extracted and analyzed. RESULTS Equine-assisted interventions among veterans disproportionately targeted psychosocial outcomes and yielded promising results. The detailed methods of EAI varied in the reported studies, ranging from communicating with the horse to mounted exercises. There was also great diversity in outcome measurement. The state of theoretical development regarding the mechanisms by which equine-assisted interventions benefit the veteran population is currently underdeveloped. Studies provided insufficient detail with respect to the description of the intervention, reasons for attrition, and the dose-response relationship. CONCLUSIONS Scientific development of equine-assisted interventions targeting psychosocial outcomes among veterans is warranted to establish their efficacy. Targeted outcomes should be expanded, including outcomes more closely aligned with the nature of polytraumatic injuries. Future research must also emphasize the theoretical development of equine-assisted interventions for veterans and thoroughly describe the participants, components of the intervention, factors contributing to attrition, and optimal dose-response relationships.
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Affiliation(s)
- Adam R. Kinney
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
| | - Aaron M. Eakman
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
| | - Rebecca Lassell
- Department of Occupational Therapy, Colorado State University, Fort Collins, CO 80523 USA
- Temple Grandin Equine Center, Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523 USA
| | - Wendy Wood
- Temple Grandin Equine Center, Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523 USA
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39
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Dillahunt-Aspillaga C, Powell-Cope G. Community Reintegration, Participation, and Employment Issues in Veterans and Service Members With Traumatic Brain Injury. Arch Phys Med Rehabil 2019; 99:S1-S3. [PMID: 29406019 DOI: 10.1016/j.apmr.2017.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 04/10/2017] [Accepted: 04/15/2017] [Indexed: 10/18/2022]
Abstract
Traumatic brain injury (TBI) has been called the signature injury of the post-9/11 wars in Iraq, Afghanistan, and neighboring countries. Although similarities exist between veterans and service members with TBI, levels of severity and different constellations of coexisting comorbid conditions affect them differently. These conditions affect physical, cognitive, and emotional function, which in turn can complicate community reintegration (CR), or the ability to return to family, vocational, and community life. This special supplement of the Archives of Physical Medicine and Rehabilitation consists of articles written by accomplished teams from multiple disciplines, including anthropology, neuropsychology, nursing, occupational therapy, psychology, and rehabilitation sciences. Each article brings a different perspective to bear on what CR means for veterans and service members from examination of predictors and perceptions of veterans and service members and others to measurement studies. Collectively, this group of articles represents current thinking about CR and lays the groundwork for testing interventions to improve CR outcomes for veterans and service members (eg, employment, living situation, family life).
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Affiliation(s)
- Christina Dillahunt-Aspillaga
- Health Services Research and Development Service Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, Tampa, FL; Rehabilitation and Mental Health Counseling Program, Department of Child and Family Studies, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL
| | - Gail Powell-Cope
- Health Services Research and Development Service Center of Innovation on Disability and Rehabilitation Research, James A. Haley Veterans Hospital, Tampa, FL.
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Swan AA, Amuan ME, Morissette SB, Finley EP, Eapen BC, Jaramillo CA, Pugh MJ. Long-term physical and mental health outcomes associated with traumatic brain injury severity in post-9/11 veterans: A retrospective cohort study. Brain Inj 2018; 32:1637-1650. [DOI: 10.1080/02699052.2018.1518539] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Alicia A. Swan
- South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Megan E. Amuan
- Center for Health Care Organization and Implementation Research, Edith Nourse Rogers VA Medical Center, Bedford, MA, USA
| | - Sandra B. Morissette
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Erin P. Finley
- Department of Psychology, The University of Texas at San Antonio, San Antonio, TX, USA
| | | | | | - Mary Jo Pugh
- IDEAS 2.0 Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Pinto SM, Newman MA, Hirsch MA. Perceived Barriers to Exercise in Adults with Traumatic Brain Injury Vary by Age. J Funct Morphol Kinesiol 2018; 3:E47. [PMID: 33466976 PMCID: PMC7739410 DOI: 10.3390/jfmk3030047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 08/20/2018] [Accepted: 09/11/2018] [Indexed: 02/03/2023] Open
Abstract
Physical activity and exercise are important adjuncts to medical treatment for overall health in individuals with traumatic brain injury (TBI); however, many individuals do not partake in the recommended weekly exercise. The objective of this study was to investigate the barriers to exercise after TBI and determine whether these barriers varied by age. The sample was 172 adults with moderate to severe TBI who completed Barriers to Physical Exercise and Disability (B-PED) survey. Lack of interest, motivation, and energy as well as cost, lack of counseling on exercise by a physician, not having home equipment, and being too lazy were reported as barriers to exercise by all age groups. Those aged 35 to 54-years-old were more likely to report that cost, lack of transportation, having health concerns, not knowing where to exercise, and fear of leaving the home as barriers to exercise than those aged 18 to 34-years-old or 55-years-old and older. Overall, adults with TBI report multiple barriers to exercise, and these barriers vary by age.
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Affiliation(s)
- Shanti M. Pinto
- Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, NC 28203, USA
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Koehmstedt C, Lydick SE, Patel D, Cai X, Garfinkel S, Weinstein AA. Health status, difficulties, and desired health information and services for veterans with traumatic brain injuries and their caregivers: A qualitative investigation. PLoS One 2018; 13:e0203804. [PMID: 30208083 PMCID: PMC6135487 DOI: 10.1371/journal.pone.0203804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 08/25/2018] [Indexed: 01/22/2023] Open
Abstract
Traumatic brain injury (TBI) is considered the signature injury among military service member and Veterans who served in Operation Iraqi Freedom and Operation Enduring Freedom with over 360,000 individuals sustaining a first-time TBI in the military. These service members and Veterans, and their caregiver(s), must navigate multiple health systems and find experts across many fields of expertise to recover and optimize functionality. Twenty-two individuals, 10 caregivers of Veterans with TBI, 12 Veterans with TBI, participated in semi-structured interviews. Responses were coded using NVivo. Participants from both groups reported difficulties finding community supportive services (support groups) in local communities. Most participants identified the need for an advocate or point-person to help guide them to needed services and provide ongoing support in the post-acute health care recovery phase. Caregivers and Veterans desired a more personalized recovery plan from their medical professionals. When describing their ideal health information and services model most identified interactivity and twenty-four-hour availability as essential components. To provide Veterans and caregivers with optimal support and resources to navigate a complicated health services system, advocates and personalized care plans are needed. Future research should examine the feasibility and cost-effectiveness of these services.
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Affiliation(s)
- Christine Koehmstedt
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Susan E. Lydick
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Drasti Patel
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Xinsheng Cai
- American Institutes for Research, Washington, DC, United States of America
| | - Steven Garfinkel
- American Institutes for Research, Washington, DC, United States of America
| | - Ali A. Weinstein
- Center for the Study of Chronic Illness and Disability, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
- * E-mail:
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Cognitive Rehabilitation With Mobile Technology and Social Support for Veterans With TBI and PTSD: A Randomized Clinical Trial. J Head Trauma Rehabil 2018; 34:1-10. [PMID: 30169439 DOI: 10.1097/htr.0000000000000435] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate effects of cognitive rehabilitation with mobile technology and social support on veterans with traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). PARTICIPANTS There were 112 dyads, comprised by a veteran and a family member or friend (224 participants in total). DESIGN Dyads were randomized to the following: (1) a novel intervention, Cognitive Applications for Life Management (CALM), involving goal management training plus mobile devices for cueing and training attentional control; or (2) Brain Health Training, involving psychoeducation plus mobile devices to train visual memory. MAIN MEASURES Executive dysfunction (disinhibition, impulsivity) and emotional dysregulation (anger, maladaptive interpersonal behaviors) collected prior to randomization and following intervention completion at 6 months. RESULTS The clinical trial yielded negative findings regarding executive dysfunction but positive findings on measures of emotion dysregulation. Veterans randomized to CALM reported a 25% decrease in anger over 6 months compared with 8% reduction in the control (B = -5.27, P = .008). Family/friends reported that veterans randomized to CALM engaged in 26% fewer maladaptive interpersonal behaviors (eg, aggression) over 6 months compared with 6% reduction in the control (B = -2.08, P = .016). An unanticipated result was clinically meaningful change in reduced PTSD symptoms among veterans randomized to CALM (P < .001). CONCLUSION This preliminary study demonstrated effectiveness of CALM for reducing emotional dysregulation in veterans with TBI and PTSD.
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Faruqui SHA, Alaeddini A, Jaramillo CA, Potter JS, Pugh MJ. Mining patterns of comorbidity evolution in patients with multiple chronic conditions using unsupervised multi-level temporal Bayesian network. PLoS One 2018; 13:e0199768. [PMID: 30001371 PMCID: PMC6042705 DOI: 10.1371/journal.pone.0199768] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/13/2018] [Indexed: 11/18/2022] Open
Abstract
Over the past few decades, the rise of multiple chronic conditions has become a major concern for clinicians. However, it is still not known precisely how multiple chronic conditions emerge among patients. We propose an unsupervised multi-level temporal Bayesian network to provide a compact representation of the relationship among emergence of multiple chronic conditions and patient level risk factors over time. To improve the efficiency of the learning process, we use an extension of maximum weight spanning tree algorithm and greedy search algorithm to study the structure of the proposed network in three stages, starting with learning the inter-relationship of comorbidities within each year, followed by learning the intra-relationship of comorbidity emergence between consecutive years, and finally learning the hierarchical relationship of comorbidities and patient level risk factors. We also use a longest path algorithm to identify the most likely sequence of comorbidities emerging from and/or leading to specific chronic conditions. Using a de-identified dataset of more than 250,000 patients receiving care from the U.S. Department of Veterans Affairs for a period of five years, we compare the performance of the proposed unsupervised Bayesian network in comparison with those of Bayesian networks developed based on supervised and semi-supervised learning approaches, as well as multivariate probit regression, multinomial logistic regression, and latent regression Markov mixture clustering focusing on traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), depression (Depr), substance abuse (SuAb), and back pain (BaPa). Our findings show that the unsupervised approach has noticeably accurate predictive performance that is comparable to the best performing semi-supervised and the second-best performing supervised approaches. These findings also revealed that the unsupervised approach has improved performance over multivariate probit regression, multinomial logistic regression, and latent regression Markov mixture clustering.
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Affiliation(s)
- Syed Hasib Akhter Faruqui
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States of America
| | - Adel Alaeddini
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX, United States of America
- * E-mail:
| | - Carlos A. Jaramillo
- South Texas Veterans Health Care System, San Antonio, TX, United States of America
| | - Jennifer S. Potter
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America
| | - Mary Jo Pugh
- VA Salt Lake City Health Care System, Salt Lake City, UT, United States of America
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Abstract
BACKGROUND The use of chemoprophylaxis to prevent thromboembolic disease after primary THA and TKA can be associated with postoperative bleeding complications. Mechanical prophylaxis has been studied as an alternative to chemoprophylaxis with greater safety in patients undergoing THA, but no data have been published comparing the safety of chemoprophylaxis versus mechanical methods for patients undergoing TKA. The risk of readmission resulting from bleeding and venous thromboembolism (VTE) has also not been determined for patients undergoing THA or TKA when treated with low-molecular-weight heparin (LMWH) alone compared with mechanical prophylaxis plus aspirin (ASA). QUESTION/PURPOSES We sought to answer four questions: For the THA and TKA cohorts, respectively, (1) was the incidence of readmission resulting from VTE and bleeding complications higher with LMWH than mobile compression plus ASA; and (2) was the incidence of wound bleeding complications higher with LMWH than mechanical compression plus ASA? For the TKA cohort specifically, (3) was the frequency of systemic bleeding events and complications related to chemical prophylaxis higher with LMWH compared with mechanical compression plus ASA? (4) Was there a difference in symptomatic VTEs between LMWH and mechanical compression plus ASA? METHODS Between November 2008 and April 2011, 632 patients underwent primary THA and TKA. Seventy-two patients (11%) were identified before surgery as being at high risk for VTE (31 patients) or bleeding (41 patients) and were excluded from the study. Five hundred sixty patients (89%) were considered to be at standard risk for VTE and bleeding and comprise the study cohort. Between November 2008 and November 2009, 252 patients (76 THAs, 176 TKAs) underwent THA and TKA and were treated with LMWH (5 mg dalteparin given subcutaneously daily for 14 days) and in-hospital nonmobile mechanical compression. Between November 2009 and April 2011, a total of 308 patients undergoing THA and TKA (108 THAs, 200 TKAs) were treated using a mobile compression device plus oral aspirin once daily for 2 weeks after surgery. All complications and readmissions that occurred within 6 weeks of surgery were noted. There were no differences between the VTE treatment groups with regard to age, sex, or body mass index. RESULTS For the THA cohort, there was no difference in the frequency of readmission for a bleeding complication (wound or systemic) between the two groups (2.6% for LMWH versus 0.9% for mobile compression; p = 0.57; odds ratio [OR], 2.9). Patients undergoing TKA treated with LMWH had higher readmission rates within 6 weeks of surgery because of a bleeding complication, a wound infection, or the development of a VTE (6.8% for LMWH versus 1.5% for mobile compression; p = 0.015; OR, 4.8). For the THA cohort, there was higher wound bleeding complication frequency with LMWH (9.2% for LMWH versus 0.9% for mechanical compression; p = 0.009; OR, 10.9). Patients undergoing TKA treated with LMWH had a higher frequency of wound bleeding complications or infection (3.9% for LMWH versus 0.5% for mobile compression; p = 0.028; OR, 8.2). Patients undergoing TKA treated with LMWH had higher rates of systemic bleeding or a complication secondary to LMWH administration (2.8% for LMWH versus 0% for mobile compression; p = 0.022; OR, 12.8). No difference was noted in the rate of symptomatic VTEs between either group (for THA: 2.6% for the LMWH group versus 1.9% for the mechanical compression group; p = 1; for TKA: 1.1% versus 0%, respectively; p = 0.22). CONCLUSIONS Based on these results, we advocate for routine use of mobile mechanical compression devices in the prevention of VTEs and complications associated with more potent chemical anticoagulants. However, more focused randomized clinical trials are needed to validate these findings. LEVEL OF EVIDENCE Level III, therapeutic study.
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