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1.
Biomed Environ Sci ; 34(3): 184-191, 2021 Mar 20.
Artículo en Inglés | MEDLINE | ID: mdl-33766214

RESUMEN

Objective: Evidence is lacking regarding the combined effects of smoking and obesity on mortality from coronary heart disease in male veterans. This study aimed to explore the combined effect of smoking and obesity on coronary heart disease mortality in male veterans in China. Methods: A cohort of 1,268 male veterans from 22 veteran centers in Xi'an (Shaanxi Province, China) were followed up once every 2 years from February 1, 1987 to October 30, 2016. The endpoint was death from any cause. The hazard ratio ( HR) of each risk factor and the 95% confidence interval ( CI) were calculated using a multivariate Cox proportional hazard model. Results: The total follow-up was 24394.21 person-years; each subject was followed up for a mean duration of 19.24 years. By the end of the study, of the 1,268 veterans, 889 had died, 363 were alive, and 16 were lost to follow-up. Cox regression analysis results revealed that current smoking ( HR: 1.552, 95% CI: 1.074-2.243), obesity ( HR: 1.625, 95% CI: 1.024-2.581), and the combined effect of the two factors ( HR: 2.828, 95% CI: 1.520-5.262) were associated with coronary heart disease mortality. Conclusion: Our results suggest that obese veterans who smoke might be an important target population for coronary heart disease mortality control.


Asunto(s)
Enfermedad Coronaria/mortalidad , Obesidad/complicaciones , Fumar , Veteranos/estadística & datos numéricos , Anciano , China/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Factores de Riesgo
4.
Med Care ; 59: S36-S41, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33438881

RESUMEN

BACKGROUND: Veterans experiencing housing instability are at increased risk of suicide. Research is needed to identify gender differences in the predictors of both suicidal ideation and suicide attempt, particularly among Veterans who are unstably housed. OBJECTIVES: The objective of the present study was to explore whether correlates of suicide-related morbidity among unstably housed Veterans vary by gender and identify implications for improved care for these Veterans. METHODS: The study cohort included 86,325 Veterans who reported current housing instability between October 1, 2013, and September 30, 2016. This cross-sectional study assessed differences in demographic and outcome variables by gender using χ2 analyses and a series of multiple logistic regressions predicting suicidal ideation and suicide attempt, stratified by gender. RESULTS: Among unstably housed female Veterans, being younger than 40 years was associated with more than double the odds of having an indicator of suicidal ideation and >12 times the odds of having an indicator of a suicide attempt. The effect sizes associated with age were much less pronounced among unstably housed male Veterans. The presence of mental health and substance use conditions as well as a positive screen for military sexual trauma were associated with increased risk of suicide morbidity among both women and men. CONCLUSIONS: Intervention and prevention among unstably housed Veterans may be complicated by unpredictable living situations; further research should explore tailored interventions to address the complex needs of unstably housed Veterans and how suicide prevention can be woven throughout.


Asunto(s)
Vivienda , Ideación Suicida , Intento de Suicidio , Veteranos/psicología , Veteranos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores Sexuales , Estados Unidos/epidemiología , Adulto Joven
5.
Med Care ; 59: S51-S57, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33438883

RESUMEN

OBJECTIVE: This study aimed to (1) examine whether the latent class structure of individuals engaging in self-directed violence and indirect self-harm behaviors (eg, substance use, disordered eating) varied by gender in a sample of US veterans, and (2) test the associations of posttraumatic stress disorder (PTSD) and depressive symptoms with the resulting classes. STUDY DESIGN: Cross-sectional data from 3581 veterans, ages 18-50 (51.9% identified as women) were analyzed. Veterans self-reported histories of self-directed violence, substance use, and disordered eating. Latent class analysis and latent class regression were used to explore class structure by gender and examine association of class membership with PTSD and depressive symptoms. RESULTS: A 4-class model was supported in the sample. Class 1 (20.0%) was characterized by substance use and self-directed violent thoughts and behaviors. Class 2 (8.3%) was characterized by substance use, disordered eating, and self-directed violent thoughts and behaviors. Class 3 (12.6%) was distinguished by indirect self-harm behaviors (substance use and disordered eating). Class 4 (59.6%) reflected low likelihood of behavioral dysregulation. Classes were partially invariant across gender; endorsement of substance use behaviors was generally higher for men in each class. Comorbid clinically significant depressive and PTSD symptoms were associated with the class characterized by highest behavioral dysregulation. CONCLUSIONS: Self-directed violent thoughts and behaviors present comorbidly with indirect self-harm in men and women veterans, although patterns of indirect self-harm behaviors differ slightly by gender. Such comorbidity may be associated with more severe presentations of psychiatric concerns.


Asunto(s)
Trastornos de Alimentación y de la Ingestión de Alimentos/epidemiología , Conductas de Riesgo para la Salud , Análisis de Clases Latentes , Conducta Autodestructiva/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Veteranos/psicología , Veteranos/estadística & datos numéricos , Adolescente , Adulto , Comorbilidad , Depresión/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Sexuales , Trastornos por Estrés Postraumático/epidemiología , Estados Unidos/epidemiología , Adulto Joven
6.
Med Care ; 59: S70-S76, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-33438886

RESUMEN

BACKGROUND: Among midlife and older women, menopause symptoms and menopausal hormone therapy have been linked to mental health disorders and other comorbidities related to suicide. However, the role of hormone therapy as a prognostic factor of suicide risk is largely unknown. OBJECTIVES: To examine associations between menopausal hormone therapy, suicide attempts, and suicide among midlife and older women Veterans. RESEARCH DESIGN: In this longitudinal analysis of national Veterans Health Administration data from women Veterans aged 50 years and above, we used Fine-Gray proportional hazards models to examine associations between menopausal hormone therapy (prescribed in 2012-2013) and incident suicide attempts and suicide (index date-2016). MEASURES: Menopausal hormone therapy and psychoactive medications from pharmacy records; suicide attempts and suicide from national suicide data repositories; demographic variables, medical and psychiatric diagnoses, and substance use disorders from electronic medical record data and International Classification Diagnoses-9-CM codes. RESULTS: In this national sample of 291,709 women Veterans (mean age 60.47, SD 9.81), 6% were prescribed menopausal hormone therapy at baseline. Over an average of 4.5 years, 2673 had an incident suicide attempt (93%) or death by suicide (7%). Adjusting for age, race, and medical diagnoses, menopausal hormone therapy was associated with increased risk of suicide attempt (hazard ratio 1.41; 95% confidence interval, 1.22-1.64) and over 2-fold increased risk of death by suicide (hazard ratio 2.47; 95% confidence interval, 1.58-3.87). Associations with death by suicide remained significant after accounting for psychiatric comorbidity and psychoactive medications. CONCLUSIONS: Menopausal hormone therapy may be an important indicator of suicide risk among midlife and older women.


Asunto(s)
Terapia de Reemplazo de Hormonas/psicología , Menopausia/psicología , Intento de Suicidio/estadística & datos numéricos , Suicidio Completo/estadística & datos numéricos , Veteranos/psicología , Anciano , Centers for Medicare and Medicaid Services, U.S. , Femenino , Humanos , Incidencia , Estudios Longitudinales , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Factores de Riesgo , Estados Unidos/epidemiología , United States Department of Veterans Affairs , Veteranos/estadística & datos numéricos , Salud de los Veteranos
7.
JAMA Netw Open ; 4(1): e2034266, 2021 01 04.
Artículo en Inglés | MEDLINE | ID: mdl-33464319

RESUMEN

Importance: Although strain on hospital capacity has been associated with increased mortality in nonpandemic settings, studies are needed to examine the association between coronavirus disease 2019 (COVID-19) critical care capacity and mortality. Objective: To examine whether COVID-19 mortality was associated with COVID-19 intensive care unit (ICU) strain. Design, Setting, and Participants: This cohort study was conducted among veterans with COVID-19, as confirmed by polymerase chain reaction or antigen testing in the laboratory from March through August 2020, cared for at any Department of Veterans Affairs (VA) hospital with 10 or more patients with COVID-19 in the ICU. The follow-up period was through November 2020. Data were analyzed from March to November 2020. Exposures: Receiving treatment for COVID-19 in the ICU during a period of increased COVID-19 ICU load, with load defined as mean number of patients with COVID-19 in the ICU during the patient's hospital stay divided by the number of ICU beds at that facility, or increased COVID-19 ICU demand, with demand defined as mean number of patients with COVID-19 in the ICU during the patient's stay divided by the maximum number of patients with COVID-19 in the ICU. Main Outcomes and Measures: All-cause mortality was recorded through 30 days after discharge from the hospital. Results: Among 8516 patients with COVID-19 admitted to 88 VA hospitals, 8014 (94.1%) were men and mean (SD) age was 67.9 (14.2) years. Mortality varied over time, with 218 of 954 patients (22.9%) dying in March, 399 of 1594 patients (25.0%) dying in April, 143 of 920 patients (15.5%) dying in May, 179 of 1314 patients (13.6%) dying in June, 297 of 2373 patients (12.5%) dying in July, and 174 of 1361 (12.8%) patients dying in August (P < .001). Patients with COVID-19 who were treated in the ICU during periods of increased COVID-19 ICU demand had increased risk of mortality compared with patients treated during periods of low COVID-19 ICU demand (ie, demand of ≤25%); the adjusted hazard ratio for all-cause mortality was 0.99 (95% CI, 0.81-1.22; P = .93) for patients treated when COVID-19 ICU demand was more than 25% to 50%, 1.19 (95% CI, 0.95-1.48; P = .13) when COVID-19 ICU demand was more than 50% to 75%, and 1.94 (95% CI, 1.46-2.59; P < .001) when COVID-19 ICU demand was more than 75% to 100%. No association between COVID-19 ICU demand and mortality was observed for patients with COVID-19 not in the ICU. The association between COVID-19 ICU load and mortality was not consistent over time (ie, early vs late in the pandemic). Conclusions and Relevance: This cohort study found that although facilities augmented ICU capacity during the pandemic, strains on critical care capacity were associated with increased COVID-19 ICU mortality. Tracking COVID-19 ICU demand may be useful to hospital administrators and health officials as they coordinate COVID-19 admissions across hospitals to optimize outcomes for patients with this illness.


Asunto(s)
/mortalidad , Enfermedad Crítica/mortalidad , Hospitales de Veteranos/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Veteranos/estadística & datos numéricos , Estudios de Cohortes , Humanos , Estados Unidos , United States Department of Veterans Affairs
8.
Ann Intern Med ; 174(3): 289-297, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33370170

RESUMEN

BACKGROUND: Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism. OBJECTIVE: To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension. DESIGN: Retrospective cohort study. SETTING: U.S. Veterans Health Administration. PARTICIPANTS: Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes. MEASUREMENTS: Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP. RESULTS: 4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time. LIMITATIONS: Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism. CONCLUSION: In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension. PRIMARY FUNDING SOURCE: National Institutes of Health.


Asunto(s)
Antihipertensivos/uso terapéutico , Hiperaldosteronismo/diagnóstico , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Anciano , Femenino , Humanos , Hiperaldosteronismo/etiología , Hipertensión/tratamiento farmacológico , Masculino , Estudios Retrospectivos , Insuficiencia del Tratamiento , Estados Unidos , Veteranos/estadística & datos numéricos
9.
Addict Behav ; 113: 106692, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33099250

RESUMEN

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.


Asunto(s)
/mortalidad , Enfermedades del Sistema Endocrino/epidemiología , Síndromes de Inmunodeficiencia/epidemiología , Enfermedades Pulmonares/epidemiología , Fumar/epidemiología , Veteranos/estadística & datos numéricos , Afroamericanos/estadística & datos numéricos , Factores de Edad , Anciano , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Hospitales de Veteranos , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Uso de Tabaco/epidemiología , Estados Unidos/epidemiología
10.
JMIR Public Health Surveill ; 7(1): e24502, 2021 01 22.
Artículo en Inglés | MEDLINE | ID: mdl-33338028

RESUMEN

BACKGROUND: COVID-19 has disproportionately affected older adults and certain racial and ethnic groups in the United States. Data quantifying the disease burden, as well as describing clinical outcomes during hospitalization among these groups, are needed. OBJECTIVE: We aimed to describe interim COVID-19 hospitalization rates and severe clinical outcomes by age group and race and ethnicity among US veterans by using a multisite surveillance network. METHODS: We implemented a multisite COVID-19 surveillance platform in 5 Veterans Affairs Medical Centers located in Atlanta, Bronx, Houston, Palo Alto, and Los Angeles, collectively serving more than 396,000 patients annually. From February 27 to July 17, 2020, we actively identified inpatient cases with COVID-19 by screening admitted patients and reviewing their laboratory test results. We then manually abstracted the patients' medical charts for demographics, underlying medical conditions, and clinical outcomes. Furthermore, we calculated hospitalization incidence and incidence rate ratios, as well as relative risk for invasive mechanical ventilation, intensive care unit admission, and case fatality rate after adjusting for age, race and ethnicity, and underlying medical conditions. RESULTS: We identified 621 laboratory-confirmed, hospitalized COVID-19 cases. The median age of the patients was 70 years, with 65.7% (408/621) aged ≥65 years and 94% (584/621) male. Most COVID-19 diagnoses were among non-Hispanic Black (325/621, 52.3%) veterans, followed by non-Hispanic White (153/621, 24.6%) and Hispanic or Latino (112/621, 18%) veterans. Hospitalization rates were the highest among veterans who were ≥85 years old, Hispanic or Latino, and non-Hispanic Black (430, 317, and 298 per 100,000, respectively). Veterans aged ≥85 years had a 14-fold increased rate of hospitalization compared with those aged 18-29 years (95% CI: 5.7-34.6), whereas Hispanic or Latino and Black veterans had a 4.6- and 4.2-fold increased rate of hospitalization, respectively, compared with non-Hispanic White veterans (95% CI: 3.6-5.9). Overall, 11.6% (72/621) of the patients required invasive mechanical ventilation, 26.6% (165/621) were admitted to the intensive care unit, and 16.9% (105/621) died in the hospital. The adjusted relative risk for invasive mechanical ventilation and admission to the intensive care unit did not differ by age group or race and ethnicity, but veterans aged ≥65 years had a 4.5-fold increased risk of death while hospitalized with COVID-19 compared with those aged <65 years (95% CI: 2.4-8.6). CONCLUSIONS: COVID-19 surveillance at the 5 Veterans Affairs Medical Centers across the United States demonstrated higher hospitalization rates and severe outcomes among older veterans, as well as higher hospitalization rates among Hispanic or Latino and non-Hispanic Black veterans than among non-Hispanic White veterans. These findings highlight the need for targeted prevention and timely treatment for veterans, with special attention to older aged, Hispanic or Latino, and non-Hispanic Black veterans.


Asunto(s)
/terapia , Hospitalización/estadística & datos numéricos , Hospitales de Veteranos , Vigilancia de la Población/métodos , Veteranos/estadística & datos numéricos , Afroamericanos/estadística & datos numéricos , Distribución por Edad , Anciano , Anciano de 80 o más Años , /mortalidad , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Disparidades en el Estado de Salud , Hispanoamericanos/estadística & datos numéricos , Humanos , Masculino , Resultado del Tratamiento , Estados Unidos/epidemiología
11.
JAMA Netw Open ; 3(12): e2028117, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33346846

RESUMEN

Importance: Bariatric surgical procedures have been associated with increased risk of unhealthy alcohol use, but no previous research has evaluated the long-term alcohol-related risks after laparoscopic sleeve gastrectomy (LSG), currently the most used bariatric procedure. No US-based study has compared long-term alcohol-related outcomes between patients who have undergone Roux-en-Y gastric bypass (RYGB) and those who have not. Objective: To evaluate the changes over time in alcohol use and unhealthy alcohol use from 2 years before to 8 years after a bariatric surgical procedure among individuals with or without preoperative unhealthy alcohol use. Design, Setting, and Participants: This retrospective cohort study analyzed electronic health record (EHR) data on military veterans who underwent a bariatric surgical procedure at any of the bariatric centers in the US Department of Veterans Affairs (VA) health system between October 1, 2008, and September 30, 2016. Surgical patients without unhealthy alcohol use at baseline were matched using sequential stratification to nonsurgical control patients without unhealthy alcohol use at baseline, and surgical patients with unhealthy alcohol use at baseline were matched to nonsurgical patients with unhealthy alcohol use at baseline. Data were analyzed in February 2020. Interventions: LSG (n = 1684) and RYGB (n = 924). Main Outcomes and Measures: Mean alcohol use, unhealthy alcohol use, and no alcohol use were estimated using scores from the validated 3-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), which had been documented in the VA EHR. Alcohol outcomes were estimated with mixed-effects models. Results: A total of 2608 surgical patients were included in the final cohort (1964 male [75.3%] and 644 female [24.7%] veterans. Mean (SD) age of surgical patients was 53.0 (9.9) years and 53.6 (9.9) years for the matched nonsurgical patients. Among patients without baseline unhealthy alcohol use, 1539 patients who underwent an LSG were matched to 14 555 nonsurgical control patients and 854 patients who underwent an RYGB were matched to 8038 nonsurgical control patients. In patients without baseline unhealthy alcohol use, the mean AUDIT-C scores and the probability of unhealthy alcohol use both increased significantly 3 to 8 years after an LSG or an RYGB, compared with control patients. Eight years after an LSG, the probability of unhealthy alcohol use was higher in surgical vs control patients (7.9% [95% CI, 6.4-9.5] vs 4.5% [95% CI, 4.1-4.9]; difference, 3.4% [95% CI, 1.8-5.0])). Similarly, 8 years after an RYGB, the probability of unhealthy alcohol use was higher in surgical vs control patients (9.2% [95% CI, 8.0-10.3] vs 4.4% [95% CI, 4.1-4.6]; difference, 4.8% [95% CI, 3.6-5.9]). The probability of no alcohol use also decreased significantly 5 to 8 years after both procedures for surgical vs control patients. Among patients with unhealthy alcohol use at baseline, prevalence of unhealthy alcohol use was higher for patients who underwent an RYGB than matched controls. Conclusions and Relevance: In this multi-site cohort study of predominantly male patients, among those who did not have unhealthy alcohol use in the 2 years before bariatric surgery, the probability of developing unhealthy alcohol use increased significantly 3-8 years after bariatric procedures compared with matched controls during follow-up.


Asunto(s)
Alcoholismo/etiología , Cirugía Bariátrica/psicología , Obesidad/cirugía , Complicaciones Posoperatorias/psicología , Veteranos/psicología , Alcoholismo/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Obesidad/psicología , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Estados Unidos/epidemiología , Veteranos/estadística & datos numéricos
12.
JAMA Netw Open ; 3(12): e2031357, 2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33369662

RESUMEN

Importance: Identification of subgroups at greatest risk for suicide mortality is essential for prevention efforts and targeting interventions. Sexual minority individuals may have an increased risk for suicide compared with heterosexual individuals, but a lack of sufficiently powered studies with rigorous methods for determining sexual orientation has limited the knowledge on this potential health disparity. Objective: To investigate suicide mortality among sexual minority veterans using Veterans Health Administration (VHA) electronic health record data. Design, Setting, and Participants: This retrospective population-based cohort study used data on 8.1 million US veterans enrolled in the VHA after fiscal year 1999 that were obtained from VHA electronic health records from October 1, 1999 to September 30, 2017. Data analysis was carried out from March 1, 2020 to October 31, 2020. Exposure: Veterans with documentation of a minority sexual orientation. Documentation of sexual minority status was obtained through natural language processing of clinical notes and extraction of structured administrative data for sexual orientation in VHA electronic health records. Main Outcomes and Measures: Suicide mortality rate using data on the underlying cause of death obtained from the National Death Index. Crude and age-adjusted mortality rates were calculated for all-cause death and death from suicide among sexual minority veterans compared with the general US population and the general population of veterans. Results: Among the 96 893 veterans with at least 1 sexual minority documentation in the electronic health record, the mean (SD) age was 46 (16) years, 68% were male, and 70% were White. Of the 12 591 total deaths, 3.5% were from suicide. Veterans had a significantly higher rate of mortality from suicide (standardized mortality ratio, 4.50; 95% CI, 4.13-4.99) compared with the general US population. Suicide was the fifth leading cause of death in 2017 among sexual minority veterans (3.8% of deaths) and the tenth leading cause of death in the general US population (1.7% of deaths). The crude suicide rate among sexual minority veterans (82.5 per 100 000 person-years) was higher than the rate in the general veteran population (37.7 per 100 000 person-years). Conclusions and Relevance: The results of this population-based cohort study suggest that sexual minority veterans have a greater risk for suicide than the general US population and the general veteran population. Further research is needed to determine whether and how suicide prevention efforts reach sexual minority veterans.


Asunto(s)
Minorías Sexuales y de Género/estadística & datos numéricos , Suicidio/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Adulto , Femenino , Disparidades en el Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Minorías Sexuales y de Género/psicología , Suicidio/psicología , Estados Unidos/epidemiología , United States Department of Veterans Affairs , Veteranos/psicología
13.
BMC Psychol ; 8(1): 115, 2020 Nov 03.
Artículo en Inglés | MEDLINE | ID: mdl-33143748

RESUMEN

BACKGROUND: The current study examined the predictors of the onset of alcohol use as well as predictors of remission and relapse, both from heavy drinking and from alcohol dependence. Similarities and differences in both clinical and psychosocial predictors across the transitions were examined. METHODS: A sample of men from the Vietnam Era Twin Registry (N = 1769) completed an assessment of lifetime drinking history, which allowed age markers for starting and stopping different drinking patterns. The men also completed various assessments regarding personality, alcohol motives, and psychiatric diagnoses. Survival analyses were used to examine the predictors of the three transitions of onset, remission, and relapse for the phenotypes of heavy drinking and of alcohol dependence, censoring the individuals who had not yet experienced an event. RESULTS: As expected, predictors of onset for drinking, heavy drinking, and alcohol dependence were largely consistent and included externalizing symptomology, nicotine dependence, and cotwin history of drinking as risk factors. Predictors of remission from heavy drinking, somewhat similarly to remission from alcohol dependence, included the risk factor of externalizing disorders but also, as predicted, included more risk and protective factors in the psychosocial realm that were not predictors of onset. Contrary to our prediction, relapse to heavy drinking and alcohol dependence were predicted largely by unique psychosocial risk and protective factors including social and coping motives. CONCLUSION: Current findings extend the findings of past research to remission and relapse in the later decades of life and have implications for treatment of alcohol use problems.


Asunto(s)
Consumo de Bebidas Alcohólicas/epidemiología , Alcoholismo/epidemiología , Adulto , Edad de Inicio , Consumo de Bebidas Alcohólicas/psicología , Alcoholismo/psicología , Humanos , Masculino , Persona de Mediana Edad , Motivación , Recurrencia , Sistema de Registros , Factores de Riesgo , Análisis de Supervivencia , Gemelos/psicología , Veteranos/psicología , Veteranos/estadística & datos numéricos , Guerra de Vietnam
14.
PLoS Med ; 17(9): e1003379, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32960880

RESUMEN

BACKGROUND: There is growing concern that racial and ethnic minority communities around the world are experiencing a disproportionate burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19). We investigated racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent mortality in the largest integrated healthcare system in the United States. METHODS AND FINDINGS: This retrospective cohort study included 5,834,543 individuals receiving care in the US Department of Veterans Affairs; most (91%) were men, 74% were non-Hispanic White (White), 19% were non-Hispanic Black (Black), and 7% were Hispanic. We evaluated associations between race/ethnicity and receipt of COVID-19 testing, a positive test result, and 30-day mortality, with multivariable adjustment for a wide range of demographic and clinical characteristics including comorbid conditions, health behaviors, medication history, site of care, and urban versus rural residence. Between February 8 and July 22, 2020, 254,595 individuals were tested for COVID-19, of whom 16,317 tested positive and 1,057 died. Black individuals were more likely to be tested (rate per 1,000 individuals: 60.0, 95% CI 59.6-60.5) than Hispanic (52.7, 95% CI 52.1-53.4) and White individuals (38.6, 95% CI 38.4-38.7). While individuals from minority backgrounds were more likely to test positive (Black versus White: odds ratio [OR] 1.93, 95% CI 1.85-2.01, p < 0.001; Hispanic versus White: OR 1.84, 95% CI 1.74-1.94, p < 0.001), 30-day mortality did not differ by race/ethnicity (Black versus White: OR 0.97, 95% CI 0.80-1.17, p = 0.74; Hispanic versus White: OR 0.99, 95% CI 0.73-1.34, p = 0.94). The disparity between Black and White individuals in testing positive for COVID-19 was stronger in the Midwest (OR 2.66, 95% CI 2.41-2.95, p < 0.001) than the West (OR 1.24, 95% CI 1.11-1.39, p < 0.001). The disparity in testing positive for COVID-19 between Hispanic and White individuals was consistent across region, calendar time, and outbreak pattern. Study limitations include underrepresentation of women and a lack of detailed information on social determinants of health. CONCLUSIONS: In this nationwide study, we found that Black and Hispanic individuals are experiencing an excess burden of SARS-CoV-2 infection not entirely explained by underlying medical conditions or where they live or receive care. There is an urgent need to proactively tailor strategies to contain and prevent further outbreaks in racial and ethnic minority communities.


Asunto(s)
Técnicas de Laboratorio Clínico/estadística & datos numéricos , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/mortalidad , Grupos Étnicos/estadística & datos numéricos , Neumonía Viral/diagnóstico , Neumonía Viral/mortalidad , Veteranos/estadística & datos numéricos , Adulto , Afroamericanos/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Betacoronavirus , Estudios de Cohortes , Infecciones por Coronavirus/etnología , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Hispanoamericanos/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/etnología , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto Joven
15.
J Med Internet Res ; 22(9): e21561, 2020 09 30.
Artículo en Inglés | MEDLINE | ID: mdl-32936773

RESUMEN

BACKGROUND: The COVID-19 pandemic has accelerated the need for telehealth at home. Although the Department of Veterans Affairs is a leading provider of telehealth, disparities may exist in reaching older veterans living in rural areas. VA Video Connect (VVC) is a video conferencing app that enables veterans to connect with their health care provider via a secure and private session. OBJECTIVE: The aim of this study was to examine the capability and willingness of older veterans to participate in a VVC visit during the COVID-19 pandemic. METHODS: A cross-sectional study was conducted on older veterans (N=118) at the Central Arkansas Veterans Healthcare System. Participants were interviewed over the phone and responses to the following items were recorded: availability of internet, email, and an electronic device with a camera; veterans' willingness to complete an appointment via a VVC visit; and availability of assistance from a caregiver for those who were unable to participate in a VVC visit alone. RESULTS: Participants' mean age was 72.6 (SD 8.3) years, 92% (n=108) were male, 69% (n=81) were Caucasian, 30% (n=35) were African Americans, and 36% (n=42) lived in a rural location. The majority reported having access to the internet (n=93, 77%) and email service (n=83, 70%), but only 56% (n=67) had a camera-equipped device. Overall, 53% (n=63) were willing and capable of participating in a VVC visit. The availability of internet access was significantly lower in rural compared to nonrural participants (P=.045) and in those with or less than a high school education compared to those who pursued higher education (P=.02). Willingness to participate in the VVC visit was significantly lower in rural compared to nonrural participants (P=.03). Of the participants who reported they were able and willing to partake in a VVC visit (n=54), 65% (n=35) opted for VVC and 35% (n=19) preferred a phone visit. In total, 77% (n=27) of the scheduled VVC visits were successful. CONCLUSIONS: Despite advances in technology, and willingness on the part of health care systems, there are some lingering issues with capability and willingness to participate in video telehealth visits, particularly among older adults residing in rural areas.


Asunto(s)
Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Salud Rural/estadística & datos numéricos , Telemedicina , Veteranos/psicología , Veteranos/estadística & datos numéricos , Comunicación por Videocoferencia , Anciano , Citas y Horarios , Arkansas/epidemiología , Cuidadores , Estudios Transversales , Prestación de Atención de Salud , Correo Electrónico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias
16.
Med Care ; 58 Suppl 2 9S: S125-S132, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32826782

RESUMEN

BACKGROUND: Veterans Affairs is dedicated to providing a Whole Health approach to care, including offering complementary and integrative health (CIH) approaches to Veterans. OBJECTIVE: The objective of this study was to examine the association of CIH participation with Veterans' patient-reported outcomes over time. RESEARCH DESIGN: A survey of patient-reported outcomes at 5 timepoints: baseline, 2, 4, 6, and 12 months. SUBJECTS: Veterans participating in any type of CIH approach at 2 Veterans Affairs medical centers. MEASURES: Mixed hierarchical models with repeated variables were used to test the hypothesis that participating in any CIH approach would be associated with Veterans' overall physical/mental health [Patient-Reported Outcomes Measurement Information System 28 (PROMIS 28)], pain intensity, perceived stress (Perceived Stress Scale-4), and engagement in their care (Patient Activation Measure-13), controlling for age, male sex, site, participation in other CIH approaches, and surveys completed. RESULTS: We received 401 surveys from 119 Veterans (72% male, age range: 29-85 y) across all timepoints. Yoga participation was related to decreases in perceived stress (P<0.001), while tai chi participation was associated with improvements in overall PROMIS 28 physical and mental health functioning (P<0.02). Specific types of CIH were associated with significant improvements in PROMIS 28 subscales: meditation participation with physical functioning at 2, 6, and 12 months; tai chi participation with anxiety at 2 and 6 months, and ability to participate in social role activities at 2 months. No CIH approach was associated with Veterans' pain or engagement in their care. CONCLUSION: As specific CIH approaches are associated with improvements in patient-reported outcomes, clinicians, Veterans, and family members may use this information in discussions of nonpharmacological options to address health and well-being.


Asunto(s)
Terapias Complementarias/estadística & datos numéricos , Medicina Integral/estadística & datos numéricos , Medición de Resultados Informados por el Paciente , Veteranos/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estado de Salud , Humanos , Estudios Longitudinales , Masculino , Salud Mental , Persona de Mediana Edad , Manejo del Dolor , Dimensión del Dolor , Participación del Paciente , Estrés Psicológico/terapia , Estados Unidos , United States Department of Veterans Affairs , Salud de los Veteranos
17.
Med Care ; 58 Suppl 2 9S: S116-S124, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32826781

RESUMEN

BACKGROUND: Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics. OBJECTIVE: The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain. RESEARCH DESIGN: National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis. SUBJECTS: US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics. MEASURES: Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function. RESULTS: In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual). CONCLUSIONS: Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.


Asunto(s)
Analgésicos Opioides/uso terapéutico , Dolor Crónico/terapia , Terapias Complementarias/estadística & datos numéricos , Medicina Integral/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Factores de Edad , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Terapias Complementarias/métodos , Femenino , Estado de Salud , Humanos , Medicina Integral/métodos , Masculino , Persona de Mediana Edad , Manejo del Dolor , Percepción del Dolor , Calidad de Vida , Factores Sexuales , Factores Socioeconómicos , Estados Unidos , United States Department of Veterans Affairs , Salud de los Veteranos
18.
Med Care ; 58 Suppl 2 9S: S133-S141, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32826783

RESUMEN

OBJECTIVES: The primary aim of this study was to examine differences in yoga practice between persons with and without chronic pain. Secondarily, we describe use of the Essential Properties of Yoga Questionnaire, Short Form (EPYQ-SF) for self-report. DESIGN: Participants were members of an existing cohort of veterans who completed a 2015-2016 survey focused on pain and nonpharmacological health practices. Cohort members who reported yoga in the past year [n=174 (9.4%) of 1850] were eligible for the present study, which used multiple-contact mixed-mode survey methodology to collect data on yoga practices. The EPYQ-SF was used to assess properties and context of yoga practice. Practice patterns were compared for participants with and without chronic pain. To explore potential reasons for reported yoga practice patterns, focused semistructured interviews were conducted with a subset of participants. RESULTS: Of 174 participants contacted, 141 (82%) returned the yoga questionnaire and 110 (78% of respondents) were still practicing yoga. Among yoga practitioners, 41 (37%) had chronic pain. Practitioners with chronic pain reported gentler (2.8 vs. 3.1, 5-point scale) and less active (2.9 vs. 3.3) yoga practice than those without. Those with chronic pain attended yoga studios less frequently and reported shorter yoga practices than those without. Most yoga practice was self-directed and at home. CONCLUSIONS: Differences in yoga practice of persons with and without chronic pain have implications for implementation of yoga interventions for chronic pain. Future interventions should focus on alternative individual delivery formats or addressing barriers to group practice among people with chronic pain.


Asunto(s)
Dolor Crónico/terapia , Veteranos/estadística & datos numéricos , Yoga , Adulto , Femenino , Estado de Salud , Humanos , Entrevistas como Asunto , Masculino , Dimensión del Dolor , Factores Socioeconómicos
19.
Womens Health Issues ; 30(5): 320-329, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32830008

RESUMEN

PURPOSE: One in four women veteran patients report experiencing sexual and gender harassment when attending the Veterans Health Administration (VA) for health care. Bystander intervention-training community members how to intervene when witnessing inappropriate behaviors-is a common approach for addressing harassment in school and military settings. We evaluated implementation of a VA harassment awareness and bystander intervention training that teaches health care staff how to identify and intervene in the harassment of women veteran patients. METHODS: Participants included 180 VA staff, including both providers and administrative staff from one VA state health care system, who participated in harassment training during the first year of implementation. Pretest and post-test evaluation surveys included questions on acceptability of training length and relevance, staff experiences with harassment, perceptions of the training, and four short-term attitudinal outcomes: awareness of harassment, barriers to intervening, self-efficacy for intervening, and intentions to intervene. RESULTS: At pretest, most staff reported witnessing harassment, yet fewer than one-half had intervened. By post-test, staff reported significantly decreased barriers to intervening and increased awareness, self-efficacy, and intentions to intervene. Belief that harassment is a problem increased from 42.4% to 75.0%. The majority of staff found the training relevant and appropriate in length. Staff felt the most useful aspects of the training were learning how to intervene, group discussion, effective facilitation, and information on harassment. CONCLUSIONS: We found that a bystander approach was acceptable to health care staff and efficacious on short-term outcomes. Bystander intervention may be a promising strategy to address harassment among patients in medical facilities.


Asunto(s)
Conducta de Ayuda , Acoso Sexual/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Adulto , Femenino , Hospitales de Veteranos , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Encuestas y Cuestionarios , Estados Unidos , Salud de los Veteranos
20.
J Natl Black Nurses Assoc ; 31(1): 41-45, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32853495

RESUMEN

This quality improvement project aimed to answer the following clinical question: Among U.S. male veterans (N = 30) living with type 2 diabetes (T2D) receiving services from a Veterans Affairs (VA) endocrinology clinic, how does a diabetes toolkit influence knowledge and glycaemic control? All the study participants were male and from 31 to 91 years of age. A pre- and post-intervention diabetes knowledge test, body mass index (BMI), lipids, blood pressure, and lifestyle data were obtained as predictor variables. A1c levels were measured at baseline and fructosamine levels at 8-12 weeks post-intervention and converted to A1c levels. A diabetes toolkit was presented as an educational intervention to participating veterans. The pre- and post-intervention knowledge test measured an increase (p = 0.001) in diabetes knowledge. The pre- and post-intervention BMI, lipids, and blood pressure assessments measured changes in such variables associated with toolkit exposure. The regression model was marginally significant (p = 0.055) and the predictor variables explained 18.8% of variance in change of A1c. A multiple regression was conducted to determine the extent to which the following post-intervention outcome variables impacted glycemic control. Of four predictors, only one was significant: a patient's change in weight predicted (p = 0.016) a decrease in A1c.


Asunto(s)
Diabetes Mellitus Tipo 2/terapia , Educación del Paciente como Asunto/métodos , Veteranos/estadística & datos numéricos , Pérdida de Peso , Adulto , Anciano , Anciano de 80 o más Años , Hemoglobina A Glucada/metabolismo , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad
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