Early Adoption of Longitudinal Surveillance for SARS-CoV-2 among Staff in Long-Term Care Facilities: Prevalence, Virologic and Sequence Analysis.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in 2019 and has become a major global pathogen in an astonishingly short period of time. The emergence of SARS-CoV-2 has been notable due to its impacts on residents in long-term care facilities (LTCFs). LTCF residents tend to possess several risk factors for severe outcomes of SARS-CoV-2 infection, including advanced age and the presence of comorbidities. Indeed, residents of LTCFs represent approximately 40% of SARS-CoV-2 deaths in the United States. Few studies have focused on the prevalence and transmission dynamics of SARS-CoV-2 among LTCF staff during the early months of the pandemic, prior to mandated surveillance testing. To assess the prevalence and incidence of SARS-CoV-2 among LTCF staff, characterize the extent of asymptomatic infections, and investigate the genomic epidemiology of the virus within these settings, we sampled staff for 8 to 11 weeks at six LTCFs with nasopharyngeal swabs from March through June of 2020. We determined the presence and levels of viral RNA and infectious virus and sequenced 54 nearly complete genomes. Our data revealed that over 50% of infections were asymptomatic/mildly symptomatic and that there was a strongly significant relationship between viral RNA (vRNA) and infectious virus, prolonged infections, and persistent vRNA (4+ weeks) in a subset of individuals, and declining incidence over time. Our data suggest that asymptomatic SARS-CoV-2-infected LTCF staff contributed to virus persistence and transmission within the workplace during the early pandemic period. Genetic epidemiology data generated from samples collected during this period support that SARS-CoV-2 was commonly spread between staff within an LTCF and that multiple-introduction events were less common. IMPORTANCE Our work comprises unique data on the characteristics of SARS-CoV-2 dynamics among staff working at LTCFs in the early months of the SARS-CoV-2 pandemic prior to mandated staff surveillance testing. During this time period, LTCF residents were largely sheltering-in-place. Given that staff were able to leave and return daily and could therefore be a continued source of imported or exported infection, we performed weekly SARS-CoV-2 PCR on nasal swab samples collected from this population. There are limited data from the early months of the pandemic comprising longitudinal surveillance of staff at LTCFs. Our data reveal the surprisingly high level of asymptomatic/presymptomatic infections within this cohort during the early months of the pandemic and show genetic epidemiological analyses that add novel insights into both the origin and transmission of SARS-CoV-2 within LTCFs.

Longitudinal Surveillance for SARS-CoV-2 Among Staff in Six Colorado Long-Term Care Facilities: Epidemiologic, Virologic and Sequence Analysis.

BACKGROUND: SARS-CoV-2 emerged in 2019 and has become a major global pathogen. Its emergence is notable due to its impacts on individuals residing within long term care facilities (LTCFs) such as rehabilitation centers and nursing homes. LTCF residents tend to possess several risk factors for more severe SARS-CoV-2 outcomes, including advanced age and multiple comorbidities. Indeed, residents of LTCFs represent approximately 40% of SARS-CoV-2 deaths in the United States. METHODS: To assess the prevalence and incidence of SARS-CoV-2 among LTCF workers, determine the extent of asymptomatic SARS-CoV-2 infection, and provide information on the genomic epidemiology of the virus within these unique care settings, we collected nasopharyngeal swabs from workers for 8-11 weeks at six Colorado LTCFs, determined the presence and level of viral RNA and infectious virus within these samples, and sequenced 54 nearly complete genomes. FINDINGS: Our data reveal a strikingly high degree of asymptomatic/mildly symptomatic infection, a strong correlation between viral RNA and infectious virus, prolonged infections and persistent RNA in a subset of individuals, and declining incidence over time. INTERPRETATION: Our data suggest that asymptomatic SARS-CoV-2 infected individuals contribute to virus persistence and transmission within the workplace, due to high levels of virus. Genetic epidemiology revealed that SARS-CoV-2 likely spreads between staff within an LTCF. FUNDING: Colorado State University Colleges of Health and Human Sciences, Veterinary Medicine and Biomedical Sciences, Natural Sciences, and Walter Scott, Jr. College of Engineering, the Columbine Health Systems Center for Healthy Aging, and the National Institute of Allergy and Infectious Diseases.

Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder.

OBJECTIVE: A key symptom of posttraumatic stress disorder (PTSD) is hyperreactivity to trauma-relevant stimuli. Though physiological arousal is reliably elevated in PTSD, the question remains whether this arousal responds to treatment. Virtual reality (VR) has been posited to increase emotional engagement during prolonged exposure therapy (PE) for PTSD by augmenting imaginal exposures with trauma-relevant sensory information. However, the comparative effects of VR exposure therapy (VRE) have received limited empirical inquiry. METHOD: Ninety active-duty soldiers with combat-related PTSD participating in a randomized-controlled trial to receive PE, VRE, or a waitlist-control (WL) condition had their physiological reactivity, indexed by galvanic skin response (GSR), to their trauma memories assessed at pre-, mid-, and posttreatment. RESULTS: Although both VRE and PE conditions showed reduced GSR reactivity to trauma memories from pre- to posttreatment, only the VRE group differed significantly from WL. Across the sample, reductions in GSR were significantly correlated with reductions in self-reported PTSD and anxiety symptoms. CONCLUSIONS: This was the first study comparing effects of VRE and PE on psychophysiological variables. Given previous research finding limited differences between VRE and PE in PTSD symptom reduction, these findings lend support to the rationale for including VR in exposure therapy protocols while raising important questions about the potential benefits of VRE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effectiveness of the Intent to Complete and Intent to Attend Intervention to Predict and Prevent Posttraumatic Stress Disorder Treatment Drop Out Among Soldiers.

Active duty military service members have high dropout rates for trauma-focused treatment in both clinical practice and research settings. Measuring patients' intent to complete (ITC) and intent to attend (ITA) treatment have been suggested as methods to reduce dropout, but no studies have examined the effectiveness of such measures. In an attempt to reduce high dropout rates, measures of ITC and ITA were included in a randomized controlled trial evaluating prolonged exposure (PE) and virtual reality exposure (VRE) in active duty soldiers with posttraumatic stress disorder (PTSD). Participants (N = 108) were randomized to either PE or VRE, and the last 49 to enroll were administered a measure of ITC at enrollment and a measure of ITA at the end of every session. A score of 7 or below triggered a problem-solving discussion with the individual's therapist. The results revealed that the ITA assessment predicted treatment dropout after controlling for mental health stigma, PTSD symptoms, and age, odds ratio (OR) = 0.24, p = .023. Additionally, participants who completed the ITA assessment were less likely to drop out than those who were not administered the ITA, OR = 0.29 p = .002. The ITC did not predict treatment dropout OR = 0.98, p = .402. These findings suggest that assessing ITA throughout trauma-focused therapy may reduce treatment dropout rather than solely measuring ITC prior to starting psychotherapy. Based on these preliminary findings, future research should randomize the measurement of ITA in clinical trials to evaluate its impact on treatment dropout.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) La efectividad de la intención de completar y la intención de asistir a la intervención para predecir y prevenir el abandono del tratamiento para el TEPT del soldado INTENCIÓN DE ASISTIR A LA TERAPIA DE EXPOSICIÓN PARA EL TEPT Los miembros del servicio militar en servicio activo tienen altas tasas de abandono del tratamiento centrado en el trauma, tanto en la práctica clínica como en la investigación. La medición de la intención de los pacientes de completar el tratamiento (ITC en su sigla en inglés) y la intención de asistir (ITA en su sigla en inglés) se han sugerido como métodos para reducir el abandono, pero ningún estudio ha examinado la efectividad de tales medidas. En un intento por reducir las altas tasas de abandono, se incluyeron medidas de la ITC y la ITA en un ensayo controlado aleatorio que evaluaba la exposición prolongada (PE en su sigla en inglés) y la exposición de realidad virtual (VRE en su sigla en inglés) en soldados en servicio activo con trastorno de estrés postraumático (TEPT). Los participantes (N = 108) fueron asignados al azar a PE o VRE, y a los últimos 49 que se inscribieron se les administró una medida de ITC al momento de la inscripción y una medida de ITA al final de cada sesión. Un puntaje de 7 o menos desencadenó una discusión de resolución de problemas con el terapeuta del individuo. Los resultados revelaron que la evaluación ITA predijo el abandono del tratamiento después de controlar el estigma de salud mental, los síntomas del TEPT y la edad, razón de probabilidades (OR) = 0.24, p = .023. Además, los participantes que completaron la evaluación ITA tenían menos probabilidades de abandonar que aquellos que no recibieron la ITA, OR = 0.29, p = .002. El ITC no predijo el abandono del tratamiento OR = 0.98, p = .402. Estos hallazgos sugieren que evaluar la ITA a lo largo de la terapia centrada en el trauma puede reducir el abandono del tratamiento en lugar de solo medir el ITC antes de comenzar la psicoterapia. En base a estos hallazgos preliminares, la investigación futura debe aleatorizar la medición de ITA en ensayos clínicos para evaluar su impacto en el abandono del tratamiento.

Reductions in reported persecutory ideation and psychotic-like experiences during exposure therapy for posttraumatic stress disorder.

While psychotic-like experiences (PLEs), including persecutory ideation and auditory or visual hallucinations, are common in PTSD, questions remain about their relationships to core PTSD symptoms and responsiveness to treatment. This study examined data from a waitlist (WL) controlled clinical study of the effect of virtual reality (VR) and prolonged exposure (PE) in a sample of active-duty service members with deployment-related trauma (n = 161). PLEs were assessed and examined with regard to their responsiveness to trauma focused treatment (combining conditions) relative to the WL, as well as their relationships to PTSD symptoms. Persecutory ideation symptoms, which were most closely related to PTSD Cluster C (avoidance and numbing) symptoms, were reduced post-treatment in the trauma-focused condition relative to WL. Auditory and visual hallucinations-which were most closely associated with PTSD re-experiencing-decreased from baseline to post-treatment assessments for WL and exposure therapy participants. The presence of PLEs at baseline did not predict a reduced PTSD symptom response to treatment. Trauma-focused treatments appear effective in addressing psychotic-like experiences that can emerge in individuals with PTSD.

Predicting post treatment client satisfaction between behavioural activation for depression delivered either in-person or via home-based telehealth.

INTRODUCTION: Treatment engagement, adherence, cancellations and other patient-centric data are important predictors of treatment outcome. But often these data are only examined retrospectively. In this investigation, we analysed data from a clinical trial focused on innovative delivery of depression treatment to identify which patients are likely to prefer either in-home or in-person treatment based on pre-treatment characteristics. METHODS: Patient satisfaction was assessed in a trial of individuals with depression treated using identical behavioural activation therapy protocols in person or through videoconferencing to the home (N = 87 at post treatment: 42 in-person and 45 in-home participants). The Client Satisfaction Questionnaire was administered at the end of the treatment. A Tobit regression model was used to assess moderation using treatment assignment. Regression lines were generated to model treatment satisfaction as a function of treatment assignment and to identify whether and where the groups intersected. We examined the distributions of the contributing moderators to the subsets of participants above and below the intersection point to identify differences. RESULTS: While no significant differences in patient satisfaction were observed between the two groups, or between patients receiving treatment by different providers, baseline characteristics of the sample could be used to differentiate those with a preference for traditional, in-office care from those preferring in-home care. DISCUSSION: Participants who were more likely to prefer in-home care were characterized by larger proportions of veterans and lower-ranked enlisted service members. They also had more severe symptoms at baseline and less formal education. Understanding client reactions when selecting treatment modality may allow for a more satisfying patient experience.

Suicides, homicides, accidents, and undetermined deaths in the U.S. military: comparisons to the U.S. population and by military separation status.

PURPOSE: To compare rates of external causes of mortality among individuals who served in the military (before and after separation from the military) to the U.S. METHODS: This retrospective cohort study examined all 3.9 million service members who served from 2002 to 2007. External cause mortality data from 2002 to 2009 were used to calculate standardized mortality ratios. Negative binomial regression compared differences in the mortality rates for pre- and post-separation. RESULTS: Accident and suicide mortality rates were highest among cohort members under 30 years of age, and most of the accident and suicide rates for these younger individuals exceeded expectation given the U.S. population mortality rates. Military suicide rates began below the expected U.S. rate in 2002 but exceeded the U.S. rate by 2009. Accident, homicide, and undetermined mortality rates remained below the U.S. rates throughout the study period. Mortality rates for all external causes were significantly higher among separated individuals compared with those who did not separate. Mortality rates for individuals after separation from service decreased over time but remained higher than the rates for those who had not separated from service. CONCLUSIONS: Higher rates of death for all external causes of mortality after separation suggest prevention opportunities. Future research should examine how preseparation characteristics and experiences may predict postseparation adverse outcomes to inform transition programs.

Economic evaluation of telephone-based concussion management for combat-related mild traumatic brain injury.

Introduction Mild traumatic brain injury (mTBI) is an unfortunately common repercussion of military service in a combat zone. The CONTACT study tested an individualized telephone support intervention employing problem solving therapy (PST) for mTBI in soldiers recently returned from deployment. We sought to determine the cost effectiveness of this intervention from a military healthcare system perspective. Methods We conducted an intent-to-treat post-hoc analysis by building a decision analytic model that evaluated the choice between using PST or education only (EO). The model included cost-minimization and cost-effectiveness analyses. The incremental cost-effectiveness ratios (ICERs) were calculated as the differences in costs of PST versus EO relative to the differences in the outcomes of participants. Results The PST intervention resulted in an annual per-enrolee cost of $1027 (95% CI: $836 to $1248), while EO costs were $32 (95% CI: $25 to $39), resulting in a net incremental cost of $996 per enrolee (95% CI: $806 to $1,217). The ICERs were $68,658/QALY based on EQ-5D (95% CI: -$463,535 to $596,661) and $49,284/QALY based on SF-6D (95% CI: $26,971 to $159,309). Estimates of treatment costs in a real-world setting were accompanied by substantially lower ICERs that are within accepted thresholds for willingness-to-pay. Discussion Although the intervention had short-term benefits sufficient to yield acceptable ICERs, there was no long-term effect of PST over EO observed in the study. Consequently, we suggest that future studies examine the use of low-cost approaches, such as booster relapse-prevention calls, that may lead to a sustained treatment benefit for this population.

Economic evaluation of home-based telebehavioural health care compared to in-person treatment delivery for depression.

Introduction Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members. Methods We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions. Results In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results. Discussion Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients' existing technology.

Unobserved heterogeneity in response to treatment for depression through videoconference.

OBJECTIVE: This study examined treatment response heterogeneity in a recent randomized controlled trial of treatment for depression using videoconferencing technology compared to traditional in-office care. METHOD: Growth mixture modeling was used to identify subgroups of individuals in the trial based on treatment response trajectories. Demographic and baseline characteristics were included to identify correlates of subgroup membership. RESULTS: There were two subgroups based on the trajectories of the Beck Hopelessness Scale. The first subgroup had less symptom severity at baseline, and there was no meaningful difference between the two treatment modalities in change over time. The second subgroup had higher symptom severity at baseline, and individuals who engaged in treatment through the videoconference modality had less symptom improvement than those who underwent the in-office modality. Older participants with higher loneliness and anxiety scores at baseline were more likely to be in the second group. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Treatment of depression using videoconferencing to deliver care to an individual's home offers opportunities for improved access to services, especially among those who are unwilling or unable to seek in-person treatment. However, videoconferencing may not be appropriate for everyone. An individual's symptom level, age, and comorbidities are important clinical considerations when selecting an appropriate treatment modality. (PsycINFO Database Record

Suicide Risk Among Wounded U.S. Service Members.

The association between suicide and combat injuries sustained during the wars in Iraq and Afghanistan was examined. A retrospective population-based cohort design was conducted using official military records to identify combat injuries (October 7, 2001, to December 31, 2007). Those who were injured during combat had higher crude suicide rates than those who deployed and were not injured (incidence rate ratio [IRR] = 1.50; confidence interval [CI] = 1.06, 2.12), or never deployed (IRR = 1.46; CI = 1.04, 2.06). After adjusting for demographics, these findings were no longer statistically significant. Although our data did not support an elevated suicide risk among wounded service members, additional research is needed to examine the impact of injury severity.

Telephone Problem Solving for Service Members with Mild Traumatic Brain Injury: A Randomized, Clinical Trial.

Mild traumatic brain injury (mTBI) is a common injury for service members in recent military conflicts. There is insufficient evidence of how best to treat the consequences of mTBI. In a randomized, clinical trial, we evaluated the efficacy of telephone-delivered problem-solving treatment (PST) on psychological and physical symptoms in 356 post-deployment active duty service members from Joint Base Lewis McChord, Washington, and Fort Bragg, North Carolina. Members with medically confirmed mTBI sustained during deployment to Iraq and Afghanistan within the previous 24 months received PST or education-only (EO) interventions. The PST group received up to 12 biweekly telephone calls from a counselor for subject-selected problems. Both groups received 12 educational brochures describing common mTBI and post-deployment problems, with follow-up for all at 6 months (end of PST), and at 12 months. At 6 months, the PST group significantly improved on a measure of psychological distress (Brief Symptom Inventory; BSI-18) compared to the EO group (p = 0.005), but not on post-concussion symptoms (Rivermead Post-Concussion Symptoms Questionnaire [RPQ]; p = 0.19), the two primary endpoints. However, these effects did not persist at 12-month follow-up (BSI, p = 0.54; RPQ, p = 0.45). The PST group also had significant short-term improvement on secondary endpoints, including sleep (p = 0.01), depression (p = 0.03), post-traumatic stress disorder (p = 0.04), and physical functioning (p = 0.03). Participants preferred PST over EO (p < 0.001). Telephone-delivered PST appears to be a well-accepted treatment that offers promise for reducing psychological distress after combat-related mTBI and could be a useful adjunct treatment post-mTBI. Further studies are required to determine how to sustain its effects. (Trial registration: ClinicalTrials.gov Identifier: NCT01387490 https://clinicaltrials.gov ).

Risk of motor vehicle accident death among 1.3 million veterans of the Iraq and Afghanistan wars.

OBJECTIVE: We conducted a cohort study of recent wartime veterans to determine the postservice mortality risk due to motor vehicle accidents (MVAs). METHODS: Veterans were identified from the Defense Manpower Data Center records. Deployment to te Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from their discharge dates between 2001 to 2007 until earlier of date of death or December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9,353 deaths (deployed, 1,650; nondeployed, 7,703), of which 779 were MVA deaths as drivers (166; 613), both cohorts had 25 to 24% lower mortality risk from all causes but had 44 to 45% higher risk of MVA deaths relative to the U.S. general population. The higher MVA mortality risk was not associated with deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, the risk for deployed veterans was comparable to that of nondeployed veterans (hazard ratio = 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS: Veterans exhibit significantly higher risk of MVA deaths compared to the U.S. general population. However, deployment to the Iraq or Afghanistan war was not associated with the excess risk.

Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deployment-related posttraumatic stress disorder (PTSD).

OBJECTIVE: Prolonged exposure (PE) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD) but there is limited research with active-duty military populations. Virtual reality exposure (VRE) has shown promise but randomized trials are needed to evaluate efficacy relative to existing standards of care. This study evaluated the efficacy of VRE and PE for active duty soldiers with PTSD from deployments to Iraq and Afghanistan. METHOD: Active-duty soldiers (N = 162) were randomized to 10-sessions of PE, VRE, or a minimal attention waitlist (WL). Blinded assessors evaluated symptoms at baseline, halfway through treatment, at posttreatment, and at 3- and 6-month follow-ups using the Clinician Administered PTSD Scale (CAPS). RESULTS: Intent-to-treat analyses found that both PE and VRE resulted in significant reductions in PTSD symptoms relative to those in the WL. The majority of patients demonstrated reliable change in PTSD symptoms. There was no difference between PE and VRE regarding treatment drop out before completing 10 sessions (44 and 41% for VRE and PE, respectively). Contrary to hypotheses, analyses at posttreatment did not show that VRE was superior to PE. Post hoc analyses found that PE resulted in significantly greater symptom reductions than VRE at 3- and 6-month follow-up. Both treatments significantly reduced self-reported stigma. CONCLUSIONS: PE is an efficacious treatment for active-duty Army soldiers with PTSD from deployments to Iraq or Afghanistan. Results extend previous evidence supporting the efficacy of PE to active-duty military personnel and raise important questions for future research on VRE. (PsycINFO Database Record

Home-based telebehavioral health for U.S. military personnel and veterans with depression: A randomized controlled trial.

OBJECTIVE: Evidence of feasibility, safety, and effectiveness of home-based telebehavioral health (HBTBH) needs to be established before adoption of HBTBH in the military health system can occur. The purpose of this randomized controlled noninferiority trial was to compare the safety, feasibility, and effectiveness of HBTBH to care provided in the traditional in-office setting among military personnel and veterans. METHOD: One hundred and twenty-one U.S. military service members and veterans were recruited at a military treatment facility and a Veterans Health Administration hospital. Participants were randomized to receive 8 sessions of behavioral activation treatment for depression (BATD) either in the home via videoconferencing (VC) or in a traditional in-office (same room) setting. Participants were assessed at baseline, midtreatment (4 weeks), posttreatment (8 weeks), and 3 months posttreatment. RESULTS: Mixed-effects modeling results with Beck Hopelessness Scale and Beck Depression Inventory II scores suggested relatively strong and similar reductions in hopelessness and depressive symptoms for both groups; however, noninferiority analyses failed to reject the null hypothesis that in-home care was no worse than in-office treatment based on these measures. There were not any differences found between treatment groups in regards to treatment satisfaction. Safety procedures were successfully implemented, supporting the feasibility of home-based care. CONCLUSION: BATD can be feasibly delivered to the homes of active duty service members and veterans via VC. Small-group differences suggest a slight benefit of in-person care over in-home telehealth on some clinical outcomes. Reasons for this are discussed. (PsycINFO Database Record

Clinical Characteristics, Diagnostic Evaluation, and Antibiotic Prescribing Patterns for Skin Infections in Nursing Homes.

BACKGROUND: The epidemiology and management of skin infections in nursing homes has not been adequately described. We reviewed the characteristics, diagnosis, and treatment of skin infections among residents of nursing homes to identify opportunities to improve antibiotic use. METHODS: This was a retrospective study involving 12 nursing homes in the Denver metropolitan area. For residents at participating nursing homes diagnosed with a skin infection between July 1, 2013 and June 30, 2014, clinical and demographic information was collected through manual chart review. RESULTS: Of 100 cases included in the study, the most common infections were non-purulent cellulitis (n = 55), wound infection (n = 27), infected ulcer (n = 8), and cutaneous abscess (n = 7). In 26 cases, previously published minimum clinical criteria for initiating antibiotics (Loeb criteria) were not met. Most antibiotics (n = 52) were initiated as a telephone order following a call from a nurse, and 41 patients were not evaluated by a provider within 48 h after initiation of antibiotics. Nearly all patients (n = 95) were treated with oral antibiotics alone. The median treatment duration was 7 days (interquartile range 7-10); 43 patients received treatment courses of ≥10 days. CONCLUSION: Most newly diagnosed skin infections in nursing homes were non-purulent infections treated with oral antibiotics. Antibiotics were initiated by telephone in over half of cases, and lack of a clinical evaluation within 48 h after starting antibiotics was common. Improved diagnosis through more timely clinical evaluations and decreasing length of therapy are important opportunities for antibiotic stewardship in nursing homes.

Anger intensification with combat-related PTSD and depression comorbidity.

Anger is becoming more widely recognized for its involvement in the psychological adjustment problems of current war veterans. Recent research with combat veterans has found anger to be related to psychological distress, psychosocial functioning, and harm risk variables. Using behavioral health data for 2,077 treatment-seeking soldiers who had been deployed to Iraq and Afghanistan, this study examined whether anger disposition was intensified for those who met screen-threshold criteria for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Anger was assessed with a 7-item screening measure previously validated with the study population. The study tested the hypothesis that anger would be highest when "PTSD & MDD" were conjoined, compared with "PTSD only," "MDD only," and "no PTSD, no MDD." PTSD and depression were assessed with well-established screening instruments. A self-rated "wanting to harm others" variable was also incorporated. Age, gender, race, military component, military grade, and military unit social support served as covariates. Hierarchical multiple regression was used to test the hypothesis, which was confirmed. Anger was intensified in the PTSD & MDD condition, in which it was significantly higher than in the other 3 conditions. Convergent support was obtained for "wanting to harm others" as an exploratory index. Given the high prevalence and co-occurrence of PTSD and MDD among veterans, the results have research and clinical practice relevance for systematic inclusion of anger assessment postdeployment from risk-assessment and screening standpoints.

Risk of Suicide Among US Military Service Members Following Operation Enduring Freedom or Operation Iraqi Freedom Deployment and Separation From the US Military.

IMPORTANCE: A pressing question in military suicide prevention research is whether deployment in support of Operation Enduring Freedom or Operation Iraqi Freedom relates to suicide risk. Prior smaller studies report differing results and often have not included suicides that occurred after separation from military service. OBJECTIVE: To examine the association between deployment and suicide among all 3.9 million US military personnel who served during Operation Enduring Freedom or Operation Iraqi Freedom, including suicides that occurred after separation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort design used administrative data to identify dates of deployment for all service members (October 7, 2001, to December 31, 2007) and suicide data (October 7, 2001, to December 31, 2009) to estimate rates of suicide-specific mortality. Hazard ratios were estimated from time-dependent Cox proportional hazards regression models to compare deployed service members with those who did not deploy. MAIN OUTCOMES AND MEASURES: Suicide mortality from the Department of Defense Medical Mortality Registry and the National Death Index. RESULTS: Deployment was not associated with the rate of suicide (hazard ratio, 0.96; 99% CI, 0.87-1.05). There was an increased rate of suicide associated with separation from military service (hazard ratio, 1.63; 99% CI, 1.50-1.77), regardless of whether service members had deployed or not. Rates of suicide were also elevated for service members who separated with less than 4 years of military service or who did not separate with an honorable discharge. CONCLUSIONS AND RELEVANCE: Findings do not support an association between deployment and suicide mortality in this cohort. Early military separation (<4 years) and discharge that is not honorable were suicide risk factors.

Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars.

PURPOSE: We conducted a retrospective cohort mortality study to determine the postservice suicide risk of recent wartime veterans comparing them with the US general population as well as comparing deployed veterans to nondeployed veterans. METHODS: Veterans were identified from the Defense Manpower Data Center records, and deployment to Iraq or Afghanistan war zone was determined from the Contingency Tracking System. Vital status of 317,581 deployed and 964,493 nondeployed veterans was followed from the time of discharge to December 31, 2009. Underlying causes of death were obtained from the National Death Index Plus. RESULTS: Based on 9353 deaths (deployed, 1650; nondeployed, 7703), of which 1868 were suicide deaths (351; 1517), both veteran cohorts had 24% to 25% lower mortality risk from all causes combined but had 41% to 61% higher risk of suicide relative to the US general population. However, the suicide risk was not associated with a history of deployment to the war zone. After controlling for age, sex, race, marital status, branch of service, and rank, deployed veterans showed a lower risk of suicide compared with nondeployed veterans (hazard ratio, 0.84; 95% confidence interval, 0.75-0.95). Multiple deployments were not associated with the excess suicide risk among deployed veterans (hazard ratio, 1.00; 95% confidence interval, 0.79-1.28). CONCLUSIONS: Veterans exhibit significantly higher suicide risk compared with the US general population. However, deployment to the Iraq or Afghanistan war, by itself, was not associated with the excess suicide risk.

Precipitating circumstances of suicide among active duty U.S. Army personnel versus U.S. civilians, 2005-2010.

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents' military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.