Relationship between donor ejection fraction, left ventricular wall thickness and mortality in heart transplants recipients.

This study explored the impact of donor left ventricular ejection fraction (EF) and left ventricular wall thickness (LVWT) on mortality among heart transplant (HTx) recipients. Utilizing data from the United Network for Organ Sharing (UNOS) registry, adult HTx recipients between 2006-2022 were analyzed. Patients were categorized into four groups based on donor EF(>50 % or ≤50 %) and LVWT(<1.4 cm or ≥1.4 cm). 21,012 patients were included. There were significant differences in baseline characteristics among the groups. Unadjusted mortality was 6.3 %, 6.0 %, 6.0 %, and 2.4 %(p=0.86) at 30-days; 16.2 %, 13.5 %, 16.8 %, and 7.3 %(p=0.08) at 1-year; and 32.2 %, 29.2 %, 35.4 %, and 29.0 %(p=0.18) at 5-years, respectively. In addition, adjusted mortality did not differ across the groups. There were no significant differences in recipient mortality in groups based on donor EF and LVWT. Expanding the donor selection criteria would allow for increase in the donor pool and assist in decreasing the mortality, while on the waitlist for HTx.

Short report: Transition to International Classification of Diseases, 10th Revision and the prevalence of autism in a cohort of healthcare systems.

LAY ABSTRACT: Currently, the prevalence of autism spectrum disorder (henceforth "autism") is 1 in 36, an increasing trend from previous estimates. In 2015, the United States adopted a new version (International Classification of Diseases, 10th Revision) of the World Health Organization coding system, a standard for classifying medical conditions. Our goal was to examine how the transition to this new coding system impacted autism diagnoses in 10 healthcare systems. We obtained information from electronic medical records and insurance claims data from July 2014 through December 2016 for each healthcare system. We used member enrollment data for 30 consecutive months to observe changes 15 months before and after adoption of the new coding system. Overall, the rates of autism per 1000 enrolled members was increasing for 0- to 5-year-olds before transition to International Classification of Diseases, 10th Revision and did not substantively change after the new coding was in place. There was variation observed in autism diagnoses before and after transition to International Classification of Diseases, 10th Revision for other age groups. The change to the new coding system did not meaningfully affect autism rates at the participating healthcare systems. The increase observed among 0- to 5-year-olds is likely indicative of an ongoing trend related to increases in screening for autism rather than a shift associated with the new coding.

Maternal chronic hypertension in women veterans.

OBJECTIVE: To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre-pregnancy and pregnancy periods. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN: We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010-2019. DATA COLLECTION/EXTRACTION METHODS: Veterans aged 18-50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multivariable logistic regression explored the association of covariates with recommended and non-recommended AHMs received 0-6 months before pregnancy and during pregnancy. PRINCIPAL FINDINGS: In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non-recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6-6.4) and diabetes (OR = 2.3; 1.7-3.0) were most strongly associated with use of a non-recommended AHM during pregnancy. CONCLUSIONS: Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential.

Infertility Services for Veterans Enrolled in Veterans Health Administration Care.

BACKGROUND: Infertility care is provided to Veterans through the Veterans Health Administration (VHA) medical benefits package and includes infertility evaluation and many infertility treatments. OBJECTIVE: Our objective was to examine the incidence and prevalence of infertility diagnoses and the receipt of infertility healthcare among Veterans using Veterans Health Administration (VHA) healthcare from 2018 to 2020. METHODS: Veterans using the VHA and diagnosed with infertility during October 2017-September 2020 (FY18-20) were identified in VHA administrative data and through VA-purchased care (i.e., community care) claims. Infertility was categorized among men as azoospermia, oligospermia, and other and unspecified male infertility, and among women as anovulation, infertility of tubal origin, infertility of uterine origin, and other and unspecified female infertility using diagnosis and procedure codes (ICD-10, CPT). KEY RESULTS: A total of 17,216 Veterans had at least one VHA infertility diagnosis in FY18, FY19, or FY20, including 8766 male Veterans and 8450 female Veterans. Incident diagnoses of infertility were observed in 7192 male Veterans (10.8/10,000 person (p)-years) and 5563 female Veterans (93.6/10,000 p-years). A large proportion of Veterans who were diagnosed with infertility received an infertility-related procedure in the year of their incident diagnosis (males: 74.7, 75.3, 65.0%, FY18-20 respectively; females: 80.9, 80.8, 72.9%, FY18-20 respectively). CONCLUSIONS: In comparison to a recent study of active duty servicemembers, we found a lower rate of infertility among Veteran men and a higher rate among Veteran women. Further work is needed to investigate military exposures and circumstances that may lead to infertility. Given the rates of infertility among Veterans and active duty servicemembers, enhancing communications between Department of Defense and VHA systems regarding sources of and treatment for infertility is essential to help more men and women benefit from infertility care during military service or as Veterans.

Retrospective analysis of the impact of pre-transplant implantable cardioverter-defibrillator status on long-term prognosis in heart transplant patients.

BACKGROUND: Sudden cardiac death (SCD) post-heart transplantation affects 8%-35% of patients; however, the risk profile remains to be completely elucidated. While pre-transplant ICDs are typically removed during transplantation, no information exists to suggest if this pre-transplant risk stratification is also associated with post-transplant outcomes. The objective of this study was to assess the impact of pre-transplant ICD status on long-term prognosis post-heart transplant. METHODS: The United Network for Organ Sharing registry was queried for all adult heart transplant recipients from 2010 to 2018. Patients were categorized as with versus without ICD prior to heart transplantation. Survival was compared using Kaplan-Meier analysis. Proportional hazards regression analysis assessed the impact of ICDs adjusting for clinical and demographic covariates. RESULTS: Of 19 026 patients included, 78.6% (n = 14 960) had received an ICD at time of registration. Patients with an ICD were older [54.9 (±11.6) years vs. 48.6 (±15.3) years, p < .001], less likely to be female [25.7% (n = 3842) vs. 31.2% (n = 1269), p < .001], and more commonly diabetic [29.3% (n = 4376) vs 23.5% (n = 954), p < .001]. Kaplan-Meier analysis showed no difference in unadjusted survival trajectory by ICD status (chi-square = .48, p = .49). Survival was unrelated to ICD status in the multivariable model (HR = .98; 95% CI .90-1.07). CONCLUSIONS: Patients receiving an ICD pre-transplant had a higher prevalence of risk factors for SCD than non-ICD patients, yet ICD status prior to heart transplantation was not associated with a change in long-term prognosis post-heart transplantation.

Newborn Outcomes Among Veterans Utilizing VHA Maternity Benefits, 2016-2020.

INTRODUCTION: Public Law 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended the Veterans Health Administration's (VHA) medical benefits package to include 7 days of medical care for newborns delivered by Veterans. We examined the newborn outcomes among a cohort of women Veterans receiving VHA maternity benefits and care coordination. MATERIALS AND METHODS: We conducted a secondary analysis of phone interview data from Veterans enrolled in the COMFORT (Center for Maternal and Infant Outcomes Research in Translation) study 2016-2020. Multivariable regression estimated associations with newborn outcomes (preterm birth; low birthweight). RESULTS: During the study period, 829 infants were born to 811 Veterans. Mothers reported "excellent health" for 94% of infants. The prevalence of preterm birth was slightly higher in our cohort (11% vs. 10%), as were low birthweight (9%) deliveries, compared to the general population (8.28%). Additionally, 42% of infants in our cohort required follow-up care for non-routine health conditions; 11% were uninsured at 2 months of age. Adverse newborn outcomes were more common for mothers who were older in age, self-identified as non-white in race and/or of Hispanic ethnicity, had a diagnosis of posttraumatic stress disorder, or had gestational comorbidities. CONCLUSIONS: The current VHA maternity coverage appears to be an effective policy for ensuring the well-being and health care coverage for the majority of Veterans and their newborns in the first days of life, thereby reducing the risk of inadequate prenatal and neonatal care. Future research should examine costs associated with extending coverage to 14 days or longer, comparing those to the projected excess costs of neonatal health problems. VHA policy should continue to support expanding care and resources through the Maternity Care Coordinator model.

The transition to civilian life: Impact of comorbid PTSD, chronic pain, and sleep disturbance on veterans' social functioning and suicidal ideation.

OBJECTIVE: Trauma-exposed veterans may be more likely to experience posttraumatic stress disorder (PTSD), chronic pain, and sleep disturbance together rather than in isolation. Although these conditions are independently associated with distress and impairment, how they relate to social functioning and suicidal ideation (SI) when experienced comorbidly is not clear. METHOD: Using longitudinal data on 5,461 trauma-exposed U.S. veterans from The Veterans Metrics Initiative study and self-reported disorders, we assessed (a) the extent to which PTSD co-occurs with sleep disturbance and chronic pain (CP); (b) the relationship of PTSD in conjunction with sleep disturbance and chronic pain with later social functioning and SI; and (c) the extent to which social functioning mediates the impact of multimorbidity on SI. RESULTS: At approximately 15 months postseparation, 90.5% of veterans with probable PTSD also reported sleep disturbance and/or CP. Relative to veterans without probable PTSD, veterans with all 3 conditions (n = 907) experienced the poorest social functioning (B = -.56, p < .001) and had greater risk for SI (OR = 3.78, p < .001); Social functioning partially mediated the relationship between multimorbidity and SI. However, relative to those with PTSD alone, sleep disturbance and CP did not confer greater risk for SI. CONCLUSIONS: Although these findings underscore the impact of PTSD on functioning and SI, they also highlight the complexity of multimorbidity and the importance of bolstering social functioning for veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Emergence of probable PTSD among U.S. veterans over the military-to-civilian transition.

OBJECTIVE: Despite theorizing that posttraumatic stress disorder (PTSD) symptomatology may be exacerbated during the military-to-civilian transition, little research has delved into the trajectory of trauma-related symptomatology or the impact of diverse factors on timing of PTSD onset. To understand risk and protective factors for PTSD during the transition into civilian life, this study examined demographic, experiential, and psychosocial characteristics that may explain variation in PTSD symptoms and timing of onset. METHOD: A nationwide sample representing 48,965 U.S. veterans separating from military service in fall 2016 responded to six Web-based surveys over 3 years. Assessments included PTSD symptoms, stress, warfare exposures, military sexual trauma, moral injury events, resilience, and social support. Multivariable models estimated covariates of positive PTSD screen or symptoms. RESULTS: Trauma exposure during military service was high at 59%. Probable PTSD was detected in 26% of the sample at baseline, with additional cases in each survey wave for an overall rate of 30%. Meeting criteria for probable PTSD covaried with current stress, female gender, and minority race/ethnicity; baseline psychological resilience and concurrent social support mitigated the risk. PTSD symptoms correlated positively with stress levels at current and previous time points. Social support was protective but only when contemporaneous with the PTSD symptoms. CONCLUSIONS: This study illustrates the need for ongoing social support for veterans coping with symptoms of PTSD, life stressors, and postmilitary trauma, suggesting a countervailing influence of psychological resilience and contemporaneous (but not historical) social support on symptom exacerbation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Agent Orange Exposure, Transformation From MGUS to Multiple Myeloma, and Outcomes in Veterans.

Background: Multiple myeloma (MM) accounts for 1% to 2% of all cancers. Exposure to the pesticide Agent Orange (AO) has been established as a potential risk factor for the development of monoclonal gammopathy of undetermined significance (MGUS) and, subsequently, MM in Vietnam War veterans. Methods: This study explored variation in survival related to AO exposure, transformation from MGUS to MM, and covariates. Vietnam War veterans with MM or MGUS were identified in Veterans Health Administration (VHA) health records data. Cox proportional hazards models analyzed survival as a function of AO, race, ethnicity, body mass index, nicotine dependence, alcohol use disorder, Charlson Comorbidity Index, and treatment. Autologous hematopoietic cell transplantation for MM was defined by procedure codes. Results: In the VHA 16,366 patients were identified: 11,112 patients diagnosed with MGUS and 7261 with MM during fiscal years 2010 to 2015 were identified; 12% (n = 2007) had both diagnoses. No statistically significant difference in the rate of transformation from MGUS to MM in the AO exposed and AO not exposed groups was found. In survival models, AO exposure was associated with slightly lower mortality. Alcohol use disorder, nicotine dependence, older age, and greater comorbidity burden increased mortality risk. Black race, female sex, obesity/overweight, and hematopoietic cell transplantation for patients with MM were protective factors. AO exposure was associated with decreased mortality for both MM/MGUS groups. Transformation increased mortality risk for patients with MGUS and decreased mortality risk for patients with MM. Conclusions: Because AO exposure is a nonmodifiable risk factor, focus should be placed on modifiable risk factors (eg, nicotine dependence, alcohol and drug use disorders, underlying comorbid conditions) as these were associated with worse outcomes. Future studies should examine the correlation of AO exposure, cytogenetics, and clinical outcomes in these veterans to best identify their disease course and optimize their care in the latter part of their life.

The VA vascular injury study: A glimpse at quality of care in Veterans with traumatic vascular injury repair.

OBJECTIVE: The high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI. MATERIALS AND METHODS: We identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics. RESULTS: The 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18-56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD. CONCLUSION: Despite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders. IMPACT: The treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI.

Financial Status and Well-being in Recently Separated Military Veterans.

INTRODUCTION: Veterans transitioning from military service to civilian life manage numerous changes simultaneously, in health, employment, social relationships, and finances. Financial problems may impact financial well-being as well as adjustment to civilian life in general; yet, research on Veterans' financial challenges remains limited. This study examined six indicators of perceived financial status among newly transitioned Veterans over a period of 3 years and then examined perceived financial well-being measured in two domains-satisfaction and functioning-and difficulty adjusting to civilian life as functions of financial status. MATERIALS AND METHODS: A sample representing 48,965 Veterans who separated from active duty/activated status in fall 2016 provided informed consent and survey data over their first 33 post-military months; data were analyzed in weighted regression models that included demographics, military characteristics, social support, resilience, life stress, and indicators of financial status. RESULTS: Financial status immediately post-separation included having stable housing (88%), being able to pay for necessities (83%), keeping up with creditors (88%), having insurance for catastrophic events such as disability (79%), saving for retirement (62%), and setting aside 3 months of salary (50%). Thirteen percent of Veterans disclosed troubled financial status, having achieved no more than two of these financial goals; 38% had moderate and 49% excellent financial status. Troubled or moderate financial status, Black race, enlisted, and higher levels of stress predicted lower financial functioning. Older age, college degree at baseline, employment, and social support predicted better financial satisfaction. Veterans with troubled financial status reported greater difficulty adjusting to civilian life (odds ratio 1.34); women were less likely to report difficulty adjusting to civilian life (odds ratio 0.85). CONCLUSIONS: Findings indicate that financial satisfaction and functioning may be sensitive to psychosocial factors (social support and stress). Findings also underscore the value of assessing Veterans' financial status (poor debt management and lack of future planning), providing encouragement and assistance to pursue a college degree, and improving household financial management, thus increasing the likelihood that Veterans will have the necessary tools to manage their finances after separation and achieve whole health well-being.

Medications with Potential for Fetal Risk Prescribed to Veterans.

Background: Women service members of the past 20 years experienced high rates of traumatizing events resulting in pharmacological treatment. Post-military lives may include having children. Typically, Veterans Health Administration (VHA) patients' pregnancies are managed outside the VHA. This study examined medication exposures during pregnancy. Materials and Methods: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study collected primary survey data and linked secondary health care data from the VHA from 2015 to 2021. Medication fills and covariates were extracted for three 9-month periods: preconception, pregnancy, and postpartum. Multiple regression assessed factors associated with use during pregnancy of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) or of non-recommended, potentially risky drugs, and of discontinuation of those medications from prepregnancy to pregnancy. Results: The cohort comprised 501 women-29% Black, 65% White, and 6% other races, of whom 63% had 50%-100% service-connected disability. During pregnancy, 36% had a pain-related disorder, 19% major depression, and 18% post-traumatic stress disorder. The median number of drug classes prescribed during pregnancy was 5. The use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy including new starts; 15% discontinued SSRI/SNRI. Comorbidity predicted medication use. Depression predicted discontinuing SSRI/SNRI during pregnancy; no predictors of discontinuing potentially risky drugs were identified. Conclusions: Based on prescriptions filled within the VHA only-ignoring potential community-based fills-women veterans were prescribed numerous medications during pregnancy and discontinued antidepressants alarmingly. Veterans of childbearing potential should receive counseling about medication use before pregnancy occurs. Their non-VHA obstetricians and VHA providers should share information to optimize outcomes, reviewing medications as soon as pregnancy is detected as well as after pregnancy concludes.

The influence of employment program components upon job attainment during a time of identity and career transition.

This study assessed the effectiveness of employment programs components, which resulted in the identification of content and process components that increase employability. Employment program use was studied among 1172 United States of America military veterans to determine which content (i.e., interviewing skills) and process (i.e., working with a mentor/coach) components influence job attainment during a time of career and identity transition. Components were distilled utilizing a common components analysis approach (Morgan et al., 2018). Associations with finding employment up to 15 months after the military-to-civilian transition were explored. Veterans who engaged with employment programs were primarily accessing the following components: career planning, resume writing, and interviewing skills. However, only a few content components were significantly related to obtaining employment: interviewing (with mentor/coach), resume writing (online tools), translating military to civilian work (with mentor/coach), entrepreneurship (with mentor/coach), and virtual career fairs. Furthermore, not all processes or modes of instruction for content components were associated with success in the job market. Having a mentor/coach was one of the most effective delivery strategies. For example, veterans using programs delivered by a mentor/coach that translated military skills to civilian work were more likely to find a job at 6-9-months (84%) and 12-15-months (91%) post military separation. In addition, risks that predicted lower use of employment program components by veterans were identified such as junior enlisted rank, combat exposure, combat arms occupation, and physical health problems. With these findings, program developers, implementers, and funders can channel efforts towards the utilization of employment programs with effective components.

L'influence des composantes du programme d'emploi sur l'obtention d'un travail au cours d' une période de transition identitaire et professionnelle L'utilisation des programmes d'emploi a été étudiée parmi 1172 vétérans de l'armée américaine afin de déterminer quelles composantes du contenu et du processus influencent l'obtention d'un emploi. Une approche d'analyse des composantes communes (common component analysis, CCA) a été utilisée. Les associations avec l'obtention d'un emploi jusqu'à 15 mois après la transition de l'armée à la société civile ont identifié des composantes significativement liées à l'obtention d'un emploi: l'entretien (avec un mentor/coach), la rédaction d'un CV (outils en ligne), la transposition du travail militaire au travail civil (avec un mentor/coach), l'esprit entrepreneurial (avec un mentor/coach) et les salons de l'emploi virtuels. Le recours à un mentor/coach était l'une des stratégies de prestation les plus efficaces. Les risques prédisant une utilisation moindre des composantes du programme ont été identifiés: grade d'enrôlé junior, exposition au combat, occupation dans les armes de combat et problèmes de santé physique.

La influencia de los componentes del programa de empleo en la consecución del trabajo durante una época de transición de identidad y carrera Se estudió el uso del programa de empleo entre 1,172 veteranos militares de los Estados Unidos para determinar qué contenido y componentes del proceso influyen en la consecución del empleo. Se utilizó un enfoque de análisis de componentes comunes. Las asociaciones con la búsqueda de empleo hasta 15 meses después de la transición de militar a civil identificaron componentes relacionados significativamente con la obtención de empleo: entrevistas (con mentor / entrenador), redacción de currículos (herramientas en línea), traducción de trabajo militar a civil (con mentor / entrenador), emprendimiento (con mentor / coach) y ferias de carreras virtuales. Tener un mentor / entrenador fue una de las estrategias de ejecución más efectivas. Se identificaron los riesgos que predecían un menor uso de los componentes del programa: rango de alistados juveniles, exposición al combate, ocupación de armas de combate y problemas de salud física.

Changes in the health and broader well-being of U.S. veterans in the first three years after leaving military service: Overall trends and group differences.

OBJECTIVES: Scholars have theorized that the initial period after military discharge may be a particularly vulnerable time for veterans. Yet, several recent studies raise the prospect that risk for poor adjustment may actually increase rather than decrease over time. The current study examined whether the U.S. military veteran population experiences improvements or declines in their health and broader well-being during the first three years after leaving military service and documented differences based on gender, military rank, and warzone deployment history. METHODS: A population-based sample of 3733 newly separated veterans completed a survey within three months of separation (Fall 2016), followed by five additional surveys at six-month intervals. Weighted multilevel logistic regressions were conducted to examine changes in the proportion of veterans reporting good health and broader well-being over time. RESULTS: Most aspects of veterans' health and broader well-being worsened over time, with a noteworthy increase in reporting of mental health conditions and a decline in veterans' community involvement. Declines in the proportion of veterans reporting good health and well-being were most notable for women, with smaller differences observed for other subgroups. CONCLUSIONS: The finding that veterans experienced worsening health and broader well-being over time highlights the need for enhanced prevention and early intervention efforts to mitigate these declines. Findings also point to the importance of attending to the unique readjustment concerns of female veterans and other at-risk subgroups.

Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression.

BACKGROUND: Although research has shown that exposure to potentially traumatic and morally injurious events is associated with psychological symptoms among veterans, knowledge regarding functioning impacts remains limited. METHODS: A population-based sample of post-9/11 veterans completed measures of intimate relationship, health, and work functioning at approximately 9, 15, 21, and 27 months after leaving service. Moral injury, posttraumatic stress, and depression were assessed at ~9 months post-separation. We used Latent Growth Mixture Models to identify discrete classes characterized by unique trajectories of change in functioning over time and to examine predictors of class membership. RESULTS: Veterans were assigned to one of four functioning trajectories: high and stable, high and decreasing, moderate and increasing, and moderate and stable. Whereas posttraumatic stress, depression, and moral injury associated with perpetration and betrayal predicted worse outcomes at baseline across multiple functioning domains, moral injury associated with perpetration and depression most reliably predicted assignment to trajectories characterized by relatively poor or declining functioning. CONCLUSIONS: Moral injury contributes to functional problems beyond what is explained by posttraumatic stress and depression, and moral injury due to perpetration and depression most reliably predicted assignment to trajectories characterized by functional impairment over time.

The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans.

Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.

Prenatal Stress Exposure and Post-traumatic Stress Disorder Associated With Risk of Postpartum Alcohol Misuse Among Women Veterans.

OBJECTIVES: Maternal alcohol misuse during the postpartum period is associated with negative maternal and infant outcomes. This study examined whether greater stress exposure in the year before the baby's birth and maternal post-traumatic stress disorder (PTSD) were associated with postpartum alcohol misuse among a sample of women veterans. Maternal PTSD was also examined as a moderator of the association between stress exposure and postpartum alcohol misuse. METHODS: Data were drawn from the Center for Maternal and Infant Outcomes Research in Translation study, a multisite prospective cohort study of pregnant and postpartum women veterans. Interviews were conducted within 12 weeks after birth. At this post-birth interview, women reported whether they experienced stressful events (e.g., loss of job, military deployment, separation/divorce) in the year before birth. PTSD diagnosis and postpartum scores on the Alcohol Use Disorders Identification Test (AUDIT-C) were derived from the Department of Veterans Affairs medical records. RESULTS: Models testing main and interaction effects showed a statistically significant association of both PTSD (p = .02) and stress exposure (p = .04), as well as significant interaction of PTSD and stress exposure (p = .03) with AUDIT-C scores postpartum, after controlling for marital status, age, and race. Specifically, compared with women without PTSD, those with PTSD had higher overall AUDIT-C scores postpartum, regardless of stress exposure. For women without PTSD, more stress exposure before birth was associated with higher AUDIT-C scores during the postpartum phase. CONCLUSIONS: PTSD diagnosis and life stressors before infant birth predicted maternal alcohol misuse during the postpartum period. Identifying such risk factors is an initial step in preventing alcohol misuse, with the goal of enhancing postpartum health for the birthing parent and infant.

Psychosocial Determinants of Readmission After Surgery.

BACKGROUND: Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood. OBJECTIVE: We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population. RESEARCH DESIGN: This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital. SUBJECTS: We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017). MEASURES: We assessed unplanned readmission to any medical facility within 30 days of hospital discharge. RESULTS: A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery. CONCLUSIONS: Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.

Identifying factors that contribute to military veterans' post-military well-being.

Prior research has examined the independent effects of demographic and military characteristics, trauma history, and coping resources on military veterans' health. However, there is limited knowledge of how these factors intersect with one another and with veterans' health to impact their broader well-being as they readjust to civilian life. Data for this study were drawn from a longitudinal investigation of the health and broader well-being of U.S. veterans (N = 7150) who had recently left military service. Machine learning analyses (random forests of regression trees) were used to examine how factors assessed shortly after military separation were associated with veterans' well-being approximately a year later. Veterans who endorsed the combination of low depression, high social support, and high psychological resilience were most likely to report high well-being a year later. Neither demographic and military characteristics nor trauma history emerged as strong predictors of veterans' well-being when considered in the context of other factors. Although most predictors were similar for women and men, depression was a stronger predictor of women's well-being. Results highlight the importance of screening for and intervening with veterans who report high depression, low social support, and low psychological resilience when leaving military service. These findings can inform efforts to promote veterans' post-military well-being.

The Impact of Discriminatory Stress on Changes in Posttraumatic Stress Severity at the Intersection of Race/Ethnicity and Gender.

Given the diversity of military veterans and growing evidence of ethnoracial disparities in posttraumatic stress disorder (PTSD) within this population, elucidating the role of discrimination-related stress in contributing to these disparities is crucial. We examined the relative impact of discriminatory stress (i.e., due to race/ethnicity, religion, nationality, gender, sexual orientation, or physical appearance) on 6-month changes in PTSD symptom severity among trauma-exposed White (74%), Black (11%) and Hispanic/Latino/a/x (15%) veterans (17% female). PTSD symptoms were measured with the 8-item PTSD Checklist for DSM-5. A measure of the extent to which discrimination has caused stress for the respondent assessed discriminatory stress. Hierarchical regression analyses examined interactions among race/ethnicity, gender and discriminatory stress in predicting six-month changes in PTSD severity. Black and Hispanic/Latino/a/x veterans reported higher baseline PTSD severity and discriminatory stress than White veterans, with some variation by gender. Three-way interactions of race/ethnicity by discriminatory stress by gender were significant, controlling for income, education and age. The relationship between discriminatory stress and increases in PTSD severity was significantly stronger for Black women compared with Black men and did not differ between White men and women. There was also a stronger relationship between discriminatory stress and increases in PTSD severity for Hispanic/Latino/x men as compared to Black men. These findings suggest that discriminatory stress impacts PTSD severity differentially for various ethnoracial/gender groups and highlight the value of applying an intersectional framework that accounts for the synergistic connections among multiple identities to future screening, intervention, and research efforts.