Medical Therapy and Clinical Outcomes in Cardiac Sarcoidosis Patients With Systolic Heart Failure.

BACKGROUND: Cardiac sarcoidosis (CS) may result in systolic heart failure (heart failure with reduced ejection fraction [HFrEF]), but its response to guideline-directed medical therapy (GDMT) remains uncertain. METHODS AND RESULTS: We investigated 881 patients evaluated for CS to identify those with diagnosed CS, left ventricular ejection fraction (LVEF) ≤40% at diagnosis, and follow-up echocardiogram within 11-24 months. Demographics, LVEF, GDMT as quantified by Kansas City Medical Optimization (KCMO) score, and immunosuppressive treatment were recorded. The primary outcome was a composite of event-free survival (unplanned heart failure hospitalization, left ventricular assist device [LVAD]/heart transplant, or death). Seventy-nine (9%) CS patients met the inclusion criteria (35% female, median age 57 years, mean LVEF 30.9%, median New York Heart Association class II [46%], mean number of GDMT agents 1.7, and mean KCMO score 31.8). Most (87%) were treated with immunosuppressive treatment. At follow-up (median 16 months), the mean number of GDMT agents increased to 2.2 (P=0.02), and the mean KCMO score to 70.1 (P<0.001). Mean LVEF improved to 39.9% (excluding LVAD/transplant; P<0.001) and the change in LVEF was correlated with follow-up KCMO score (P<0.001). The primary outcome occurred in 13 (16%) patients and differed by KCMO score (log-rank P<0.001), but not by immunosuppressive treatment (log-rank P=0.36). CONCLUSIONS: GDMT optimization is associated with better cardiac remodeling and clinical outcomes in CS patients with HFrEF.

18F-FDG/13N-ammonia cardiac PET findings in ATTR cardiac amyloidosis.

18F-flurodeoxyglycose (FDG)/13N-ammonia positron emission tomography/computed tomography (PET/CT) is frequently utilized to evaluate cardiac sarcoidosis (CS) but findings can reflect other forms of myocardial inflammation or altered myocardial metabolic activity. Herein, we present five cases where cardiac PET findings suggested CS, but right ventricular endomyocardial biopsy samples revealed ATTR-type cardiac amyloidosis.

Multidimensional Evaluation of Screening Brief Intervention and Referral to Treatment Training for Medical Students.

OBJECTIVE: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying and addressing alcohol use in non-specialty settings. Many medical schools teach SBIRT, but most published evaluations of these efforts exclude rigorous skill assessments and teaching methods. METHODS: During the 2017-2018 academic year, 146 third-year medical students received classroom-based learning on SBIRT and motivational interviewing (MI) and at least two SBIRT practices with feedback as part of a 4-week psychiatry clerkship. The objective of this curriculum was to improve SBIRT knowledge, attitudes, and confidence and enable learners to skillfully deliver SBIRT. Outcomes evaluated included satisfaction, knowledge, attitudes and confidence, and clinical skill in delivering SBIRT to a standardized patient (rated by the actor, as well as an expert). RESULTS: Results indicated acceptable satisfaction at post-curriculum and significant improvements in attitudes and knowledge from pre- to post-curriculum. On the clinical skills exam, all students were rated as having mastered at least 80% of SBIRT elements by standardized patients and 91.8% were rated at this level by a faculty expert. Student attitudes and knowledge were unrelated to expert ratings, and standardized patient ratings had limited associations with expert ratings. CONCLUSIONS: These results suggest curriculum objectives were achieved and provide unique contributions to the SBIRT curricular outcome research for healthcare trainees. Other findings included that trainee knowledge and confidence may not relate to skill, and standardized patient feedback provides different information on SBIRT and MI skill than expert ratings.

Disability as Diversity: Educational Opportunities for Family Medicine.

Disability is an aspect of diversity that often receives less attention in healthcare and medical education than other aspects of diversity, such as gender or race. Approximately one in four Americans has some type of disability, and individuals with disabilities have less access to healthcare, greater dissatisfaction with their healthcare, and report being in poorer health than individuals without a disability. Although many factors likely contribute to these disparities, physician perception and understanding of disability have been examined as potential pathways that influence health inequity. It is important to incorporate disability as a form of diversity in family medicine education to train physicians that provide excellent care to patients with disabilities and work toward equitable healthcare for them. In this article, we review definitions and data related to disability. We examine disparities and forms of stigmatization toward individuals with disabilities. We then present scenarios in the context of family medicine residency education that involve stigmatization of a person with a disability. Following each scenario, we identify the stigmatizing problem and its potential impact on the individual with a disability. In addition, we outline a potential intervention as an individual witnessing this scenario, and an alternative, non-stigmatizing approach to the scenario. Finally, we present proposed core competencies on disability for health care education and potential strategies to incorporate these competencies into family medicine curricula.

Erythropoietin Prevents Anemia and Transfusions in Extremely Premature Lambs Supported by an EXTrauterine Environment for Neonatal Development (EXTEND).

BACKGROUND: We recently developed an EXTrauterine Environment for Neonatal Development (EXTEND) that provides physiologic support for premature lambs. Here, we assess the efficacy of exogenous erythropoietin (EPO) to prevent anemia and transfusions on EXTEND. MATERIALS AND METHODS: Lambs were cannulated at 0.7 gestation and supported on EXTEND for up to 4 weeks. The lambs were divided into three groups: (1) No EPO, (2) Low EPO (300 U kg-1 per day), and (3) High EPO (800 U kg-1 per day). Daily hematocrit and weekly complete blood count were assessed. RESULTS: The mean percentage change in hematocrit from baseline was significantly different between the groups (No EPO -23.6 ± 7.8% vs. Low EPO -16.6 ± 6.4% vs. High EPO +2.6 ± 6.6%; p = 0.02). This occurred despite a greater median number of blood transfusions in the No EPO group (5 vs. 1 vs. 0; p = 0.02). EPO administration was associated with a higher mean corpuscular volume (MCV; p < 0.01) and reticulocyte count (p = 0.02). The High EPO group was comparable to in utero control fetuses with respect to hematocrit (p = 0.49), MCV (p = 0.24), and reticulocyte count (p = 0.68). CONCLUSIONS: EPO (800 U kg-1 per day) prevents anemia, eliminates transfusions, and restores normal red blood cell indices in premature lambs supported by EXTEND.

Chronically Hypoxic Fetal Lambs Supported by an Extra-Uterine Device Exhibit Mitochondrial Dysfunction and Elevations of Hypoxia Inducible Factor 1-Alpha.

INTRODUCTION: We have recently developed an extra-uterine environment for neonatal development (EXTEND) capable of supporting premature fetal lambs and have been able to replicate hypoxic in utero conditions by controlling fetal oxygen delivery. In this study, we investigated the fetal mitochondrial response to hypoxia. METHODS: Eight premature fetal lambs were delivered via hysterotomy and transitioned to extra-uterine support for 3 weeks. The lambs were divided into 2 groups: normoxic fetuses which maintained physiologic oxygen delivery and hypoxic fetuses in which oxygen delivery was significantly reduced. Control fetuses were delivered via hysterotomy but not cannulated. Measurements of mitochondrial membrane potential (MMP) were performed in peripheral blood mononuclear cells. RESULTS: There were no significant differences in MMP between normoxic EXTEND fetuses and controls. Hypoxic fetuses had significantly more depolarized mitochondria compared to normoxic fetuses overall, and these changes were specifically appreciated in weeks 1 and 2, but not by week 3. Hypoxic fetuses had significantly elevated levels of HIF-1α compared to normoxic fetuses in the first 2 weeks. DISCUSSION: Normoxic fetal lambs supported by EXTEND demonstrate normal mitochondrial function as evidenced by equivalent membrane potentials compared to control fetuses. Hypoxic fetuses exhibit mitochondrial dysfunction, though they do show evidence of adaptation after 3 weeks of hypoxic exposure.

Umbilical cannulation optimizes circuit flows in premature lambs supported by the EXTra-uterine Environment for Neonatal Development (EXTEND).

KEY POINTS: Bronchopulmonary dysplasia is a disease of extreme prematurity that occurs when the immature lung is exposed to gas ventilation. We designed a novel 'artificial womb' system for supporting extreme premature lambs (called EXTEND) that obviates gas ventilation by providing oxygen via a pumpless arteriovenous circuit with the lamb submerged in sterile artificial amniotic fluid. In the present study, we compare different arteriovenous cannulation strategies on EXTEND, including carotid artery/jugular vein (CA/JV), carotid artery/umbilical vein (CA/UV) and umbilical artery/umbilical vein (UA/UV). Compared to CA/JV and CA/UV cannulation, UA/UV cannulation provided significantly higher, physiological blood flows to the oxygenator, minimized flow interruptions and supported significantly longer circuit runs (up to 4 weeks). Physiological circuit blood flow in UA/UV lambs made possible normal levels of oxygen delivery, which is a critical step toward the clinical application of artificial womb technology. ABSTRACT: EXTEND (EXTra-uterine Environment for Neonatal Development) is a novel system that promotes physiological development by maintaining the premature lamb in a sterile fluid environment and providing gas exchange via a pumpless arteriovenous oxygenator circuit. During the development of EXTEND, different cannulation strategies evolved with the aim of improving circuit flow. The present study examines how different cannulation strategies affect EXTEND circuit haemodynamics in extreme premature lambs. Seventeen premature lambs were cannulated at gestational ages 105-117 days (term 145-150 days) and supported on EXTEND for up to 4 weeks. Experimental groups were distinguished by cannulation strategy: carotid artery outflow and jugular vein inflow (CA/JV; n = 4), carotid artery outflow and umbilical vein inflow (CA/UV; n = 5) and double umbilical artery outflow and umbilical vein inflow (UA/UV; n = 8). Circuit flows and pressures were measured continuously. As we transitioned from CA/JV to CA/UV to UA/UV cannulation, mean duration of circuit run and weight-adjusted circuit flows increased (P < 0.001) and the frequency of flow interruptions declined (P < 0.05). Umbilical vessels generally accommodated larger-bore cannulas, and cannula calibre was directly correlated with circuit pressures and indirectly correlated with flow:pressure ratio (a measure of post-membrane resistance). We conclude that UA/UV cannulation in fetal lambs on EXTEND optimizes circuit flow dynamics and flow stability and also supports circuit flows that closely approximate normal placental flow.

End-of-Life Discussions in Patients With Heart Failure.

BACKGROUND: Although guidelines call on clinicians to conduct regular conversations about advance care planning and end-of-life (EOL) preferences with patients with heart failure (HF), research suggests that physicians often avoid these discussions. METHODS AND RESULTS: From January 20, 2014, to January 18, 2016, Southeastern Minnesota residents hospitalized with acute decompensated HF (ADHF) at Mayo Clinic hospitals were enrolled into an observational cohort study that included the administration of face-to-face questionnaires. Risk of death (prognosis) was estimated using the Meta-analysis Global Group in Chronic Heart Failure score. Among 400 patients (mean age 77.7 years, 46% female, 48% preserved ejection fraction), only 69 (17%) reported previously discussing EOL wishes with their physician. Patients reporting EOL discussions more often had an advance directive (81% vs 66%; P = .009), recognized the term "hospice" (96% vs 87%; P = .027), and had more favorable attitudes of dying and hospice (P = .030). Resuscitation preferences and rates of completion of advance directives varied with prognosis, although patient-clinician EOL discussions did not. CONCLUSIONS: The majority of patients hospitalized with ADHF did not recall discussing their preferences for EOL care with their physician. This represents an important modifiable gap in the optimal longitudinal care of HF patients.

The influence of widowhood and social engagement on cognitive impairment among Chinese older adults and factors mediating their association.

Background: Prior studies exploring the impact of widowhood on cognitive impairment in later life have been focussed on the USA and Europe. We aimed to explore the mediating role of social engagement, health behaviours, and subjective well-being in the association between widowhood and cognitive impairment in the Chinese population. Methods: We conducted a study on 7796 older individuals enrolled in the 2018 wave of the Chinese Longitudinal Health Longevity Study. We used logistic regression models to analyse the impact of widowhood on cognitive health among older adults and performed mediation analysis to determine possible mediating factors in this relationship. Results: Widows and widowers had a higher risk of having cognitive impairment than married older adults (95% confidence interval (CI) = 1.312, 2.279). The results from structural equation modelling (SEM) provided a good fit to the observed data (χ2 = 24.909; P = 0.00) and indicated that the effect of widowhood on cognitive impairment was partially mediated by social engagement, lifestyle behaviours, and subjective well-being (ß = 0.075; P < 0.01). Conclusions: Our findings contribute to existing research on the mechanisms underlying the association between widowhood and cognitive impairment among older individuals, suggesting a need for policies targeted at the specific needs of this vulnerable population, such as the maintenance of social interactions, adoption of a healthy lifestyle, improvement of subjective well-being, and provision of necessary support systems.

Put the Vanc Down, Flip It and Reverse It: Comparison of Vancomycin and Daptomycin Health Care Utilization and Cost in Outpatient Parenteral Antimicrobial Therapy.

Vancomycin and daptomycin are frequently used in outpatient parenteral antimicrobial therapy (OPAT). We analyze health care utilization and cost to the health care system for vancomycin vs daptomycin in the outpatient setting and find that vancomycin results in significantly higher health care utilization and similar cost per course compared with daptomycin in OPAT.

Cardiac remodelling during pregnancy in women with congenital heart disease and systemic left ventricle.

AIMS: Women with congenital heart disease (CHD) are at risk of pregnancy-related adverse outcomes (PRAO). The purpose of this study was to assess temporal changes in cardiac structure and function (cardiac remodelling) during pregnancy, and the association with PRAO in women with CHD. METHODS AND RESULTS: Retrospective study of pregnant women with CHD and serial echocardiograms (2003-2021). Cardiac structure and function were assessed at pre-specified time points: prepregnancy, early pregnancy, late pregnancy, and postnatal period. PRAO was defined as the composite of maternal cardiovascular, obstetric, and neonatal complications. The study comprised 81 women with CHD (age, 29 ± 5 years). Compared to the baseline echocardiogram, there was a relative increase in right ventricular systolic pressure (RVSP) (relative change 13 ± 5%, P < 0.001, in early pregnancy; and 18 ± 5%, P < 0.001, in late pregnancy). There was a relative decrease in right ventricle free wall strain (RVFWS) (relative change -11 ± 3%, P < 0.001, in late pregnancy; and -11 ± 4%, P = 0.003, in postnatal period), and a relative decrease in RVFWS/RVSP (relative change, -10 ± 5%, P = 0.02 in early pregnancy, -26 ± 7%, P < 0.001, in late pregnancy, and -14 ± 5%, P < 0.001, in postnatal period). Baseline right ventricular to pulmonary arterial (RV-PA) coupling, and temporal change in RV-PA coupling were associated with PRAO, after adjustment for maternal age and severity of cardiovascular disease. CONCLUSION: Women with CHD had a temporal decrease in RV systolic function and RV-PA coupling, and these changes were associated with PRAO. Further studies are required to delineate the aetiology of deterioration in RV-PA coupling during pregnancy, and the long-term implications of right heart dysfunction observed in the postnatal period.

Dalba Got Back? Use of Dalbavancin for the Treatment of Vertebral Osteomyelitis.

Data evaluating dalbavancin use for vertebral osteomyelitis remain limited. In our retrospective cohort, 29 of 34 (85.3%) patients completed their dalbavancin course. Adverse reactions occurred for 6 (17.6%) and infection recurrence in 3 (8.8%) within 90 days. Dalbavancin appears to be safe and well-tolerated for vertebral osteomyelitis.

Is Cardiac Surgery Safe During Pregnancy? A 40-Year Single-Institution Experience.

BACKGROUND: Limited data exist to characterize maternal and fetal outcomes during pregnancy undergoing cardiac operations using cardiopulmonary bypass. METHODS: A retrospective review was performed of all pregnant individuals who underwent cardiac surgery using cardiopulmonary bypass at a single center from 1978 to 2023. Descriptive statistical analysis was performed, with a median reported for continuous variables and incidence for dichotomous variables. RESULTS: Twenty-nine pregnant patients with a median age of 28 years (interquartile range [IQR], 25-32 years) years underwent cardiac surgery using cardiopulmonary bypass at a median gestation of 25 weeks (IQR, 16-29 weeks). Surgery was performed in the first trimester for 3 patients (10%), second trimester for 16 (55%), and third trimester for 10 (35%). Procedures were emergent in 15 (52%) and urgent in 14 (48%). There was 1 (3%) maternal death 2 days after mechanical aortic valve thrombectomy and 5 (17%) fetal losses. Fourteen patients who underwent cardiac surgery using cardiopulmonary bypass with continuing pregnancy experienced a 29% fetal mortality rate, and 7 patients underwent delivery before surgery and experienced 14% fetal mortality. Among cases of fetal loss, surgery was performed at a median of 25 weeks (IQR, 21-26 weeks) compared with a median of 23 weeks (IQR, 20-29 weeks) in cases without fetal loss (P = .55). CONCLUSIONS: Cardiac surgery during pregnancy was associated with low maternal mortality but significant fetal mortality. This single-institution series supports consideration of cesarean delivery before cardiopulmonary bypass procedures if the fetus is of a viable gestational age to minimize mortality.

Life After Neonatal Seizures: Characterizing the Longitudinal Parent Experience.

BACKGROUND: Parents of neonates with seizures report persistent symptoms of depression, anxiety, and posttraumatic stress. We aimed to characterize the parent experience of caring for children impacted by neonatal seizures, including longitudinal assessment across childhood. METHODS: This prospective, observational, multicenter study was conducted at Neonatal Seizure Registry (NSR) sites in partnership with the NSR Parent Advisory Panel. Parents completed surveys at discharge; 12, 18, and 24 months; and 3, 4, 5, 7, and 8 years. Surveys included demographic information and open-ended questions targeting parent experience. A conventional content analysis approach was used. RESULTS: A total of 320 caregivers completed at least one open-ended question, with the majority of respondents at discharge (n = 142), 12 months (n = 169), 18 months (n = 208), and 24 months (n = 245). We identified the following three primary themes. (1) Personal Burden of Care: Parents experienced emotional distress, financial strain, physical demands, and fears for their child's unknown outcome; (2) Managing Day-to-Day Life: Parents described difficulties navigating their parenting role, including managing their child's challenging behaviors and understanding their child's needs amid neurodevelopmental impairment; (3) My Joys as a Parent: Parents valued bonding with their child, being a caregiver, and watching their child's personality grow. CONCLUSIONS: Parents of children impacted by neonatal seizures face persistent challenges, which are interwoven with the joys of being a parent. Our findings suggest that future interventions should promote resiliency, address caregivers' psychosocial needs longitudinally, and provide enhanced support for parents caring for children with medical complexity.

Arrhythmic manifestations and outcomes of definite and probable cardiac sarcoidosis.

BACKGROUND: The 2014 Heart Rhythm Society consensus statement defines histological (definite) and clinical (probable) diagnostic categories of cardiac sarcoidosis (CS), but few studies have compared their arrhythmic phenotypes and outcomes. OBJECTIVE: The purpose of this study was to evaluate the electrophysiological/arrhythmic phenotype and outcomes of patients with definite and probable CS. METHODS: We analyzed the arrhythmic/electrophysiological phenotype in a single-center North American cohort of 388 patients (median age 56 years; 39% female, n = 151) diagnosed with definite (n = 58) or probable (n = 330) CS (2000-2022). The primary composite outcome was survival to first ventricular tachycardia/fibrillation (VT/VF) event or sudden cardiac death. Key secondary outcomes were also assessed. RESULTS: At index evaluation, in situ cardiac implantable electronic devices and antiarrhythmic drug use were more common in definite CS. At a median follow-up of 3.1 years, the primary outcome occurred in 22 patients with definite CS (38%) and 127 patients with probable CS (38%) (log-rank, P = .55). In multivariable analysis, only a higher ratio of the 18F-fluorodeoxyglucose maximum standardized uptake value of the myocardium to the maximum standardized uptake value of the blood pool (hazard ratio 1.09; 95% confidence interval 1.03-1.15; P = .003, per 1 unit increase) was associated with the primary outcome. During follow-up, patients with definite CS had a higher burden of device-treated VT/VF events (mean 2.86 events per patient-year vs 1.56 events per patient-year) and a higher rate of progression to heart transplant/left ventricular assist device implantation but no difference in all-cause mortality compared with patients with probable CS. CONCLUSION: Patients with definite and probable CS had similarly high risks of first sustained VT/VF/sudden cardiac death and all-cause mortality, though patients with definite CS had a higher overall arrhythmia burden. Both CS diagnostic groups as defined by the 2014 Heart Rhythm Society criteria require an aggressive approach to prevent arrhythmic complications.

Artificial intelligence-based screening for cardiomyopathy in an obstetric population: A pilot study.

Background: Cardiomyopathy is a leading cause of pregnancy-related mortality and the number one cause of death in the late postpartum period. Delay in diagnosis is associated with severe adverse outcomes. Objective: To evaluate the performance of an artificial intelligence-enhanced electrocardiogram (AI-ECG) and AI-enabled digital stethoscope to detect left ventricular systolic dysfunction in an obstetric population. Methods: We conducted a single-arm prospective study of pregnant and postpartum women enrolled at 3 sites between October 28, 2021, and October 27, 2022. Study participants completed a standard 12-lead ECG, digital stethoscope ECG and phonocardiogram recordings, and a transthoracic echocardiogram within 24 hours. Diagnostic performance was evaluated using the area under the curve (AUC). Results: One hundred women were included in the final analysis. The median age was 31 years (Q1: 27, Q3: 34). Thirty-eight percent identified as non-Hispanic White, 32% as non-Hispanic Black, and 21% as Hispanic. Five percent and 6% had left ventricular ejection fraction (LVEF) <45% and <50%, respectively. The AI-ECG model had near-perfect classification performance (AUC: 1.0, 100% sensitivity; 99%-100% specificity) for detection of cardiomyopathy at both LVEF categories. The AI-enabled digital stethoscope had an AUC of 0.98 (95% CI: 0.95, 1.00) and 0.97 (95% CI: 0.93, 1.00), for detection of LVEF <45% and <50%, respectively, with 100% sensitivity and 90% specificity. Conclusion: We demonstrate an AI-ECG and AI-enabled digital stethoscope were effective for detecting cardiac dysfunction in an obstetric population. Larger studies, including an evaluation of the impact of screening on clinical outcomes, are essential next steps.

Neuropsychological assessment of decision making in alcohol-dependent commercial pilots.

BACKGROUND: The aim of this exploratory archival study was to discern the utility of the Iowa Gambling Task (IGT) in identifying adaptive decision-making capacities among pilots with a history of alcohol dependence both with and without Cluster B personality features. METHODS: Participants included 18 male airmen at the rank of captain with a history of receiving alcohol dependence treatment and subsequent referral for a fitness-for-duty evaluation. Data from prior comprehensive neuropsychological evaluations conducted in a private practice setting at the mandate of the FAA utilizing criteria outlined in the HIMS program was used. ANOVA was conducted to compare pilots with (N = 4) and without Cluster B personality features (N = 14) on measures of decisionmaking capacities, intelligence, and executive functioning. RESULTS: Pilots with Cluster B personality features were found to have a significantly lower Total Net T-Score on IGT (M = 35.00, SD = 9.27) than pilots without features of Cluster B (M = 56.36, SD = 9.55). Furthermore, with the exception of the first 20 cards (i.e., Net 1); the groups significantly differed in their Net scores. No statistically significant difference was found on airmen's intelligence and executive functioning. DISCUSSION: The present study found that alcohol-dependent airmen with Cluster B personality features evidenced significantly poorer decisionmaking capacities as measured by the ICT in comparison to alcohol dependent airman without Cluster B personality features. Implications and limitations of the study are discussed.

Caring for the caregiver in dementia.

Caregiver stress is higher for dementia caregiving than other types. By focusing on the family, FPs can help to ease the burden.

Mental Health Stigma in Active Duty Service Members Receiving Mental Health Services.

INTRODUCTION: Mental health treatment is a service for military service members who have experienced psychological injury or trauma. Unfortunately, the stigma associated with treatment can prevent many service members from seeking and receiving treatment designed to help them recover. Previous studies have examined the impacts of stigma among military personnel as well as civilians; however, stigma among service members currently receiving mental health treatment is unknown. The purpose of this study is to understand the relationships between stigma, demographic variables, and mental health symptoms in a sample of active duty service members receiving mental health services in a partial hospitalization program. MATERIALS AND METHODS: This cross-sectional, correlational study collected data from participants in the Psychiatric Continuity Services clinic at Walter Reed National Military Medical Center, which offers a four-week partial hospitalization program specializing in trauma recovery for active duty service members of all branches. The data from behavioral health assessments were gathered over a 6-month timespan, including the Behavior and Symptom Identification Scale-24, Patient Health Questionnaire-9, Generalized Anxiety Disorder 7-item scale, and Post-traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Stigma was measured using the Military Stigma Scale (MSS). The demographic data collected included military rank and ethnicity. Pearson correlations, t-tests, and linear regression were used to further explore the relationships between the MSS scores, demographic covariates, and behavioral health measures. RESULTS: In unadjusted linear regression models, non-white ethnicity and higher behavioral health assessment intake measures were associated with higher MSS scores. However, after adjusting for gender, military rank, race, and all mental health questionnaires, only Post-traumatic Stress Disorder Checklist for DSM-5 intake scores remained associated with MSS scores. No relationship between gender or military rank and average stigma score was observed in either the unadjusted or adjusted regression models. One-way analysis of variance detected a statistically significant difference between the white/Caucasian group and Asian/Pacific Islander group and a near significant difference between white/Caucasian group and black/African American group. The rates of stigma were higher in non-whites than whites. CONCLUSIONS: In this active duty military cohort, greater mental health stigma was associated with greater severity of mental health symptoms, especially post-traumatic stress symptoms. Some evidence found that ethnicity may also play a role in stigma score differences, particularly in the Asian/Pacific Islander group. Service providers could consider assessing mental health stigma to meet the clinical needs of their patients within the context of their willingness to obtain and adhere to treatment. Anti-stigma efforts to reduce stigma and its impacts on mental health are discussed. Additional research investigating the effect stigma has on treatment outcomes would help guide the relative importance of assessing stigma, in addition to other behavioral health realms.