Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 15.796
Filtrar
1.
Psychiatr Danub ; 32(Suppl 3): 364-366, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33030454

RESUMO

Post-traumatic stress disorder (PTSD) is a spectrum disorder whose symptoms show psychological, neurobiological dysregulation and poorer functionality of a person on the social plane. PTSD characteristics are symptoms from four clusters: symptoms of intrusiveness, avoidance, negative changes in cognition and mood and changes in excitability and reactivity. Traumatic experiences of war veterans can have an impact on the development of psychopathology in their children's lives. The impact of posttraumatic stress disorder of war veterans is negatively manifested in a broader sense through secondary traumatization and is manifested differently in relation to the period of childhood and adolescence. The period of childhood and adolescence represents a delicate and dynamic period that requires adaptation and functionality in adulthood. The epidemiological studies so far indicate the link between the post-traumatic stress disorder of war veterans with the mental problems of their children.


Assuntos
Filho de Pais Incapacitados/psicologia , Fadiga por Compaixão/psicologia , Psicologia do Adolescente , Psicologia da Criança , Transtornos de Estresse Pós-Traumáticos/psicologia , Veteranos/psicologia , Adolescente , Bósnia e Herzegóvina , Criança , Feminino , Humanos , Masculino
2.
JMIR Mhealth Uhealth ; 8(9): e22079, 2020 09 21.
Artigo em Inglês | MEDLINE | ID: mdl-32955456

RESUMO

BACKGROUND: A necessary shift from in-person to remote delivery of psychotherapy (eg, teletherapy, eHealth, videoconferencing) has occurred because of the COVID-19 pandemic. A corollary benefit is a potential fit in terms of the need for equitable and timely access to mental health services in remote and rural locations. Owing to COVID-19, there may be an increase in the demand for timely, virtual delivery of services among trauma-affected populations, including public safety personnel (PSP; eg, paramedics, police, fire, correctional officers), military members, and veterans. There is a lack of evidence on the question of whether digital delivery of trauma-therapies for military members, veterans, and PSP leads to similar outcomes to in-person delivery. Information on barriers and facilitators and recommendations regarding digital-delivery is also scarce. OBJECTIVE: This study aims to evaluate the scope and quality of peer-reviewed literature on psychotherapeutic digital health interventions delivered remotely to military members, veterans, and PSP and synthesize the knowledge of needs, gaps, barriers to, and facilitators for virtual assessment of and virtual interventions for posttraumatic stress injury. METHODS: Relevant studies were identified using MEDLINE (Medical Literature Analysis and Retrieval System Online), EMBASE (Excerpta Medica dataBASE), APA (American Psychological Association) PsycINFO, CINAHL (Cumulative Index of Nursing and Allied Health Literature) Plus with Full Text, and Military & Government Collection. For collation, analysis, summarizing, and reporting of results, we used the CASP (Critical Skills Appraisal Program) qualitative checklist, PEDro (Physiotherapy Evidence Database) scale, level of evidence hierarchy, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), and narrative synthesis. RESULTS: A total of 38 studies were included in this review. Evidence for the effectiveness of digital delivery of prolonged exposure therapy, cognitive processing therapy, behavioral activation treatment with therapeutic exposure to military members, veterans, and PSP was rated level 1a, whereas evidence for cognitive behavioral therapy was conflicting. The narrative synthesis indicated that virtual delivery of these therapies can be as effective as in-person delivery but may reduce stigma and cost while increasing access to therapy. Issues of risk, safety, potential harm (ie, suicidality, enabling avoidance), privacy, security, and the match among the therapist, modality, and patient warrant further consideration. There is a lack of studies on the influences of gender, racial, and cultural factors that may result in differential outcomes, preferences, and/or needs. An investigation into other therapies that may be suitable for digital delivery is needed. CONCLUSIONS: Digital delivery of trauma therapies for military members, veterans, and PSP is a critical area for further research. Although promising evidence exists regarding the effectiveness of digital health within these populations, many questions remain, and a cautious approach to more widespread implementation is warranted.


Assuntos
Socorristas/psicologia , Militares/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Telemedicina , Veteranos/psicologia , Infecções por Coronavirus/epidemiologia , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
3.
PLoS Med ; 17(9): e1003379, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32960880

RESUMO

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


Assuntos
Técnicas de Laboratório Clínico/estatística & dados numéricos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Grupos Étnicos/estatística & dados numéricos , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Veteranos/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Estudos de Coortes , Infecções por Coronavirus/etnologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/etnologia , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
4.
Artigo em Russo | MEDLINE | ID: mdl-32929942

RESUMO

The authors consider current views on and approaches to trauma and posttraumatic stress disorder (PTSD). There are doubts about the correctness and validity of allocation of PTSD entirely according to psychogenesis of the disease. The authors consider the «post-traumatic¼ as a type of response to extreme stress. PTSD is characterized as a nonspecific pathological form of disease, which can occur in the structure of different mental disorders. Based on considering two approaches (cerebrotraumatic and psychosomatic) in solving the current issue, the authors suggest that PTSD is a psychogenic-organic disorder.


Assuntos
Intolerância Ortostática , Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Transtornos Psicofisiológicos , Transtornos Somatoformes
5.
JAMA Netw Open ; 3(9): e2022310, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32965502

RESUMO

Importance: Identifying independent risk factors for adverse outcomes in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication, resource utilization, and treatment. Objective: To identify excess risk and risk factors associated with hospitalization, mechanical ventilation, and mortality in patients with SARS-CoV-2 infection. Design, Setting, and Participants: This longitudinal cohort study included 88 747 patients tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14, 2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national health care system, including 10 131 patients (11.4%) who tested positive. Exposures: Sociodemographic characteristics, comorbid conditions, symptoms, and laboratory test results. Main Outcomes and Measures: Risk of hospitalization, mechanical ventilation, and death were estimated in time-to-event analyses using Cox proportional hazards models. Results: The 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2, those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested positive for SARS-CoV-2, characteristics significantly associated with mortality included older age (eg, ≥80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease burden (eg, ≥700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher Charlson comorbidity index score (eg, ≥5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95% CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests, which exhibited dose-response associations with mortality, including aspartate aminotransferase (>89 U/L vs ≤25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR, 3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs ≤2.71: aHR, 2.88; 95% CI, 2.12-3.91). With the exception of geographic region, the same covariates were independently associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex (aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30; 95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in adjusted analyses included obesity (body mass index ≥35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21), Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson Comorbidity Index score of at least 1 (11.1%). Conclusions and Relevance: In this national cohort of VA patients, most SARS-CoV-2 deaths were associated with older age, male sex, and comorbidity burden. Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race, Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.


Assuntos
Causas de Morte , Infecções por Coronavirus , Hospitalização , Pandemias , Pneumonia Viral , Respiração Artificial , Veteranos , Idoso , Betacoronavirus , Estudos de Coortes , Comorbidade , Coronavirus , Infecções por Coronavirus/sangue , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Dispneia/etiologia , Dispneia/terapia , Feminino , Febre/etiologia , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/sangue , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Modelos de Riscos Proporcionais , Fatores de Risco , Síndrome Respiratória Aguda Grave , Índice de Gravidade de Doença , Estados Unidos , United States Department of Veterans Affairs
6.
J Med Internet Res ; 22(9): e21561, 2020 09 30.
Artigo em Inglês | MEDLINE | ID: mdl-32936773

RESUMO

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


Assuntos
Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Saúde da População Rural/estatística & dados numéricos , Telemedicina , Veteranos/psicologia , Veteranos/estatística & dados numéricos , Comunicação por Videoconferência , Idoso , Agendamento de Consultas , Arkansas/epidemiologia , Cuidadores , Estudos Transversais , Assistência à Saúde , Correio Eletrônico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias
7.
J Natl Black Nurses Assoc ; 31(1): 41-45, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32853495

RESUMO

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


Assuntos
Diabetes Mellitus Tipo 2/terapia , Educação de Pacientes como Assunto/métodos , Veteranos/estatística & dados numéricos , Perda de Peso , Adulto , Idoso , Idoso de 80 Anos ou mais , Hemoglobina A Glicada/metabolismo , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade
8.
Med Care ; 58(9): 805-814, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826746

RESUMO

OBJECTIVE: The objective of this study was to examine site of death and hospice use, identifying potential disparities among veterans dying in Department of Veterans Affairs (VA) Home Based Primary Care (VA-HBPC). METHODS: Administrative data (2008, 2012, and 2016) were compiled using the VA Residential-History-File which tracks health care service location, daily. Outcomes were site of death [home, nursing home (NH), hospital, inpatient hospice]; and hospice use on the day of death. We compared VA-HBPC rates to rates of 2 decedent benchmarks: VA patients and 5% Traditional Medicare non-veteran males. Potential age, race, urban/rural residence and living alone status disparities in rates among veterans dying in VA-HBPC in 2016 were examined by multinomial logistic regression. RESULTS: In 2016, 7796 veterans died in VA-HBPC of whom 62.1% died at home, 11.8% in NHs, 14.7% in hospitals and 11.4% in inpatient hospice. Hospice was provided to 60.9% of veterans dying at home and 63.9% of veterans dying in NH. Over the 2008-2012-2016 period, rates of VA-HBPC veterans who died at home and rates of home death with hospice increased and were higher than both benchmarks. Among VA-HBPC decedents, younger/older veterans were more/less likely to die at home and less/more likely to die with hospice. Race/ethnicity and urban/rural residence were unrelated to death at home but veterans living alone were less likely to die at home. CONCLUSIONS: Results reflect VA-HBPC's primary goal of supporting its veterans at home, including at the end-of-life, surpassing other population benchmarks with some potential disparities remaining.


Assuntos
Benchmarking/estatística & dados numéricos , Morte , Serviços de Assistência Domiciliar/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Grupos de Populações Continentais , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Características de Residência , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs , Veteranos
9.
Am J Occup Ther ; 74(5): 7405205010p1-7405205010p11, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32804619

RESUMO

IMPORTANCE: Occupational therapy practitioners can use therapeutic activity to promote veterans' well-being, but the mechanisms through which participation promotes well-being are poorly understood. OBJECTIVE: To examine whether coping ability, meaningful activity, and social support mediate the relationship between participation and two indicators of veterans' overall well-being: life meaning (psychological well-being) and life satisfaction (subjective well-being). DESIGN: Explanatory cross-sectional design. We used two multiple mediation models to test whether coping ability, meaningful activity, and social support explained the relationship between participation and both life meaning and life satisfaction. Models were adjusted for demographic characteristics and service-related health conditions (e.g., posttraumatic stress disorder). SETTING: Community. PARTICIPANTS: Three hundred eighty-nine community-based veterans attending college. INTERVENTION: None. OUTCOMES AND MEASURES: Measures of participation, coping ability, meaningful activity, social support, life meaning, life satisfaction, and service-related health conditions. RESULTS: Meaningfulness of activity partially explained the relationship between participation and both psychological well-being (B = 0.16, standard error [SE] = 0.04, 99% confidence interval [CI] [0.07, 0.27]) and subjective well-being (B = 0.14, SE = 0.03, 99% CI [0.07, 0.24]). Social support partially explained the relationship between participation and subjective well-being (B = 0.05, SE = 0.02, 99% CI [0.01, 0.11]). These findings persisted when symptoms of service-related health conditions were accounted for. CONCLUSIONS AND RELEVANCE: Veterans' participation is associated with a greater sense of meaningful activity and social support, which in turn promotes psychological and subjective well-being. Occupational therapy practitioners may promote veterans' well-being by supporting engagement in activities that elicit meaning and enable social interaction, although further study is needed. WHAT THIS ARTICLE ADDS: This is among the first studies to test mechanisms underlying the relationship between veterans' engagement in activities and their overall well-being. Results may inform treatment theories for activity-based interventions in the veteran population. For example, results indicate that occupational therapy interventions that facilitate engagement in meaningful and shared activities could be developed to promote veterans' well-being.


Assuntos
Transtornos de Estresse Pós-Traumáticos , Veteranos , Adaptação Psicológica , Estudos Transversais , Humanos , Relações Interpessoais , Apoio Social
10.
PLoS One ; 15(8): e0237430, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32841307

RESUMO

BACKGROUND & AIMS: Given ongoing challenges in non-invasive non-alcoholic liver disease (NAFLD) diagnosis, we sought to validate an ALT-based NAFLD phenotype using measures readily available in electronic health records (EHRs) and population-based studies by leveraging the clinical and genetic data in the Million Veteran Program (MVP), a multi-ethnic mega-biobank of US Veterans. METHODS: MVP participants with alanine aminotransferases (ALT) >40 units/L for men and >30 units/L for women without other causes of liver disease were compared to controls with normal ALT. Genetic variants spanning eight NAFLD risk or ALT-associated loci (LYPLAL1, GCKR, HSD17B13, TRIB1, PPP1R3B, ERLIN1, TM6SF2, PNPLA3) were tested for NAFLD associations with sensitivity analyses adjusting for metabolic risk factors and alcohol consumption. A manual EHR review assessed performance characteristics of the NAFLD phenotype with imaging and biopsy data as gold standards. Genetic associations with advanced fibrosis were explored using FIB4, NAFLD Fibrosis Score and platelet counts. RESULTS: Among 322,259 MVP participants, 19% met non-invasive criteria for NAFLD. Trans-ethnic meta-analysis replicated associations with previously reported genetic variants in all but LYPLAL1 and GCKR loci (P<6x10-3), without attenuation when adjusted for metabolic risk factors and alcohol consumption. At the previously reported LYPLAL1 locus, the established genetic variant did not appear to be associated with NAFLD, however the regional association plot showed a significant association with NAFLD 279kb downstream. In the EHR validation, the ALT-based NAFLD phenotype yielded a positive predictive value 0.89 and 0.84 for liver biopsy and abdominal imaging, respectively (inter-rater reliability (Cohen's kappa = 0.98)). HSD17B13 and PNPLA3 loci were associated with advanced fibrosis. CONCLUSIONS: We validate a simple, non-invasive ALT-based NAFLD phenotype using EHR data by leveraging previously established NAFLD risk-associated genetic polymorphisms.


Assuntos
Alanina Transaminase/metabolismo , Hepatopatia Gordurosa não Alcoólica/patologia , 17-Hidroxiesteroide Desidrogenases/genética , Abdome/diagnóstico por imagem , Proteínas Adaptadoras de Transdução de Sinal/genética , Idoso , Alanina Transaminase/genética , Registros Eletrônicos de Saúde , Feminino , Loci Gênicos , Predisposição Genética para Doença , Variação Genética , Humanos , Lipase/genética , Fígado/patologia , Lisofosfolipase/genética , Masculino , Proteínas de Membrana/genética , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/etnologia , Hepatopatia Gordurosa não Alcoólica/genética , Fenótipo , Fatores de Risco , Veteranos
11.
Womens Health Issues ; 30(5): 320-329, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32830008

RESUMO

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


Assuntos
Comportamento de Ajuda , Assédio Sexual/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Estados Unidos , Saúde dos Veteranos
12.
Med Care ; 58 Suppl 2 9S: S80-S87, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826776

RESUMO

BACKGROUND: Veterans Affairs (VA) has rolled out a holistic, multicomponent Whole Health care model nationwide, yet no pragmatic trials have been conducted in real-world clinical settings to compare its effectiveness against other evidence-based approaches for chronic pain management in veterans. OBJECTIVES: We describe the adaptation of the first large pragmatic randomized controlled trial of the Whole Health model for chronic pain care for diverse VA clinical settings. RESEARCH DESIGN: Informed by the Promoting Action on Research Implementation in Health Systems implementation framework, we conducted qualitative semistructured interviews to obtain feedback on trial design from VA leadership, frontline clinicians, and veterans with chronic pain at 5 VA enrollment sites. Next, we convened in-person evidence-based quality improvement (EBQI) meetings with study stakeholders (including frontline clinicians and administrators) at each site to discuss study design; review interview themes; and identify site-specific barriers, facilitators, and approaches to implementation. Ethnographic observations from EBQI meetings provided additional insight into implementation strategies. SUBJECTS: Seventy-four veteran and VA staff stakeholders were interviewed; 71 stakeholders participated in EBQI meetings. RESULTS: At each site, unique clinical contexts and varying resources for Whole Health and pain care delivery affected plans for trial implementation. We present examples of local adaptations that emerged through the formative evaluation process to facilitate implementation and yield a more pragmatic trial design. CONCLUSIONS: A systematic formative evaluation can facilitate engagement and buy-in of study stakeholders. Locally tailored pragmatic implementation strategies may improve the likelihood of successful trial execution as well as future implementation of evidence-based pain care approaches in real-world clinical settings.


Assuntos
Dor Crônica/terapia , Medicina Integrativa/organização & administração , Projetos de Pesquisa , United States Department of Veterans Affairs/organização & administração , Antropologia Cultural , Atitude do Pessoal de Saúde , Medicina Baseada em Evidências , Humanos , Entrevistas como Assunto , Seleção de Pacientes , Melhoria de Qualidade/organização & administração , Estados Unidos , Veteranos , Saúde dos Veteranos
13.
Med Care ; 58 Suppl 2 9S: S94-S100, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826778

RESUMO

BACKGROUND: Chronic pain and associated symptoms are debilitating for veterans. Medical costs of treatments are high and current treatment options, most notably with opioid medications, have been associated with significant risk. Mindfulness-based interventions appear promising for chronic pain, but require additional testing in veteran care settings. OBJECTIVE: This project was designed to test the feasibility of engaging and retaining veterans with chronic lower back pain in a new mindfulness protocol tailored for veterans, mindfulness-based care for chronic pain (MBCP). Clinical outcomes were also assessed. DESIGN: An open pilot trial of an 8-week MBCP course that included meditation, gentle yoga, and psychoeducation. SUBJECTS: Twenty-two veterans (mean age=49.77; 18% women) were recruited from a VA Medical Center in the Northeastern US. After screening for inclusion/exclusion criteria, 20 were eligible at baseline. MEASURES: Veterans were assessed at baseline and postintervention for functional impairment, pain intensity and bothersomeness, depression, and mindfulness. RESULTS: The average number of sessions completed was 5; only 4 (20%) attended all sessions. Eleven of the 20 participants (55%) attended 5 or more sessions and had complete preintervention and postintervention visits. Five of the 11 had a clinically meaningful decrease in pain intensity and in depressive symptoms, while 6 of 11 had a meaningful decrease in pain bothersomeness and functional impairment. CONCLUSIONS: It was challenging to enroll and retain participants in this study, even with our intervention designed for veterans. We discuss possible adaptations and refinements in MBCP for veterans with chronic pain to enhance feasibility and improve upon these interventions.


Assuntos
Dor Lombar/terapia , Terapias Mente-Corpo/métodos , Adulto , Idoso , Doença Crônica , Protocolos Clínicos , Depressão/epidemiologia , Depressão/terapia , Avaliação da Deficiência , Feminino , Nível de Saúde , Humanos , Dor Lombar/epidemiologia , Masculino , Meditação/métodos , Pessoa de Meia-Idade , Atenção Plena/métodos , Medição da Dor , Educação de Pacientes como Assunto/métodos , Desempenho Físico Funcional , Projetos Piloto , Índice de Gravidade de Doença , Fatores Socioeconômicos , Veteranos , Saúde dos Veteranos , Ioga
14.
Med Care ; 58 Suppl 2 9S: S101-S107, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826779

RESUMO

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.


Assuntos
Acupuntura Auricular/métodos , Dor Crônica/terapia , Veteranos , Acupuntura Auricular/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Estudos de Coortes , Comorbidade , Estudos Transversais , Feminino , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/organização & administração , Saúde dos Veteranos , Adulto Jovem
15.
Med Care ; 58 Suppl 2 9S: S108-S115, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826780

RESUMO

OBJECTIVES: Veterans Health Administration encourages auricular acupuncture (Battlefield Acupuncture/BFA) as a nonpharmacologic approach to pain management. Qualitative reports highlighted a "gateway hypothesis": providing BFA can lead to additional nonpharmacologic treatments. This analysis examines subsequent use of traditional acupuncture. RESEARCH DESIGN: Cohort study of Veterans treated with BFA and a propensity score matched comparison group with a 3-month follow-up period to identify subsequent use of traditional acupuncture. Matching variables included pain, comorbidity, and demographics, with further adjustment in multivariate regression analysis. SUBJECTS: We identified 41,234 patients who used BFA across 130 Veterans Health Administration medical facilities between October 1, 2016 and March 31, 2019. These patients were matched 2:1 on Veterans who used VA care but not BFA during the same period resulting in a population of 24,037 BFA users and a comparison cohort of 40,358 non-BFA users. Patients with prior use of traditional acupuncture were excluded. RESULTS: Among Veterans receiving BFA, 9.5% subsequently used traditional acupuncture compared with 0.9% of non-BFA users (P<0.001). In adjusted analysis, accounting for patient characteristics and regional availability of traditional acupuncture, patients who used BFA had 10.9 times greater odds (95% confidence interval, 8.67-12.24) of subsequent traditional acupuncture use. CONCLUSIONS: Providing BFA, which is easy to administer during a patient visit and does not require providers be formally certified, led to a substantial increase in use of traditional acupuncture. These findings suggest that the value of offering BFA may not only be its immediate potential for pain relief but also subsequent engagement in additional therapies.


Assuntos
Terapia por Acupuntura/métodos , Terapia por Acupuntura/estatística & dados numéricos , Acupuntura Auricular/métodos , Acupuntura Auricular/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Feminino , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Manejo da Dor/métodos , Pontuação de Propensão , Análise de Regressão , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos , Saúde dos Veteranos , Adulto Jovem
16.
Med Care ; 58 Suppl 2 9S: S116-S124, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826781

RESUMO

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


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Crônica/terapia , Terapias Complementares/estatística & dados numéricos , Medicina Integrativa/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/administração & dosagem , Dor Crônica/tratamento farmacológico , Terapias Complementares/métodos , Feminino , Nível de Saúde , Humanos , Medicina Integrativa/métodos , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Percepção da Dor , Qualidade de Vida , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , United States Department of Veterans Affairs , Saúde dos Veteranos
17.
Med Care ; 58 Suppl 2 9S: S125-S132, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826782

RESUMO

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


Assuntos
Terapias Complementares/estatística & dados numéricos , Medicina Integrativa/estatística & dados numéricos , Medidas de Resultados Relatados pelo Paciente , Veteranos/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Nível de Saúde , Humanos , Estudos Longitudinais , Masculino , Saúde Mental , Pessoa de Meia-Idade , Manejo da Dor , Medição da Dor , Participação do Paciente , Estresse Psicológico/terapia , Estados Unidos , United States Department of Veterans Affairs , Saúde dos Veteranos
18.
Med Care ; 58 Suppl 2 9S: S133-S141, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826783

RESUMO

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


Assuntos
Dor Crônica/terapia , Veteranos/estatística & dados numéricos , Ioga , Adulto , Feminino , Nível de Saúde , Humanos , Entrevistas como Assunto , Masculino , Medição da Dor , Fatores Socioeconômicos
19.
Med Care ; 58 Suppl 2 9S: S142-S148, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826784

RESUMO

BACKGROUND: Yoga interventions can improve function and reduce pain in persons with chronic low back pain (cLBP). OBJECTIVE: Using data from a recent trial of yoga for military veterans with cLBP, we analyzed the incremental cost-effectiveness of yoga compared with usual care. METHODS: Participants (n=150) were randomized to either 2× weekly, 60-minute yoga sessions for 12 weeks, or to delayed treatment (DT). Outcomes were measured at 12 weeks, and 6 months. Quality-adjusted life years (QALYs) were measured using the EQ-5D scale. A 30% improvement on the Roland-Morris Disability Questionnaire (primary outcome) served as an additional effectiveness measure. Intervention costs including personnel, materials, and transportation were tracked during the study. Health care costs were obtained from patient medical records. Health care organization and societal perspectives were examined with a 12-month horizon. RESULTS: Incremental QALYs gained by the yoga group over 12 months were 0.043. Intervention costs to deliver yoga were $307/participant. Negligible differences in health care costs were found between groups. From the health care organization perspective, the incremental cost-effectiveness ratio to provide yoga was $4488/QALY. From the societal perspective, yoga was "dominant" providing both health benefit and cost savings. Probabilistic sensitivity analysis indicates an 89% chance of yoga being cost-effective at a willingness-to-pay of $50,000. A scenario comparing the costs of yoga and physical therapy suggest that yoga may produce similar results at a much lower cost. DISCUSSION/CONCLUSIONS: Yoga is a cost-effective treatment for reducing pain and disability among military veterans with cLBP.


Assuntos
Dor Lombar/economia , Dor Lombar/terapia , Ioga , Adulto , Idoso , Doença Crônica , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Avaliação da Deficiência , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Modalidades de Fisioterapia/economia , Anos de Vida Ajustados por Qualidade de Vida , Veteranos , Saúde dos Veteranos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA