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BACKGROUND: The role of immune-oncology (IO) therapy in soft tissue sarcoma (STS) is underexplored. This study characterized IO use in STS. METHODS: This is a retrospective analysis of patients with a soft tissue mass in the National Cancer Database, 2011-2021. Patients were categorized by IO receipt status. Groupwise testing and proportional trend tests were performed with Chi-squared tests. Multivariate logistic regression was performed to assess factors associated with IO receipt. RESULTS: Of the 103,092 patients with STS, 1935 (1.9 â%) received or were recommended IO therapy. IO use increased 10-fold (0.24 â%-2.5 â% from 2011 to 2021; p â< â0.0001). Patients had higher odds of receiving IO when having higher grade tumors and metastatic disease, and when treated at an academic research center (all p â< â0.001). CONCLUSIONS: IO use in STS is low but increasing and primarily used in the metastatic setting. Future studies should identify biomarkers of IO response and facilitators for treatment receipt.
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Importance: Adverse patient events are inevitable in surgical practice. Objectives: To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants: In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures: The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results: Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance: In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.
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Cirurgiões , Humanos , Masculino , Feminino , Cirurgiões/psicologia , Cirurgiões/educação , Adulto , Adaptação Psicológica , Erros Médicos/psicologia , Erros Médicos/estatística & dados numéricos , Internato e Residência , Inquéritos e Questionários , Cirurgia Geral/educaçãoRESUMO
BACKGROUND: Federal regulations require a history and physical (H&P) update performed 30 days or less before a planned procedure. We evaluated the use and burdens of H&P update visits by determining impact on operative management, suitability for telehealth, and visit time and travel burden. STUDY DESIGN: We identified H&P update visits performed in our health system during 2019 for 8 surgical specialties. As available, up to 50 visits per specialty were randomly selected. Primary outcomes were interval changes in history, examination, or operative plan between the initial and updated H&P notes, and visit suitability for telehealth, as determined by 2 independent physician reviewers. Clinic time was captured, and round-trip driving time and distance between patients' home and clinic ZIP codes were estimated. RESULTS: We identified 8,683 visits and 362 were randomly selected for review. Documented changes were most commonly identified in histories (60.8%), but rarely in physical examinations (11.9%) and operative plans (11.6%). Of 362 visits, 359 (99.2%) visits were considered suitable for telehealth. Median clinic time was 52 minutes (interquartile range 33.8 to 78), driving time was 55.6 minutes (interquartile range 35.5 to 85.5), and driving distance was 20.2 miles (interquartile range 8.5 to 38.4). At the health system level, patients spent an estimated aggregate 7,000 hours (including 4,046 hours of waiting room and travel time) and drove 142,273 miles to attend in-person H&P update visits in 2019. CONCLUSIONS: Given their minimal impact on operative management, regulatory requirements for in-person H&P updates should be reconsidered. Flexibility in update timing and modality might help defray the substantial burdens these visits impose on patients.
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Anamnese , Exame Físico , Telemedicina , Humanos , Anamnese/estatística & dados numéricos , Exame Físico/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Feminino , Masculino , Cuidados Pré-Operatórios/estatística & dados numéricos , Pessoa de Meia-Idade , Especialidades Cirúrgicas/estatística & dados numéricos , Fatores de Tempo , Estudos Retrospectivos , Adulto , IdosoRESUMO
PURPOSE: In this pilot study, we evaluated the feasibility of implementing the Needs Assessment & Service Bridge (NA-SB)- an intervention to address the pervasive unmet needs of adolescents and young adults (AYAs) during cancer treatment. METHODS: We conducted a mixed methods single-arm feasibility pilot study of NA-SB at the North Carolina Basnight Cancer Hospital. Eligible participants were AYAs ages 18-39 in active cancer treatment. After receiving NA-SB, participants completed a postintervention survey assessing their perceptions of NA-SB. We interviewed participating providers to assess their implementation experiences. RESULTS: On average, AYA participants (n = 26) rated NA-SB's feasibility as 4.5/5, its acceptability as 4.5/5, and its appropriateness as 4.4/5. 77% of participants agreed or strongly agreed that their needs were met in the study period. CONCLUSION: This pilot study generated preliminary evidence to establish NA-SB's feasibility as well as proof of concept for the intervention as a viable approach for identifying and addressing AYAs' unmet needs.
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Neoplasias , Humanos , Adolescente , Adulto Jovem , Avaliação das Necessidades , Projetos Piloto , Estudos de Viabilidade , Neoplasias/terapia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: With the COVID-19 pandemic came rapid uptake in virtual oncology care. During this, sociodemographic inequities in access to virtual visits (VVs) have become apparent. To better understand these issues, we conducted a qualitative study to describe the perceived usability and acceptability of VVs among Black adults diagnosed with cancer. METHODS: Adults who self-identified as Black and had a diagnosis of prostate, multiple myeloma, or head and neck cancer were recruited from 2 academic medical centers, and their community affiliates to participate in a semi-structured interview, regardless of prior VV experience. A patient and family advisory board was formed to inform all components of the study. Interviews were conducted between September 2, 2021 and February 23, 2022. Transcripts were organized topically, and themes and subthemes were determined through iterative and interpretive immersion/crystallization cycles. RESULTS: Of the 49 adults interviewed, 29 (59%) had participated in at least one VV. Three overarching themes were derived: (1) VVs felt comfortable and convenient in the right contexts; (2) the technology required for VVs with video presented new challenges, which were often resolved by an audio-only telephone call; and (3) participants reported preferring in-person visits, citing concerns regarding gaps in nonverbal communication, trusting providers, and distractions during VV. CONCLUSION: While VVs were reported to be acceptable in specific circumstances, Black adults reported preferring in-person care, in part due to a perceived lack of interpersonal connectedness. Nonetheless, retaining reimbursement for audio-only options for VVs is essential to ensure equitable access for those with less technology savvy and/or limited device/internet capabilities.
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COVID-19 , Pandemias , Adulto , Masculino , Humanos , Oncologia , Centros Médicos Acadêmicos , COVID-19/epidemiologia , InternetRESUMO
PURPOSE: Acute care events (ACEs), comprising emergency department visits and hospitalizations, are a priority area for reduction in oncology. Prognostic models are a compelling strategy to identify high-risk patients and target preventive services, but have yet to be broadly implemented, partly because of challenges with electronic health record (EHR) integration. To facilitate EHR integration, we adapted and validated the previously published PRediction Of Acute Care use during Cancer Treatment (PROACCT) model to identify patients at highest risk for ACEs after systemic anticancer treatment. METHODS: A retrospective cohort of adults with a cancer diagnosis starting systemic therapy at a single center between July and November 2021 was divided into development (70%) and validation (30%) sets. Clinical and demographic variables were extracted, limited to those in structured format in the EHR, including cancer diagnosis, age, drug category, and ACE in prior year. Three logistic regression models of increasing complexity were developed to predict risk of ACEs. RESULTS: Five thousand one hundred fifty-three patients were evaluated (3,603 development and 1,550 validation). Several factors were predictive of ACEs: age (in decades), receipt of cytotoxic chemotherapy or immunotherapy, thoracic, GI or hematologic malignancy, and ACE in the prior year. We defined high-risk as the top 10% of risk scores; this population had 33.6% ACE rate compared with 8.3% for the remaining 90% in the low-risk group. The simplest Adapted PROACCT model had a C-statistic of 0.79, sensitivity of 0.28, and specificity of 0.93. CONCLUSION: We present three models designed for EHR integration that effectively identify oncology patients at highest risk for ACE after initiation of systemic anticancer treatment. By limiting predictors to structured data fields and including all cancer types, these models offer broad applicability for cancer care organizations and may offer a safety net to identify and target resources to this high risk.
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Neoplasias , Adulto , Humanos , Estudos Retrospectivos , Neoplasias/tratamento farmacológico , Fatores de Risco , Prognóstico , Modelos LogísticosRESUMO
Purpose: Every year, nearly 100,000 adolescents and young adults (15-39 years, AYAs) are diagnosed with cancer in the United States and many have unmet physical, psychosocial, and practical needs during and after cancer treatment. In response to demands for improved cancer care delivery for this population, specialized AYA cancer programs have emerged across the country. However, cancer centers face multilevel barriers to developing and implementing AYA cancer programs and would benefit from more robust guidance on how to approach AYA program development. Methods: To contribute to this guidance, we describe the development of an AYA cancer program at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center. Results: We summarize the evolution of UNC's AYA Cancer Program since it was established in 2015, offering pragmatic strategies for developing, implementing, and sustaining AYA cancer programs. Conclusion: The development of the UNC AYA Cancer Program since 2015 has generated many lessons learned that we hope may be informative to other cancer centers seeking to build specialized services for AYAs.
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Neoplasias , Humanos , Adolescente , Adulto Jovem , Estados Unidos , Neoplasias/psicologia , Atenção à SaúdeRESUMO
Electronic cigarette, or vaping, product use-associated lung injury (EVALI) is an increasingly recognized entity with the potential for severe pulmonary toxicity. We present the case of a young man first evaluated at a tertiary care center in the United States in 2019 with newly diagnosed testicular cancer with acute respiratory failure, which was initially attributed to possible metastatic disease but eventually determined to be related to EVALI. This case highlights the clinical features of EVALI, the potential diagnostic dilemma that can arise with EVALI when occurring in the setting of malignancy and the importance of inquiring about vaping use among patients with malignancy, especially in adolescents and young adults.
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Sistemas Eletrônicos de Liberação de Nicotina , Lesão Pulmonar , Neoplasias Embrionárias de Células Germinativas , Neoplasias Testiculares , Vaping , Masculino , Adolescente , Adulto Jovem , Humanos , Estados Unidos , Lesão Pulmonar/diagnóstico , Lesão Pulmonar/etiologia , Lesão Pulmonar/terapia , Neoplasias Testiculares/diagnóstico , Neoplasias Testiculares/etiologia , Vaping/efeitos adversos , Neoplasias Embrionárias de Células Germinativas/complicaçõesRESUMO
BACKGROUND: United States regulations require a history and physical (H&P) ≤30 days before planned procedures. We evaluated the impact of H&P update visits in colorectal surgery. METHODS: Preoperative H&P update visits conducted in colorectal clinics at our institution during 2019 were identified. Two independent reviewers assessed whether update visits identified interval changes to history, exam, or operative plan. Secondary outcomes included visit times, estimated travel times and distances. RESULTS: For 132 visits, interval changes were identified in 39% of histories, but only 4.2% of exams and 6.8% of operative plans. When plans changed, visit goals could have been accomplished via telehealth in 77.8%. Median clinic and round-trip driving time were 61.5 and 62.2 min, respectively. CONCLUSIONS: H&P update visits conducted to satisfy the 30-day regulation rarely result in clinically relevant changes yet impose time and travel burdens on patients. Regulations should be revised to provide flexibility in H&P update modalities.
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Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Telemedicina , Humanos , Estados UnidosRESUMO
Earlier research has shown the significant role of personality in serving as risk or protective factors in psychological wellbeing. However, it is less clear the extent to which personality plays in coping with the Covid-19 pandemic. The aim of the current study was to examine the role of a personality risk factors such as self-criticism, and personality strengths such as efficacy and intrinsic motivation representing resilience in predicting psychological outcomes in response to the Covid-19 pandemic. As part of a broader longitudinal study, personality measures were assessed at ages 23 and 29, and Covid-19-related outcomes were measured at age 41 on a subsample of 83 Israeli participants, who were approached after the first lockdown that was implemented (April 2020). Findings showed that self-criticism measured at age 23 anticipated greater Covid-19-related distress and lower satisfaction at age 41. Decrease in self-criticism from age 23 to 29, which indicates developmental progress toward maturity, explained lower non-adaptive emotional reactions at age 41- lower distress and lower anxiety. In addition, a higher level of intrinsic motivation at age 29 explained a greater likelihood to expect post pandemic growth. Findings highlight the role of personality in addressing unexpected stressful events such as the current Covid-19 pandemic.
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The USA is experiencing a reckoning with racial injustice and graduate medical education programs are seeking ways to address this important topic in training. Fellows in hematology/oncology at the University of North Carolina recognized this important gap and adapted a curriculum for medical residents on racial equity to a subspecialty audience. Aims were (1) to improve knowledge and awareness about implicit bias and systemic racism and (2) introduce methods to address racial inequities. We used lived experiences and collated materials from scientific literature and lay media to illustrate key points. The course explored the effects of implicit bias on individual, clinical, and health system levels, anchored in Kahneman's two-system theory. Videos, journal articles, and group discussion were employed to appeal to many learning styles. A post-curriculum survey assessed perceptions of racial inequality in medicine and the series' effects using a Likert scale. Twenty-nine participants completed the survey (12 fellows), 71% reported improved awareness of racial inequities, and 61% reported improved comfort level in addressing racial inequities. All participants recognized at least "some" racial inequity in medicine, and over 75% of participants indicated interest in further sessions. Formulation of an educational curriculum by fellows and delivered in a division-wide setting was feasible and well received by participants, filling a key educational gap. We encourage other institutions to take similar steps to highlight issues of systemic racism and move our field in the right direction.
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Hematologia , Racismo , Humanos , Currículo , Oncologia/educação , Educação de Pós-Graduação em Medicina , Escolaridade , Hematologia/educaçãoRESUMO
PURPOSE: Timely lung cancer surgery is a metric of high-quality cancer care and improves survival for early-stage non-small-cell lung cancer. Historically, Black patients experience longer delays to surgery than White patients and have lower survival rates. Antiracism interventions have shown benefits in reducing racial disparities in lung cancer treatment. METHODS: We conducted a secondary analysis of Accountability for Cancer Care through Undoing Racism and Equity, an antiracism prospective pragmatic trial, at five cancer centers to assess the impact on overall timeliness of lung cancer surgery and racial disparities in timely surgery. The intervention consisted of (1) a real-time warning system to identify unmet care milestones, (2) race-specific feedback on lung cancer treatment rates, and (3) patient navigation. The primary outcome was surgery within 8 weeks of diagnosis. Risk ratios (RRs) and 95% CIs were estimated using log-binomial regression and adjusted for clinical and demographic factors. RESULTS: A total of 2,363 patients with stage I and II non-small-cell lung cancer were included in the analyses: intervention (n = 263), retrospective control (n = 1,798), and concurrent control (n = 302). 87.1% of Black patients and 85.4% of White patients in the intervention group (P = .13) received surgery within 8 weeks of diagnosis compared with 58.7% of Black patients and 75.0% of White patients in the retrospective group (P < .01) and 64.9% of Black patients and 73.2% of White patients (P = .29) in the concurrent group. Black patients in the intervention group were more likely to receive timely surgery than Black patients in the retrospective group (RR 1.43; 95% CI, 1.26 to 1.64). White patients in the intervention group also had timelier surgery than White patients in the retrospective group (RR 1.10; 95% CI, 1.02 to 1.18). CONCLUSION: Accountability for Cancer Care through Undoing Racism and Equity is associated with timelier lung cancer surgery and reduction of the racial gap in timely surgery.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Disparidades em Assistência à Saúde , Humanos , Neoplasias Pulmonares/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Estados UnidosAssuntos
Vacinas contra COVID-19/administração & dosagem , COVID-19/prevenção & controle , Registros Eletrônicos de Saúde/organização & administração , Neoplasias/terapia , Relações Comunidade-Instituição , Tomada de Decisões , Equidade em Saúde , Humanos , Neoplasias/etnologia , Portais do Paciente , Marginalização SocialRESUMO
Treatment of advanced non-small cell lung cancer (NSCLC) has markedly changed in the past decade with the integration of biomarker testing, targeted therapies, immunotherapy, and palliative care. These advancements have led to significant improvements in quality of life and overall survival. Despite these improvements, racial and socioeconomic disparities in lung cancer mortality persist. This narrative review aims to assess and synthesize the literature on sociodemographic disparities in the management of advanced NSCLC. A narrative overview of the literature was conducted using PubMed and Scopus and was narrowed to articles published from January 1, 2010, until July 22, 2020. Articles relevant to sociodemographic variation in (I) chemoradiation for stage III NSCLC, (II) molecular biomarker testing, (III) systemic treatment, including chemotherapy, targeted therapy, and immunotherapy, and (IV) palliative and end of life care were included in this review. Twenty-two studies were included. Sociodemographic disparities in the management of advanced NSCLC varied, but recurring findings emerged. Across most treatment domains, Black patients, the uninsured, and patients with Medicaid were less likely to receive recommended lung cancer care. However, some of the literature was limited due to incomplete data to adequately assess appropriateness of care, and several studies were out of date with current practice guidelines. Sociodemographic disparities in the management of advanced lung cancer are evident. Given the rapidly evolving treatment paradigm for advanced NSCLC, updated research is needed. Research on interventions to address disparities in advanced NSCLC is also needed.
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World assumptions (WAs) are cognitive schemas concerning an individual's views of themselves, the world, and others. Although it is well established that WAs are negatively distorted by trauma exposure and strongly associated with posttraumatic psychopathology, the potential impact of WAs on close interpersonal relationships remains largely uninvestigated. The current study explored the implications of veterans' and their spouses' WAs on their marital and parental relationships. Male Israeli veterans (N = 213) from the 1973 Yom Kippur War and their wives were assessed for WAs, marital adjustment, and positive parenting 35-37 years postwar. Analyses included actor-partner interdependence modeling with mediators (APIMem) and were conducted separately for the three domains of WAs: world benevolence, world meaningfulness, and self-worth. The results indicated that both husbands' and wives' lower scores for all domain-specific WA scales were associated with lower scores on measures of marital adjustment and positive parenting. Lower scores for both spouses on scales measuring world benevolence and self-worth were associated with a spillover from lower marital adjustment to lower positive parenting. Finally, associations between one spouse's lower WA scores and the other spouse's spillover from lower marital adjustment to lower positive parenting (i.e., cross-spillover effects) were identified for wives' world benevolence ratings and husbands' self-worth, ds = 0.14-0.72. These results point to the detrimental ramifications of negative WAs on family relationships and the dynamics between the marital and parental family subsystems.
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Fadiga de Compaixão/psicologia , Cônjuges/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Veteranos/psicologia , Estudos Transversais , Feminino , Humanos , Israel , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Modelos Psicológicos , Poder Familiar/psicologia , Autoimagem , Inquéritos e QuestionáriosRESUMO
RATIONALE: Aging veterans often suffer from increased vulnerability, manifested among other things in old subjective age and poor perceived health. Though research has documented the contribution of trauma related variables to these negative appraisals, their associations with impostorism (i.e., the subjective experience that one is less adequate than others perceive) remain unexamined. OBJECTIVE: Filling this gap, this study explored the relations between impostorism and subjective age and perceived health among aging combat veterans. METHOD: The study was conducted among 146 Israeli veterans of the 1973 Yom Kippur War. Participants were assessed for combat exposure, Posttraumatic Stress Disorder (PTSD) symptoms, and health-related behaviors during middle adulthood (1991; T1), and for subjective age, perceived health, impostorism, PTSD symptoms, and depressive symptoms during old age (2018; T2). RESULTS: The veterans' impostorism was associated with relatively old subjective age and poor perceived health, above and beyond the effects of age, health-related behaviors, combat exposure, depressive symptoms, and PTSD symptoms. CONCLUSIONS: The current results suggest that impostorism may contribute to veterans' stress and negatively affect their evaluations regarding age and health.
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Distúrbios de Guerra , Transtornos de Estresse Pós-Traumáticos , Veteranos , Adulto , Envelhecimento , Nível de Saúde , Humanos , Transtornos de Estresse Pós-Traumáticos/epidemiologiaRESUMO
OBJECTIVES: Exposure to captivity increases the risk for multiple disturbances that may intensify during old age. In later phases of life, former-prisoners-of-war (ex-POWs) may suffer from depression as well as from accelerated aging, manifested in older subjective age and leukocyte telomere shortening. The current study assesses the link between these varied facets of increased vulnerability during old age and explores (a) the associations between subjective age and telomere length; (b) the mediating role of changes in subjective age over time within the associations between depression and telomere length. METHODS: Eighty-eight ex-POWs were assessed prospectively 30 (T1), 35 (T2), and 45 (T3) years after the 1973 Israeli Yom-Kippur War. Depression was assessed at T1; subjective age was assessed at T2 and T3; and telomere length and control variables were assessed at T3. RESULTS: Older subjective age at T3 was associated with concurrent shorter telomeres, beyond the effect of chronological age. Change in subjective age between T2 and T3 mediated the relations between depression at T1 and shorter telomeres at T3 beyond the effects of control variables. DISCUSSION: Findings suggest that the detrimental ramifications of accelerated subjective age involve premature cellular senesces, and may explain the relation between depression and accelerated aging processes among trauma victims. Hence, clinical interventions may seek to address accelerated subjective age among trauma survivors who suffer from depression.
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Senilidade Prematura/metabolismo , Depressão/metabolismo , Prisioneiros de Guerra , Trauma Psicológico/metabolismo , Encurtamento do Telômero/fisiologia , Idoso , Feminino , Humanos , Israel , Estudos Longitudinais , Masculino , Pessoa de Meia-IdadeRESUMO
Objectives: The aging process may be affected by negative life events as well as social factors. Though psychological aspects of the aging process in veterans have been the focus of considerable research, decorated veterans have been scarcely investigated in this domain. The current study sought to assess psychiatric distress (PD) levels among aging decorated and non-decorated veterans' (DVs and n-DVs, respectively) and examine its association with the maladaptive perception that others will identify a high-achieving person as an impostor (i.e. impostorism) and perceived social isolation (i.e. loneliness).Methods: Two groups of Israeli veterans of the 1973 Yom Kippur War, DVs (n = 75) and n-DVs (n = 73), were assessed for PD and combat exposure in middle adulthood (1991; T1); in later life (2018; T2) they were assessed for negative life events, impostorism, loneliness and PD.Results: Impostorism, loneliness and PD were all inter-correlated. DVs evinced less PD at T1 and T2 than n-DVs but similar levels of impostorism and loneliness at T2. Nevertheless, negative life events, impostorism and loneliness explained PD at T2, with loneliness being more significant, especially among the n-DVs. Combat exposure did not explain variances in late-life PD.Conclusion: Aging DVs seem to be less vulnerable to late-life PD than n-DVs, and impostorism and loneliness may be important factors in this respect. Being the first study to investigate aging DVs' mental health and impostorism among aging veterans, the findings further underscore the clinical imperative of psychosocial factors in understanding aging veterans' mental health.