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3.
J Altern Complement Med ; 27(S1): S45-S59, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33788599

RESUMO

Objective: To conduct an interim analysis of data collected from an ongoing multisite randomized clinical trial (RCT) assessing the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) for post-traumatic stress disorder (PTSD) among women veterans with PTSD related to military sexual trauma (MST). The purpose of the interim analysis was to assess outcomes from the primary site, which is geographically, demographically, culturally, and procedurally distinct from the second site. Design: RCT was conducted within a Veterans Administration Health Care System. Data collection included preintervention through 3 months postintervention. Participants: Enrollment for the main site was 152 women. The sample size for the intent-to-treat analysis was 104. The majority were African American (91.3%) with a mean age of 48.46 years. Intervention: The TCTSY intervention (n = 58) was conducted by TCTSY-certified yoga facilitators and consisted of 10 weekly 60-min group sessions. The control intervention, cognitive processing therapy (CPT; n = 46), consisted of 12 90-min weekly group sessions conducted per Veterans Administration protocol by clinicians in the PTSD Clinic. Outcome measures: The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was used to assess current PTSD diagnosis and symptom severity, including overall PTSD and four symptom clusters. The PTSD checklist for DSM-5 (PCL-5) was used to obtain self-report of PTSD symptom severity, including total score and four symptom clusters. Results: The findings reported here are interim results from one clinical site. For both the CAPS-5 and PCL-5, total scores and all four criterion scores decreased significantly (p < 0.01) over time in all five multilevel linear models within both TCTSY and CPT groups, without significant differences between groups. There were clinically meaningful improvements seen for both TCTSY and CPT with 51.1%-64.3% of TCTSY subjects and 43.5%-73.7% of CPT decreasing their CAPS-5 scores by 10 points or more. Effect sizes for total symptom severity were large for TCTSY (Cohen's d = 1.10-1.18) and CPT (Cohen's d = 0.90-1.40). Intervention completion was higher in TCTSY (60.3%) than in CPT (34.8%). Symptom improvement occurred earlier for TCTSY (midintervention) than for CPT (2 weeks postintervention). Safety: There were no unanticipated adverse events in this study. Conclusion: The results of this study demonstrate that TCTSY may be an effective treatment for PTSD that yields symptom improvement more quickly, has higher retention than CPT, and has a sustained effect. TCTSY may be an effective alternative to trauma-focused therapy for women veterans with PTSD related to MST. The study is registered in ClinicalTrials.gov (CTR no.: NCT02640690).


Assuntos
/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Saúde dos Veteranos , Ioga , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Transtornos de Estresse Pós-Traumáticos/psicologia , Resultado do Tratamento , Estados Unidos , Veteranos , Adulto Jovem
4.
J Altern Complement Med ; 27(S1): S37-S44, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33788603

RESUMO

Objectives: Veterans often suffer from multiple chronic illnesses, including mental health disorders, diabetes, obesity, and cardiovascular disease. The improvement of engagement in their own health care is critical for enhanced well-being and overall health. Peer-led group programs may be an important tool to provide support and skill development. We conducted a pilot study to explore the impact of a peer-led group-based program that teaches Veterans to become empowered to engage in their own health and well-being through mindful awareness practices, self-care strategies, and setting life goals. Design: Surveys were collected before and immediately after participation in the Taking Charge of My Life and Health (TCMLH) peer-led group program. Settings/location: Sessions were held in non-clinical settings within a VA medical center in the Midwest. Subjects: Our sample comprised 48 Veteran participants who were enrolled in TCMLH and completed a pretest and post-test survey. Intervention: TCMLH is a 9-week peer-led group program with an established curriculum that leverages the power of peer support to improve patient engagement, empowerment, health, and well-being among Veterans through Whole Health concepts, tools, and strategies. Programs were led by 1 of 12 trained Veteran peer facilitators. Outcome measures: Program impact on Veteran well-being was assessed by pre-post measures, including the Patient Activation Measure (PAM), the Perceived Stress Scale (PSS), the Patient-Reported Outcomes Measurement Information System Scale (PROMIS-10), the Perceived Health Competency Scale (PHCS), and the Life Engagement Test (LET). Results: There was a significant decrease in perceived stress (PSS score). Significant improvements were also seen in mental health and quality of life (PROMIS-10), participant accordance with the statement "I have a lot of reasons for living" (LET), and patient engagement (PAM score). Conclusions: As the Whole Health movement expands-both in VA and elsewhere-our findings suggest that guiding patients in an exploration of their personal values and life goals can help in key areas of patient engagement and mental and physical health outcomes. Further study is warranted, and expansion of the TCMLH program will allow for a more rigorous evaluation with a larger sample size.


Assuntos
Promoção da Saúde/métodos , Participação do Paciente/métodos , Grupo Associado , Saúde dos Veteranos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente , Projetos Piloto , Psicoterapia de Grupo , Estados Unidos , Veteranos
5.
J Altern Complement Med ; 27(S1): S14-S27, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33788604

RESUMO

Objective: Suicide is a major public health problem, specifically among U.S. veterans, who do not consistently engage in mental health services, often citing stigma as a barrier. Complementary and Integrative Health (CIH) interventions are promising alternatives in promoting patient engagement and further, they may play a critical role in transitioning people into mental health care. Toward this goal, the Resilience and Wellness Center (RWC) was developed to break through the stigma barrier by addressing risk factors of suicide through multimodal CIH interventions via cohort design, promoting social connectedness and accountability among participants. Design: This is a program evaluation study at a large urban VA medical center, where assessments were evaluated from pre- to post-program completion to determine the effectiveness of an intensive multimodal CIH 4-week group outpatient intervention for suicide prevention. Outcome measures: Primary outcomes measured included group connectedness, severity of depression and hopelessness symptoms, suicidal ideation, sleep quality, and diet. Secondary outcomes included measures of post-traumatic stress disorder (PTSD), generalized anxiety severity stress/coping skills, pain, and fatigue. Results: The RWC showed high participant engagement, with an 84%-95% attendance engagement rate depending on suicide risk history. Data from 15 cohorts (N = 126) demonstrate favorable outcomes associated with participation in this comprehensive program, as evidenced by a reduction in suicidal ideation, depression, and hopelessness, but not sleep quality and diet. In addition, in a subset of veterans with a history of suicidal ideation or attempt, significant improvements were noted in pain, PTSD/anxiety symptoms, and stress coping measures. Conclusions: The RWC shows that an intensive complement of CIH interventions is associated with a significant improvement with high veteran engagement. Findings from this program evaluation study can be used to aid health care systems and their providers in determining whether or not to utilize such multimodal CIH integrated interventions as an effective treatment for at-risk populations as a part of suicide prevention efforts.


Assuntos
Terapias Complementares , Suicídio/prevenção & controle , Saúde dos Veteranos , Adaptação Psicológica , Adulto , Idoso , Ansiedade/terapia , Depressão/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Estresse Pós-Traumáticos/terapia , Estados Unidos , Veteranos
6.
Diagn Microbiol Infect Dis ; 100(1): 115312, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33561606

RESUMO

Reporting of Coronavirus disease 2019 (COVID-19) co-infections with other respiratory pathogens has varied. We evaluated 825,280 molecular and/or viral culture respiratory assays within the Veterans Health Administration from September 29, 2019 to May 31, 2020. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in 10,222 of 174,746 (5.8%) individuals. 30,063 (17.2%) of 174,746 individuals tested for SARS-CoV-2 had additional respiratory pathogen testing; co-infection was identified in 56 of 3757 (1.5%) individuals positive for SARS-CoV-2. Among those negative for SARS-CoV-2, 1022 of 26,306 (3.9%) were positive for at least 1 respiratory pathogen. Compared to COVID-19 mono-infection, individuals with COVID-19 co-infection had lower odds of being female. Compared to non-COVID-19 respiratory pathogen infection, individuals with COVID-19 co-infection had lower odds of being female, were hospitalized more frequently, had higher odds of death, and were younger at death. Our findings suggest COVID-19 co-infections were rare; however, not all COVID-19 patients were concurrently tested for other respiratory pathogens and seasonal decreases in other respiratory pathogens were occurring as COVID-19 emerged.


Assuntos
/epidemiologia , Infecções Respiratórias/epidemiologia , Saúde dos Veteranos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Coinfecção/epidemiologia , Feminino , Humanos , Influenza Humana/epidemiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Infecções Respiratórias/microbiologia , Infecções Respiratórias/virologia , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Serviços de Saúde para Veteranos Militares , Adulto Jovem
7.
PLoS One ; 16(2): e0246825, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33571280

RESUMO

There is growing evidence that thrombotic and inflammatory pathways contribute to the severity of COVID-19. Common medications such as aspirin, that mitigate these pathways, may decrease COVID-19 mortality. This retrospective assessment was designed to quantify the correlation between pre-diagnosis aspirin and mortality for COVID-19 positive patients in our care. Data from the Veterans Health Administration national electronic health record database was utilized for the evaluation. Veterans from across the country with a first positive COVID-19 polymerase chain reaction lab result were included in the evaluation which comprised 35,370 patients from March 2, 2020 to September 13, 2020 for the 14-day mortality cohort and 32,836 patients from March 2, 2020 to August 28, 2020 for the 30-day mortality cohort. Patients were matched via propensity scores and the odds of mortality were then compared. Among COVID-19 positive Veterans, preexisting aspirin prescription was associated with a statistically and clinically significant decrease in overall mortality at 14-days (OR 0.38, 95% CI 0.32-0.46) and at 30-days (OR 0.38, 95% CI 0.33-0.45), cutting the odds of mortality by more than half. Findings demonstrated that pre-diagnosis aspirin prescription was strongly associated with decreased mortality rates for Veterans diagnosed with COVID-19. Prospective evaluation is required to more completely assess this correlation and its implications for patient care.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Aspirina/uso terapêutico , /mortalidade , Inibidores da Agregação de Plaquetas/uso terapêutico , Adulto , Idoso , /epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Fatores de Proteção , Estudos Retrospectivos , /isolamento & purificação , Saúde dos Veteranos
8.
PLoS Med ; 18(1): e1003490, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33428624

RESUMO

BACKGROUND: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. METHODS AND FINDINGS: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%-59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%-71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% -27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%-23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. CONCLUSIONS: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.


Assuntos
/mortalidade , Disparidades em Assistência à Saúde/normas , Saúde Pública , Determinantes Sociais da Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Idoso , Comorbidade , Grupos Étnicos/estatística & dados numéricos , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Mortalidade , Saúde Pública/métodos , Saúde Pública/normas , Melhoria de Qualidade/organização & administração , Estados Unidos , Saúde dos Veteranos/estatística & dados numéricos
9.
Obesity (Silver Spring) ; 29(5): 825-828, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33403755

RESUMO

OBJECTIVE: The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS: The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS: We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS: Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.


Assuntos
Índice de Massa Corporal , Veteranos/estatística & dados numéricos , Idoso , Estudos de Coortes , Comorbidade , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Fatores de Risco , Estados Unidos/epidemiologia , Saúde dos Veteranos , Serviços de Saúde para Veteranos Militares
10.
Clin Imaging ; 73: 151-161, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33422974

RESUMO

INTRODUCTION: The Veterans Affairs Partnership to increase Access to Lung Screening (VA-PALS) is an enterprise-wide initiative to implement lung cancer screening programs at VA medical centers (VAMCs). VA-PALS will be using implementation strategies that include program navigators to coordinate screening activities, trainings for navigators and radiologists, an open-source software management system, tools to standardize low-dose computed tomography image quality, and access to a support network. VAMCs can utilize strategies according to their local needs. In this protocol, we describe the planned program evaluation for the initial 10 VAMCs participating in VA-PALS. MATERIALS AND METHODS: The implementation of programs will be evaluated using the Consolidated Framework for Implementation Research to ensure broad contextual guidance. Program evaluation measures have been developed using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Adaptations of screening processes will be assessed using the Framework for Reporting Adaptations and Modifications to Evidence Based Interventions. Measures collected will reflect the inner settings, estimate and describe the population reached, adoption by providers, implementation of the programs, report clinical outcomes and maintenance of programs. Analyses will include descriptive statistics and regression to evaluate predictors and assess implementation over time. DISCUSSION: This theory-based protocol will evaluate the implementation of lung cancer screening programs across the Veterans Health Administration using scientific frameworks. The findings will inform plans to expand the VA-PALS initiative beyond the original sites and can guide implementation of lung cancer screening programs more broadly.


Assuntos
Neoplasias Pulmonares , Saúde dos Veteranos , Detecção Precoce de Câncer , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Estados Unidos , United States Department of Veterans Affairs
12.
Med Care ; 59: S31-S35, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33438880

RESUMO

BACKGROUND: Limited research suggests that rates of suicide death among transgender people may be higher than their nontransgender peers. OBJECTIVE: The objective of this study was to compare rates of suicide deaths by different means between transgender and nontransgender patients. RESEARCH DESIGN: This secondary analysis used VHA administrative and electronic health record (EHR) data from October 1, 1999 through December 31, 2016. SUBJECTS: Transgender patients (n=8981) were categorized as such based on a set of International Classification of Disease codes, and a comparison sample was selected by randomly choosing 3 nontransgender patients (n=26,924). MEASURES AND ANALYSES: Cause and date of death data are from the National Death Index. Because of low frequencies amid different methods of suicide death, we combined categories into self-poisoning; hanging, strangulation and suffocation; discharge of firearms; and self-harm by all other and unspecified means. We conducted Cox regression analyses to model time-to-event for each method of suicide, adjusted for age, sex based on EHR, race, ethnicity, marital status, and whether patients had ever been diagnosed with depression. RESULTS: Among transgender patients, 73 died by suicide (22 female EHR-based sex, 51 male EHR-based sex), and among nontransgender patients, 71 died by suicide (4 female EHR-based sex, 67 male EHR-based sex). In adjusted models, transgender patients had significantly greater hazards of death by self-poisoning and firearms than their nontransgender peers. CONCLUSIONS: Differences in methods of suicide death suggest that firearms and self-poisoning may be specific areas of concern for transgender individuals experiencing suicidal crisis, which underscore needs for examining effective delivery of evidence-based care.


Assuntos
Causas de Morte , Heterossexualidade/estatística & dados numéricos , Suicídio/estatística & dados numéricos , Pessoas Transgênero/estatística & dados numéricos , Adulto , Idoso , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , United States Department of Veterans Affairs , Saúde dos Veteranos
13.
Med Care ; 59: S65-S69, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33438885

RESUMO

BACKGROUND: Appropriate after-care for the estimated 1.4 million people with nonfatal suicide attempts each year in the United States is critical, yet little research has focused on recovery needs after an attempt and whether important gender differences in those needs may exist. In this study, we examined gender differences in recovery needs after a suicide attempt among a national sample of women and men veterans. METHODS: We interviewed 25 women and 25 men veterans from Veterans Health Administration health care systems across the country. Purposive sampling was used to obtain a demographically and clinically diverse sample. Transcripts were analyzed using thematic analysis. RESULTS: Although some recovery topics were similar between genders, the participants' primary recovery needs, or goals, differed by gender. Women focused on developing connections with others and wanted to increase their self-knowledge and self-worth. Men were focused on trying to live up to their ideal selves by living and doing "right." Men also wanted to feel like they were needed by others. Both women and men also wanted to feel a stronger sense of purpose in their lives. CONCLUSIONS: Findings suggest that recovery needs among veterans after a nonfatal suicide attempt vary by gender: women may benefit more from psychoeducational approaches in group settings with other women, whereas men may benefit more from approaches that help them focus on making changes in their lives towards becoming their ideal selves.


Assuntos
Assistência ao Convalescente/psicologia , Tentativa de Suicídio/psicologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Fatores Sexuais , Estados Unidos , United States Department of Veterans Affairs , Saúde dos Veteranos
14.
Med Care ; 59: S70-S76, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33438886

RESUMO

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.


Assuntos
Terapia de Reposição Hormonal/psicologia , Menopausa/psicologia , Tentativa de Suicídio/estatística & dados numéricos , Suicídio Consumado/estatística & dados numéricos , Veteranos/psicologia , Idoso , Centers for Medicare and Medicaid Services, U.S. , Feminino , Humanos , Incidência , Estudos Longitudinais , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Fatores de Risco , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Veteranos/estatística & dados numéricos , Saúde dos Veteranos
15.
Ann Epidemiol ; 55: 10-14, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33338646

RESUMO

PURPOSE: Veterans represent a significant proportion of the U.S. population (7%), and the impact of the coronavirus disease 2019 (COVID-19) in this group of vulnerable patients has been largely overlooked. This analysis reports COVID-19 patient demographics, infection, mortality, and case-fatality rates in the veteran population. METHODS: This is a cross-sectional analysis using the Veterans Affairs informatics and computing infrastructure tool to assess the veterans' COVID-19 infections at the Veterans Affairs facilities from March 4th to June 23rd, 2020. RESULTS: Of the 10,621,580 veterans in this analysis, 59.7% were ≥65 yo, 92.5% were men, 68.7% were white, and 14.2% were black. Veterans ≥65 yo comprised 52.1% of cases and 89.9% of deaths. The relative mortality and case-fatality rates of black veterans, when compared with white veterans, were 2.83 (CI 2.56-3.14; P < .001) and 0.75 (CI 0.68-0.82; P < .001), respectively. Among the veterans who died from COVID-19, 87.4% had a history of cardiovascular disease, 56.5% had a history of diabetes, and 33.6% were obese. CONCLUSIONS: Elderly veterans (≥65yo) and veterans with a history of cardiovascular disease represent a large proportion of the VA COVID-19 cases and deaths. Black veterans had higher mortality rates but lower case fatality rates when than white veterans.


Assuntos
/epidemiologia , Veteranos , Adolescente , Adulto , Grupo com Ancestrais do Continente Africano , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Estudos Transversais , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , United States Department of Veterans Affairs , Saúde dos Veteranos , Adulto Jovem
16.
JAMA Netw Open ; 3(12): e2030824, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33351088

RESUMO

Importance: Mild traumatic brain injury (TBI) may predispose individuals to progressive neurodegeneration. Objective: To identify evidence of neurodegeneration through longitudinal evaluation of changes in retinal layer thickness using optical coherence tomography in veterans with a history of mild TBI. Design, Setting, and Participants: This longitudinal cohort study evaluated veterans who were receiving services at the Minneapolis Veterans Affairs Health Care System. Symptomatic or mild TBI was diagnosed according to the Mayo TBI Severity Classification System. Participants in the age-matched control group had no history of TBI. Participants with any history or evidence of retinal or optic nerve disease that could affect retinal thickness were excluded. Data analysis was performed from July 2019 to February 2020. Exposures: The presence and severity of mild TBI were determined through consensus review of self-report responses during the Minnesota Blast Exposure Screening Tool semistructured interview. Main Outcomes and Measures: Change over time of retinal nerve fiber layer (RNFL) thickness. Results: A total of 139 veterans (117 men [84%]; mean [SD] age, 49.9 [11.1] years) were included in the study, 69 in the TBI group and 70 in the control group. Veterans with mild TBI showed significantly greater RNFL thinning compared with controls (mean [SE] RNFL slope, -1.47 [0.24] µm/y vs -0.31 [0.32] µm/y; F1,122 = 8.42; P = .004; Cohen d = 0.52). Functionally, veterans with mild TBI showed greater declines in visual field mean deviation (mean [SE] slope, -0.09 [0.14] dB/y vs 0.46 [0.23] dB/y; F1,122 = 4.08; P = .046; Cohen d = 0.36) and pattern standard deviation (mean [SE] slope, 0.09 [0.06] dB/y vs -0.10 [0.07] dB/y; F1,122 = 4.78; P = .03; Cohen d = 0.39) and high spatial frequency (12 cycles/degree) contrast sensitivity compared with controls. Cognitively, there was a significantly greater decrease in the number of errors over time during the Groton Maze Learning Test (GMLT) in controls compared with veterans with mild TBI (mean [SE] slope, -9.30 [1.48] errors/y vs -5.23 [1.24] errors/y; F1,127 = 4.43; P = .04; Cohen d = 0.37). RNFL tissue loss was significantly correlated with both worsening performance on the GMLT over time (Spearman ρ = -0.20; P = .03) and mild TBI severity (Spearman ρ = -0.25; P = .006). The more severe the mild TBI (larger Minnesota Blast Exposure Screening Tool severity score), the faster the reduction in RNFL thickness (ie, the more negative the slope) across time. Conclusions and Relevance: This cohort study found longitudinal evidence for significant, progressive neural degeneration over time in veterans with mild TBI, as indicated by greater RNFL tissue loss in patients with mild TBI vs controls, as well as measures of function. These results suggest that these longitudinal measures may be useful biomarkers of neurodegeneration. Changes in this biomarker may provide early detection of subsequent cognitive and functional deficits that may impact veterans' independence and need for care.


Assuntos
Concussão Encefálica , Cognição , Doenças Neurodegenerativas , Testes Neuropsicológicos/estatística & dados numéricos , Tomografia de Coerência Óptica/métodos , Testes de Campo Visual , Concussão Encefálica/complicações , Concussão Encefálica/fisiopatologia , Doença Crônica , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Doenças Neurodegenerativas/diagnóstico , Doenças Neurodegenerativas/etiologia , Doenças Neurodegenerativas/psicologia , Estados Unidos/epidemiologia , Saúde dos Veteranos/estatística & dados numéricos , Testes de Campo Visual/métodos , Testes de Campo Visual/estatística & dados numéricos
17.
PLoS One ; 15(11): e0241825, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33175863

RESUMO

BACKGROUND: Available COVID-19 mortality indices are limited to acute inpatient data. Using nationwide medical administrative data available prior to SARS-CoV-2 infection from the US Veterans Health Administration (VA), we developed the VA COVID-19 (VACO) 30-day mortality index and validated the index in two independent, prospective samples. METHODS AND FINDINGS: We reviewed SARS-CoV-2 testing results within the VA between February 8 and August 18, 2020. The sample was split into a development cohort (test positive between March 2 and April 15, 2020), an early validation cohort (test positive between April 16 and May 18, 2020), and a late validation cohort (test positive between May 19 and July 19, 2020). Our logistic regression model in the development cohort considered demographics (age, sex, race/ethnicity), and pre-existing medical conditions and the Charlson Comorbidity Index (CCI) derived from ICD-10 diagnosis codes. Weights were fixed to create the VACO Index that was then validated by comparing area under receiver operating characteristic curves (AUC) in the early and late validation cohorts and among important validation cohort subgroups defined by sex, race/ethnicity, and geographic region. We also evaluated calibration curves and the range of predictions generated within age categories. 13,323 individuals tested positive for SARS-CoV-2 (median age: 63 years; 91% male; 42% non-Hispanic Black). We observed 480/3,681 (13%) deaths in development, 253/2,151 (12%) deaths in the early validation cohort, and 403/7,491 (5%) deaths in the late validation cohort. Age, multimorbidity described with CCI, and a history of myocardial infarction or peripheral vascular disease were independently associated with mortality-no other individual comorbid diagnosis provided additional information. The VACO Index discriminated mortality in development (AUC = 0.79, 95% CI: 0.77-0.81), and in early (AUC = 0.81 95% CI: 0.78-0.83) and late (AUC = 0.84, 95% CI: 0.78-0.86) validation. The VACO Index allows personalized estimates of 30-day mortality after COVID-19 infection. For example, among those aged 60-64 years, overall mortality was estimated at 9% (95% CI: 6-11%). The Index further discriminated risk in this age stratum from 4% (95% CI: 3-7%) to 21% (95% CI: 12-31%), depending on sex and comorbid disease. CONCLUSION: Prior to infection, demographics and comorbid conditions can discriminate COVID-19 mortality risk overall and within age strata. The VACO Index reproducibly identified individuals at substantial risk of COVID-19 mortality who might consider continuing social distancing, despite relaxed state and local guidelines.


Assuntos
Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Betacoronavirus/isolamento & purificação , Comorbidade , Infecções por Coronavirus/patologia , Infecções por Coronavirus/virologia , Bases de Dados Factuais , Grupos Étnicos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/patologia , Pneumonia Viral/virologia , Curva ROC , Fatores de Risco , Saúde dos Veteranos , Adulto Jovem
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