Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States.

BACKGROUND: Research on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking. METHODS: This cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015. RESULTS: Results of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22-1.71), back pain (AOR, 1.83; 95% CI, 1.56-2.14), diabetes (AOR, 1.42; 95% CI, 1.03-1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80-3.98), major depression (AOR, 1.78; 95% CI, 1.53-2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34-2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts. CONCLUSIONS: OIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers' increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.

Impact of Alcohol Use Disorder Treatment on Clinical Outcomes Among Patients With Cirrhosis.

BACKGROUND AND AIMS: Despite the significant medical and economic consequences of coexisting alcohol use disorder (AUD) in patients with cirrhosis, little is known about AUD treatment patterns and their impact on clinical outcomes in this population. We aimed to characterize the use of and outcomes associated with AUD treatment in patients with cirrhosis. APPROACH AND RESULTS: This retrospective cohort study included Veterans with cirrhosis who received Veterans Health Administration care and had an index diagnosis of AUD between 2011 and 2015. We assessed the baseline factors associated with AUD treatment (pharmacotherapy or behavioral therapy) and clinical outcomes for 180 days following the first AUD diagnosis code within the study time frame. Among 93,612 Veterans with cirrhosis, we identified 35,682 with AUD, after excluding 2,671 who had prior diagnoses of AUD and recent treatment. Over 180 days following the index diagnosis of AUD, 5,088 (14%) received AUD treatment, including 4,461 (12%) who received behavioral therapy alone, 159 (0.4%) who received pharmacotherapy alone, and 468 (1%) who received both behavioral therapy and pharmacotherapy. In adjusted analyses, behavioral and/or pharmacotherapy-based AUD treatment was associated with a significant reduction in incident hepatic decompensation (6.5% vs. 11.6%, adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.52, 0.76), a nonsignificant decrease in short-term all-cause mortality (2.6% vs. 3.9%, AOR, 0.79; 95% CI, 0.57, 1.08), and a significant decrease in long-term all-cause mortality (51% vs. 58%, AOR, 0.87; 95% CI, 0.80, 0.96). CONCLUSIONS: Most Veterans with cirrhosis and coexisting AUD did not receive behavioral therapy or pharmacotherapy treatment for AUD over a 6-month follow-up. The reductions in hepatic decompensation and mortality suggest that future studies should focus on delivering evidence-based AUD treatments to patients with coexisting AUD and cirrhosis.

Development of a Perceived Access Inventory for Community Care Mental Healthcare Services for Veterans.

INTRODUCTION: Access to high-quality healthcare, including mental healthcare, is a high priority for the Department of Veterans Affairs (VA). Meaningful monitoring of progress will require patient-centered measures of access. To that end, we developed the Perceived Access Inventory focused on access to VA mental health services (PAI-VA). However, VA is purchasing increasing amounts of mental health services from community mental health providers. In this paper, we describe the development of a PAI for users of VA-funded community mental healthcare that incorporates access barriers unique to community care service use and compares the barriers most frequently reported by veterans using community mental health services to those most frequently reported by veterans using VA mental health services. MATERIALS AND METHODS: We conducted mixed qualitative and quantitative interviews with 25 veterans who had experience using community mental health services through the Veterans Choice Program (VCP). We used opt-out invitation letters to recruit veterans from three geographic regions. Data were collected on sociodemographics, rurality, symptom severity, and service satisfaction. Participants also completed two measures of perceived barriers to mental healthcare: the PAI-VA adapted to focus on access to mental healthcare in the community and Hoge's 13-item measure. This study was reviewed and approved by the VA Central Institutional Review Board. RESULTS: Analysis of qualitative interview data identified four topics that were not addressed in the PAI-VA: veterans being billed directly by a VCP mental health provider, lack of care coordination and communication between VCP and VA mental health providers, veterans needing to travel to a VA facility to have VCP provider prescriptions filled, and delays in VCP re-authorization. To develop a PAI for community-care users, we created items corresponding to each of the four community-care-specific topics and added them to the 43-item PAI-VA. When we compared the 10 most frequently endorsed barriers to mental healthcare in this study sample to the ten most frequently endorsed by a separate sample of current VA mental healthcare users, six items were common to both groups. The four items unique to community-care were: long waits for the first mental health appointment, lack of awareness of available mental health services, short appointments, and providers' lack of knowledge of military culture. CONCLUSIONS: Four new barriers specific to veteran access to community mental healthcare were identified. These barriers, which were largely administrative rather than arising from the clinical encounter itself, were included in the PAI for community care. Study strengths include capturing access barriers from the veteran experience across three geographic regions. Weaknesses include the relatively small number of participants and data collection from an early stage of Veteran Choice Program implementation. As VA expands its coverage of community-based mental healthcare, being able to assess the success of the initiative from the perspective of program users becomes increasingly important. The 47-item PAI for community care offers a useful tool to identify barriers experienced by veterans in accessing mental healthcare in the community, overall and in specific settings, as well as to track the impact of interventions to improve access to mental healthcare.

Effect of Dual Use of Veterans Affairs and Medicare Part D Drug Benefits on Antihypertensive Medication Supply in a National Cohort of Veterans with Dementia.

OBJECTIVE: To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING: National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN: We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS: Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS: Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS: Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.

The Voice of the Consumer: A Survey of Veterans and Other Users of Assistive Technology.

Introduction: A total of 3.6 million Americans and over 250,000 veterans use wheelchairs. The need for advancements in mobility-assistive technologies is continually growing due to advances in medicine and rehabilitation that preserve and prolong the lives of people with disabilities, increases in the senior population, and increases in the number of veterans and civilians involved in conflict situations. The purpose of this study is to survey a large sample of veterans and other consumers with disabilities who use mobility-assistive technologies to identify priorities for future research and development. Materials and Methods: This survey asked participants to provide opinions on the importance of developing various mobility-assistive technologies and to rank the importance of certain technologies. Participants were also asked to provide open-ended comments and suggestions. Results: A total of 1,022 individuals, including 500 veterans, from 49 states within the USA and Puerto Rico completed the survey. The average age of respondents was 54.3 yr, and they represented both new and experienced users of mobility-assistive technologies. The largest diagnostic group was spinal cord injury (SCI) (N = 491, 48.0%). Several themes on critical areas of research emerged from the open-ended questions, which generated a total of 1,199 comments. Conclusion: This survey revealed several themes for future research and development. Advanced wheelchair design, smart device applications, human-machine interfaces, and assistive robotics and intelligent systems emerged as priorities. Survey results also demonstrated the importance for researchers to understand the effects of policy and cost on translational research and to be involved in educating both consumers and providers.

Dolor recurrente en fosa iliaca derecha en niños: reporte de dos casos asociados a alergia alimentaria / Recurrent right iliac fossa pain in children: two cases report related to food allergy

Objetivo: Presentar dos casos de alergia alimentaria de presentación poco común y discutir el enfoque diagnóstico de DAR en niños Casos: Caso N° 1: Niña de 11 años, aqueja dolor en fosa iliaca derecha hace 3 meses. Antecedentes: Prematuridad, atopía (dermatitis, rinitis, cólicos). Hermana y madre atópicas. Al examen físico: Dolor exquisito a la palpación de fosa iliaca derecha, cuerda cólica bilateral. Piel seca. Laboratorio: Hematobiometría sin alteraciones. Examen de orina normal, parasitológico seriado (-). EDN (neurotoxina derivada de eosinófilos) fecal >3210 ng/ml (V.N. <360 ng/ml). Colonoscopía: hiperplasia linfoidea de íleon. Caso N° 2: Niño de 9 años. Dolor en fosa iliaca derecha hace tres meses dolor abdominal localizado en fosa iliaca derecha, a predominio nocturno y con irradiación a muslo derecho. Un psiquiatra infantil le prescribe antidepresivos. Antecedentes personales: Lactancia mixta. Atopía: Asma, dermatitis atópica, cólicos de lactante. Antecedentes familiares: Madre alérgica a alimentos, padre presenta rinitis. Al examen físico: Cuerda cólica bilateral. Dolor a la palpación en fosa iliaca derecha. Laboratorio: Inmunoglobulina E 160,5 UI/ml (V.N. < 90). Colonoscopía: Hiperplasia linfoidea en íleon distal. Ambos casos mejoraron con dieta hipoalergénica. Conclusión: En presencia de hiperplasia nodular linfoide de íleon y antecedentes familiares y/o personales de atopía, debemos considerar en el diagnóstico diferencial de dolor abdominal recurrente de fosa iliaca derecha a la alergia alimentaria. La dieta de eliminación es diagnóstica y terapéutica a su vez.

Objective: To present two cases of food allergy of uncommon presentation and discuss the diagnostic approach to give in these cases: Case N° 1: 11-year-old girl, afflicting pain in the right iliac fossa 3 months ago. Background: Prematurity, atopy (dermatitis, rhinitis, cramping). Sister and mother are atopic too. The physical exam show exquisite pain on right iliac fossa at palpation. Laboratory: Urine normal, parasitological serial negative. EDN (neurotoxin derived from eosinophils) fecal >3210 ng/ml (V. N. < 360 ng/ml). Colonoscopy: lymphoid hyperplasia of ileum. Case N° 2: Child of 9 years of age. Right fossa iliac painful three months ago, predominantly nocturnal and with irradiation to right thigh. A child psychiatrist may prescribe antidepressants. Personal History: Breastfeeding and formula since newborn. Atopy: asthma, atopic dermatitis, infant colic. Family history: Mother allergic to food, father presents rhinitis. The physical examination: Pain on palpation in the right iliac fossa. Laboratory: Immunoglobulin E 160.5 IU/ml (V. N. < 90) Colonoscopy: lymphoid hyperplasia in the distal ileum. Both cases relieved by hypoallergenic diet. Conclusion: When both, ileal nodular lymphoid hyperplasia and atopy personal or familiar are present, we must be think in food allergy as differential diagnosis of recurrent abdominal pain of right iliac fosse in children. The elimination diet is diagnostic and therapeutic.