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1.
BMJ ; 368: m283, 2020 03 04.
Artigo em Inglês | MEDLINE | ID: mdl-32131996

RESUMO

OBJECTIVE: To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. DESIGN: Observational evaluation. SETTING: Veterans Health Administration. PARTICIPANTS: 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). MAIN OUTCOME MEASURES: A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient's death. RESULTS: 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. CONCLUSIONS: Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient's perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.


Assuntos
Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologia , Suicídio/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Idoso , Prescrições de Medicamentos , Humanos , Pessoa de Meia-Idade , Padrões de Prática Médica , Modelos de Riscos Proporcionais , Estados Unidos/epidemiologia
2.
BMC Infect Dis ; 20(1): 23, 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31914940

RESUMO

BACKGROUND: The prevalence of diabetes mellitus continues to inexorably rise in the United States and throughout the world. Lower limb amputations are a devastating comorbid complication of diabetes mellitus. Osteomyelitis increases the risk of amputation fourfold and commonly presages death. Antimicrobial therapy for diabetic foot osteomyelitis (DFO) varies greatly, indicating that high quality data are needed to inform clinical decision making. Several small trials have indicated that the addition of rifampin to backbone antimicrobial regimens for osteomyelitis outside the setting of the diabetic foot results in 28 to 42% higher cure rates. METHODS/DESIGN: This is a prospective, randomized, double-blind investigation of the addition of 6 weeks of rifampin, 600 mg daily, vs. matched placebo (riboflavin) to standard-of-care, backbone antimicrobial therapy for DFO. The study population are patients enrolled in Veteran Health Administration (VHA), ages ≥18 and ≤ 89 years with diabetes mellitus and definite or probable osteomyelitis of the foot for whom an extended course of oral or intravenous antibiotics is planned. The primary endpoint is amputation-free survival. The primary hypothesis is that using rifampin as adjunctive therapy will lower the hazard rate compared with the group that does not use rifampin as adjunctive therapy. The primary hypothesis will be tested by means of a two-sided log-rank test with a 5% significance level. The test has 90% power to detect a hazard ratio of 0.67 or lower with a total of 880 study participants followed on average for 1.8 years. DISCUSSION: VA INTREPID will test if a rifampin-adjunctive antibiotic regimen increases amputation-free survival in patients seeking care in the VHA with DFO. A positive finding and its adoption by clinicians would reduce lower extremity amputations and their associated physical and emotional impact and reduce mortality for Veterans and for the general population with diabetic foot osteomyelitis. Given that rifampin-adjunctive regimens are currently employed for therapy for the majority of DFO cases in Europe, and only in a small minority of cases in the United States, the trial results will impact therapeutic decisions, even if the null hypothesis is not rejected. TRIAL REGISTRATION: Registered January 6, 2017 at ClinicalTrials.gov, NCT03012529.


Assuntos
Amputação , Pé Diabético/tratamento farmacológico , Osteomielite/tratamento farmacológico , Rifampina/uso terapêutico , Veteranos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação/estatística & dados numéricos , Antibacterianos/uso terapêutico , Antibioticoprofilaxia , Pé Diabético/complicações , Pé Diabético/epidemiologia , Pé Diabético/cirurgia , Método Duplo-Cego , Feminino , Pé/microbiologia , Pé/patologia , Pé/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Osteomielite/complicações , Osteomielite/epidemiologia , Osteomielite/cirurgia , Placebos , Estudos Prospectivos , Prevenção Secundária/métodos , Veteranos/estatística & dados numéricos , Adulto Jovem
3.
Int J Radiat Oncol Biol Phys ; 106(1): 157-166, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31580929

RESUMO

PURPOSE: Previous studies have found that patients with head and neck cancer (HNC) with a higher relative hazard for recurrence versus competing mortality (ω+ ratio) are more likely to benefit from intensive therapy. Nomograms to predict this ratio (ω scores) can be useful to guide clinical management; however, comorbidity and other risk factors are frequently lacking from trial samples. METHODS AND MATERIALS: In this study of 7117 US veterans, we evaluated the ability of a ω score nomogram developed from clinical trial data to stratify patients with HNC treated with radiation therapy by their relative risk of cancer progression versus competing mortality. We then fit generalized competing event models to determine the effect of comorbidity and other covariates on the ω+ ratio. RESULTS: The ω score was effective in stratifying patients with HNC according to their risk for cancer recurrence relative to competing mortality, especially among patients aged >70 years. Patients with ω score ≥0.80 were more likely to receive intensive therapy compared with patients with a ω score <0.80 (66 vs. 54%; P < .001). On multivariable generalized competing event regression, T2-4 category (relative hazard ratio [RHR], 1.08; 95% confidence interval [CI], 1.01-1.16), N2-3 category (RHR, 1.07; 95% CI, 1.01-1.15), and being employed (RHR, 1.11; 95% CI, 1.03-1.20) were associated with increased ω+ ratio, and increasing age (RHR, 0.83; 95% CI, 0.78-0.89), Charlson comorbidity index ≥2 (RHR, 0.85; 95% CI, 0.79-0.91), being a current smoker (RHR, 0.90; 95% CI, 0.84-0.96), and lower body mass index (RHR, 0.89; 95% CI, 0.84-0.95) were associated with a decreased ω+ ratio. CONCLUSIONS: The ω scores are effective in stratifying patients with HNC and are correlated with the intensity of treatment given. The ω scores incorporating comorbidity and other risk factors could help identify patients with HNC most likely to benefit from intensive therapy.


Assuntos
Neoplasias de Cabeça e Pescoço/radioterapia , Recidiva Local de Neoplasia , Nomogramas , Seleção de Pacientes , Carcinoma de Células Escamosas de Cabeça e Pescoço/radioterapia , Fatores Etários , Idoso , Comorbidade , Intervalos de Confiança , Progressão da Doença , Emprego , Feminino , Neoplasias de Cabeça e Pescoço/classificação , Neoplasias de Cabeça e Pescoço/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Radioterapia de Intensidade Modulada , Análise de Regressão , Fatores de Risco , Fumantes , Carcinoma de Células Escamosas de Cabeça e Pescoço/classificação , Carcinoma de Células Escamosas de Cabeça e Pescoço/mortalidade , Magreza/complicações , Veteranos/estatística & dados numéricos
4.
Maturitas ; 132: 30-34, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31883660

RESUMO

OBJECTIVES: 25-hydroxyvitamin D [25(OH)D] deficiency is related to an increase in cardiovascular risk but the association between low 25(OH)D and hospitalization and mortality in heart failure (HF) patients remains unclear. The objective of this study was therefore to determine whether 25(OH)D deficiency is associated with a higher risk of all-cause hospitalizations and mortality in veterans with HF, as well as the differential effect of frailty. STUDY DESIGN: A retrospective cohort study of veterans with HF. MAIN OUTCOME: Association between 25(OH)D deficiency and risk of hospitalization and mortality. MEASURES: 25(OH)D status was dichotomized as deficiency (<30 ng/mL) and non-deficiency (≥30 ng/mL). A 44-item Frailty Index (FI) was constructed and used to categorize patients as non-frail (FI < .21) or frail (FI ≥ .21). The association of 25(OH)D deficiency with recurrent hospitalization was analyzed through an Andersen-Gill model and the association with mortality using Cox regression. RESULTS: We identified 284 patients, of whom 141 (50 %) exhibited 25(OH)D deficiency (67.3 ±â€¯10.5 years of age). The mean 25(OH)D levels in the deficiency and non-deficiency groups were 21.3±5.9 ng/mL and 40.9 ±â€¯10.9 ng/mL, respectively. Over a median follow-up of 1136 days (IQR = 691), there were 617 hospitalizations (68 % in those with 25(OH)D deficiency) and 131 deaths (40 % in those with 25(OH)D deficiency). A significantly higher risk of hospitalization was found in patients with 25(OH)D deficiency: hazard ratio (HR) = 1.8 (95 % CI:1.3-2.5),p < 0.001. Frail veterans had a greater risk of hospitalization than non-frail veterans: HR = 1.7 (95 % CI:1.2-2.7),p < 0.05. Mortality did not show any significant association with 25(OH)D deficiency. CONCLUSIONS: 25(OH)D deficiency was an independent risk factor for hospitalization in patients with HF and the effect persisted in those with frailty.


Assuntos
Fragilidade/epidemiologia , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Deficiência de Vitamina D/epidemiologia , Vitamina D/análogos & derivados , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Veteranos/estatística & dados numéricos , Vitamina D/sangue , Deficiência de Vitamina D/sangue
5.
Adv Gerontol ; 32(4): 492-501, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31800175

RESUMO

The study involving 317 former combatants aged 24 to 69 years was conducted. The aim of the study was to determine the regularities of the age dynamics of stress-induced pathology of combatants to develop the concept of their accelerated aging as a final component of the consequences of combat stress. It turned out that in relation to the period of influence of factors of combat stress and age, first manifests the pathology of the musculoskeletal system, gastrointestinal tract and arterial hypertension, then-cardiovascular disease associated with atherosclerosis. The formation of post-traumatic stress disorder occurred in 289 (91,2%) cases, and the chronic pain syndromes of different localization and different origin - in 192 (60,6%) at different times of the post-war period. But it is post-traumatic stress disorder in combination with chronic pain were decisive in the overall severity of the state of combatants, changes in indicators of free radical oxidation and an increase in biological age. It is proposed to consider accelerated aging, which is formed on the basis of the consequences of severe stress effects, as an independent disease.


Assuntos
Envelhecimento , Doença Crônica , Distúrbios de Guerra , Veteranos , Adulto , Idoso , Doenças Cardiovasculares/etiologia , Dor Crônica/etiologia , Distúrbios de Guerra/complicações , Gastroenteropatias/etiologia , Humanos , Pessoa de Meia-Idade , Transtornos de Estresse Pós-Traumáticos/etiologia , Veteranos/estatística & dados numéricos
6.
NeuroRehabilitation ; 45(2): 163-185, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31707378

RESUMO

OBJECTIVE: To synthesize the current evidence on sleep disturbances in military service members (SMs) and veterans with traumatic brain injury (TBI). METHODS: An electronic literature search first identified abstracts published from 2008-2018 inclusively referencing sleep, TBI, and military personnel from Operation Enduring Freedom, Operation Iraqi Freedom, Operation New Dawn, and Persian Gulf veterans. Selection criteria eliminated studies on non-combat TBI, open or penetrating injuries, and articles where the relationship between sleep and TBI was not directly examined. Articles on all military branches and components, those currently serving and veterans-ranging from medical chart reviews to clinical trials, were included. Forty-one articles were selected for full text-review. RESULTS: Twenty-four papers estimated the prevalence of sleep disturbances in TBI. Eight studies demonstrated the contribution of common co-occurring conditions, most notably posttraumatic stress disorder, to the relationship between disrupted sleep and TBI. Ten studies differentiated sleep profiles between military SMs and veterans with and without acute TBI and detected significant differences in sleep disturbances across the course of injury. Longitudinal studies were scarce but helped to establish the temporal relationship between sleep disturbances and TBI and isolate sleep-related mechanisms influencing TBI prognosis. Only three studies reported on interventions for improving sleep quality and TBI symptoms. Systematic research testing assessments and interventions that target sleep disturbances for improving sleep, TBI symptoms, and long-term functional outcomes were identified as critical knowledge gaps. CONCLUSION: Findings unequivocally establish that sleep disturbances are highly prevalent in SMs and veterans with TBI. However, studies testing the effectiveness of treatments for improving sleep in military groups with TBI have been limited and their results inconsistent. This review highlights a critical opportunity for advancing military medicine through future research aimed at identifying and testing sleep-focused treatments in SMs and veterans with combat-related TBI.


Assuntos
Lesões Encefálicas Traumáticas/epidemiologia , Militares/estatística & dados numéricos , Transtornos do Sono-Vigília/epidemiologia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Veteranos/estatística & dados numéricos , Adulto , Campanha Afegã de 2001- , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino
7.
J Frailty Aging ; 8(4): 205-209, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31637407

RESUMO

BACKGROUND: Sedentary lifestyle leads to worse health outcomes with aging, including frailty. Older adults can benefit from regular physical activity, but exercise promotion in the clinical setting is challenging. OBJECTIVES: The objective of this clinical demonstration project was to implement a Geriatric Walking Clinic for older adults and determine whether this clinical program can lead to improvements in characteristics of frailty. DESIGN: This was a clinical demonstration project/quality improvement project. SETTING: Outpatient geriatrics clinic at the South Texas Veterans Health Care System (STVHCS). PARTICIPANTS: Older Veterans, aged ≥60 years. INTERVENTION: A 6-week structured walking program, delivered by a registered nurse and geriatrician. Patients received a pedometer and a comprehensive safety evaluation at an initial face-to-face visit. They were subsequently followed with weekly phone calls and participated in a final face-to-face follow-up visit at 6 weeks. MEASUREMENTS: Grip strength (handheld dynamometer), gait speed (10-ft walk), Timed Up and Go (TUG), and body mass index (BMI) were assessed at baseline and follow-up. Frailty status for gait speed was assessed using Fried criteria. RESULTS: One hundred eighty five patients completed the program (mean age: 68.4 ±7 years, 88% male). Improvements from baseline to follow-up were observed in average steps/day, gait speed, TUG, and BMI. Improvement in gait speed (1.13 ±0.20 vs. 1.24 ± 0.23 meter/second, p<0.0001) resulted in reduced odds of meeting frailty criteria for slow gait at follow-up compared to the baseline examination (odds ratio = 0.31, 95% confidence interval: 0.13-0.72, p = 0.01). CONCLUSIONS: Our findings demonstrate that a short duration, low-intensity walking intervention improves gait speed and TUG. This new clinical model may be useful for the promotion of physical activity, and for the prevention or amelioration of frailty characteristics in older adults.


Assuntos
Terapia por Exercício/métodos , Fragilidade/prevenção & controle , Veteranos/estatística & dados numéricos , Caminhada/fisiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Velocidade de Caminhada/fisiologia
8.
Optom Vis Sci ; 96(10): 718-725, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31592954

RESUMO

SIGNIFICANCE: One-year follow-up is recommended for patients with macular diseases to assess functional changes associated with disease progression and to modify low-vision (LV) treatment plans, if indicated. PURPOSE: The purpose of this study was to observe 255 patients with macular diseases who received LV rehabilitation (rehabilitation with a therapist) or basic LV services (LV devices dispensed without therapy) during Veterans Affairs Low-vision Intervention Trial II after the trial ended at 4 months until 1-year follow-up. METHODS: The primary outcome measure was visual ability measured with the 48-item Veterans Affairs Low-vision Visual Functioning Questionnaire. Mean visual ability scores for the treatment groups were compared from baseline to 4 months, 4 months to 1 year, and baseline to 1 year. Changes from baseline to 1 year were compared between the two groups. Predictors of changes in visual ability from 4 months to 1 year were assessed using linear regression. RESULTS: Both groups experienced significant improvement in all measures of visual ability from baseline to 1 year but lost visual reading ability during the observation period (LV rehabilitation group, -0.64 [1.2] logit; 95% confidence interval [CI], -0.84 to -0.44 logit; basic LV group, -0.63 [1.4] logit; 95% CI, -0.88 to -0.38 logit), and overall visual ability was lost in the LV rehabilitation group (-0.20 [0.8] logit; 95% CI, -0.34 to -0.06 logit). Loss of visual reading ability in both groups from 4 months to 1 year was predicted by reading ability scores at 4 months, loss of near visual acuity from 4 months to 1 year, and lower EuroQol-5D utility index scores; loss of overall visual ability in the LV rehabilitation group during the same time period was predicted by lower overall ability scores at 4 months. CONCLUSIONS: Visual ability significantly improved in all groups from baseline to 1 year. However, the loss of visual reading ability experienced by both groups from 4 months to 1 year reduced the benefit of the services provided.


Assuntos
Doenças Retinianas/reabilitação , Veteranos/estatística & dados numéricos , Baixa Visão/reabilitação , Pessoas com Deficiência Visual/reabilitação , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Centros de Reabilitação , Doenças Retinianas/fisiopatologia , Perfil de Impacto da Doença , Inquéritos e Questionários , Resultado do Tratamento , Estados Unidos , United States Department of Veterans Affairs , Baixa Visão/fisiopatologia , Acuidade Visual/fisiologia
9.
Nat Commun ; 10(1): 4558, 2019 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-31594949

RESUMO

The risk of posttraumatic stress disorder (PTSD) following trauma is heritable, but robust common variants have yet to be identified. In a multi-ethnic cohort including over 30,000 PTSD cases and 170,000 controls we conduct a genome-wide association study of PTSD. We demonstrate SNP-based heritability estimates of 5-20%, varying by sex. Three genome-wide significant loci are identified, 2 in European and 1 in African-ancestry analyses. Analyses stratified by sex implicate 3 additional loci in men. Along with other novel genes and non-coding RNAs, a Parkinson's disease gene involved in dopamine regulation, PARK2, is associated with PTSD. Finally, we demonstrate that polygenic risk for PTSD is significantly predictive of re-experiencing symptoms in the Million Veteran Program dataset, although specific loci did not replicate. These results demonstrate the role of genetic variation in the biology of risk for PTSD and highlight the necessity of conducting sex-stratified analyses and expanding GWAS beyond European ancestry populations.


Assuntos
Loci Gênicos , Predisposição Genética para Doença , Transtornos de Estresse Pós-Traumáticos/genética , Ubiquitina-Proteína Ligases/genética , Grupo com Ancestrais do Continente Africano/genética , Conjuntos de Dados como Assunto , Grupo com Ancestrais do Continente Europeu/genética , Feminino , Estudo de Associação Genômica Ampla , Humanos , Masculino , Fatores Sexuais , Veteranos/estatística & dados numéricos
11.
J Surg Res ; 243: 539-552, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31377495

RESUMO

BACKGROUND: Frailty predicts poor outcome after vascular surgery. We determined the predictive utility of the modified frailty index (mFI) after first-time revascularization and identified biomarkers of frailty predictive of outcome in veterans with peripheral arterial disease. METHODS: A retrospective study was performed of first-time revascularizations (open surgery [OS] and endovascular surgery [ES]) in male veterans (2003-2016). Preoperative mFI scores were calculated, and serum and nonserum biomarkers of frailty were recorded. The primary endpoint was 2-y incidence of reintervention, amputation, and mortality. Secondary endpoints included 30-day morbidity and readmissions. RESULTS: Four hundred and thirty one patients (OS, n = 188; ES, n = 243), mean age of 66 ± 9 y, and 16 mo of median follow-up were studied. Mean mFI was 0.39 ± 0.16 for OS and 0.38 ± 0.15 for ES (P = 0.43). 30-day complications (adjusted odds ratio, 4.89; 95% confidence interval [CI]: 1.67-14.33) and readmissions (adjusted hazard ratio [aHR] 3.32; 95% CI: 1.16-9.55) were increased in the OS versus ES group when stratified by mFI. Survival analysis showed a correlation between risk of amputation, death, and composite outcome with increasing mFI (P < 0.005) in both groups. Frailty independently predicted major amputation (aHR 2.16; 1.06-4.39), mortality (aHR 2.62; 95% CI: 1.17-5.88), and composite outcome (aHR 1.97; 95% CI: 1.06-3.68) when the groups are combined. Except for absolute neutrophil count, all preoperative lab values correlated with mFI (P < 0.5). Higher albumin was independently associated with lower risk of amputation (aHR: 0.58 [0.36-0.94]) and mortality (aHR: 0.45 [0.25-0.83]); higher hemoglobin predicted limb salvage (aHR 0.7 [0.62-0.84]). CONCLUSIONS: Frailty predicts short- and long-term outcomes after first-time revascularization in veterans. Hypoalbuminemia and anemia are associated with higher mFI and independently predict poor outcome, suggesting albumin and hemoglobin are viable biomarkers of frailty in veterans.


Assuntos
Procedimentos Endovasculares/mortalidade , Fragilidade/complicações , Doença Arterial Periférica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Idoso , Biomarcadores/sangue , Fragilidade/sangue , Humanos , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Doença Arterial Periférica/complicações , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Veteranos/estatística & dados numéricos
12.
Sleep Health ; 5(5): 495-500, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31416799

RESUMO

OBJECTIVES: Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use. DESIGN AND SETTING: National cross-sectional population-based residential mail survey on sleep and other symptoms. PARTICIPANTS: Random sample of women veteran VA users who completed a postal survey (N = 1533). INTERVENTIONS: None. MEASUREMENTS: The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month. RESULTS: A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11). CONCLUSIONS: Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.


Assuntos
Consumo de Bebidas Alcoólicas/epidemiologia , Consumo de Bebidas Alcoólicas/psicologia , Medicamentos Indutores do Sono/uso terapêutico , Veteranos/psicologia , Adulto , Estudos Transversais , Feminino , Humanos , Pessoa de Meia-Idade , Assunção de Riscos , Distúrbios do Início e da Manutenção do Sono/psicologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Inquéritos e Questionários , Veteranos/estatística & dados numéricos
13.
Behav Ther ; 50(5): 910-923, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31422847

RESUMO

While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.


Assuntos
Depressão/complicações , Distúrbios do Início e da Manutenção do Sono/complicações , Transtornos do Sono-Vigília/complicações , Transtornos de Estresse Pós-Traumáticos/complicações , Veteranos/psicologia , Adulto , Idoso , Depressão/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Distúrbios do Início e da Manutenção do Sono/psicologia , Transtornos do Sono-Vigília/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/estatística & dados numéricos , Adulto Jovem
14.
Am J Public Health ; 109(9): 1233-1235, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31318586

RESUMO

Objectives. To evaluate the effect of the Affordable Care Act (ACA) on US veterans' access to care.Methods. We used US Behavioral Risk Factor Surveillance System data to compare measures of veterans' coverage and access to care, including primary care, for 3-year periods before (2011-2013) and after (2015-2017) ACA coverage provisions went into effect. We used difference-in-differences analyses to compare changes in Medicaid expansion states with those in nonexpansion states.Results. Coverage increased and fewer delays in care were reported in both expansion and nonexpansion states after 2014, with larger effects among low socioeconomic status (SES) and poor health subgroups. Coverage increases were significantly larger in expansion states than in nonexpansion states. Reports of cost-related delays, no usual source of care, and no checkup within 12 months generally improved in expansion states relative to nonexpansion states, but improvements were small; changes were mixed among veterans with low SES or poor health.Conclusions. Increases in insurance coverage among nonelderly veterans after ACA coverage expansions did not consistently translate into improved access to care. Additional study is needed to understand persisting challenges in veterans' access to care.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Sistema de Vigilância de Fator de Risco Comportamental , Humanos , Pessoa de Meia-Idade , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
15.
Health Serv Res ; 54(6): 1346-1356, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31328798

RESUMO

OBJECTIVE: To compare the costs of Community Nursing Homes (CNHs) to Medical Foster Homes (MFHs) at Veteran Health Administration (VHA) Medical Centers that established MFH programs. DATA SOURCES: Episode and costs data were derived from VA and Medicare files (inpatient, outpatient, emergency room, skilled nursing facility, dialysis, and hospice). STUDY DESIGN: Propensity scores matched 354 MFH to 1693 CNH Veterans on demographics, clinical characteristics, health care utilization, and costs. DATA EXTRACTION METHODS: Data were retrieved for years 2010-2011 from the VA Corporate Data Warehouse, VA Health Data Repository, and the VA MFH Program through the VA Informatics and Computing Infrastructure (VINCI). PRINCIPAL FINDINGS: After matching on unique characteristics of MFH Veterans, costs were $71.28 less per day alive compared to CNH care. Home-based and mental health care costs increased with savings largely attributable to avoiding CNH residential care. When average out-of-pocket payments by Veterans of $74/day are considered, MFH is at least cost neutral. Mortality was 12 percent higher among matched Veterans in CNHs. CONCLUSIONS: MFHs may serve as alternatives to traditional CNH care that do not increase total costs with mortality benefits. Future work should examine the differences for functional disability subgroups.


Assuntos
Cuidados no Lar de Adoção/economia , Cuidados no Lar de Adoção/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Medicare/economia , Medicare/estatística & dados numéricos , Casas de Saúde/economia , Casas de Saúde/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , United States Department of Veterans Affairs/economia , United States Department of Veterans Affairs/estatística & dados numéricos , Veteranos/estatística & dados numéricos
16.
J Altern Complement Med ; 25(9): 902-909, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31328956

RESUMO

Objectives: The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders. Design: Retrospective chart review. Settings: Veterans Administration Medical Center (VAMC). Subjects: Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%). Intervention: Eight-week MBCT class. Outcome measures: Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations. Results: The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535). Conclusions: MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.


Assuntos
Terapia Cognitivo-Comportamental , Transtornos Mentais/terapia , Atenção Plena , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Adulto , Terapia Cognitivo-Comportamental/métodos , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Feminino , Humanos , Masculino , Meditação , Pessoa de Meia-Idade , Atenção Plena/métodos , Atenção Plena/estatística & dados numéricos , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/terapia , Resultado do Tratamento , Adulto Jovem
18.
J Opioid Manag ; 15(3): 183-191, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31343720

RESUMO

OBJECTIVE: To characterize primary care physicians' (PCPs') perceptions of the reasons patients receive opioid medications from both VA and non-VA healthcare systems. DESIGN: Qualitative. SETTING: Department of Veterans Affairs (VA). PARTICIPANTS: Forty-two VA PCPs who prescribed opioids to at least 15 patients and who practiced in Massachusetts, Illinois, or Pennsylvania. METHODS: Thirty-minute, semistructured telephone interviews were conducted in 2016, addressing topics regarding PCPs' experiences and perspectives on patients who use both VA and non-VA healthcare systems to obtain prescription opioids. The analysis focused on two questions: attributes that PCPs believe characterize dual-use patients and reasons that PCPs believe patients obtain opioids from both VA and non-VA sources. RESULTS: PCPs identified multiple attributes of, and reasons for, patients obtaining opioid medications from both VA and non-VA healthcare systems, including pain issues, opioid misuse, having healthcare managed through multiple healthcare systems, and transferring care between systems. More than half of the PCPs identified addiction and diversion as key attributes and reasons why patients obtain prescription opioids from multiple sources. PCPs also identified several behavioral and psychological factors as attributes of these patients. CONCLUSIONS: PCPs within the VA have varying perceptions of patients obtaining opioid medications from multiple healthcare systems, with pain complaints and opioid misuse as the primary themes. This knowledge about PCPs' perceptions can be incorporated into interventions to better manage pain and prescription opioid use by VA patients.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides , Médicos de Atenção Primária/psicologia , Veteranos , Humanos , Massachusetts , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Percepção , Veteranos/estatística & dados numéricos
19.
Health Phys ; 117(6): 625-636, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31283545

RESUMO

In 1966, about 1,600 US military men-mostly Air Force-participated in a cleanup of plutonium dispersed from two nuclear bombs in Palomares, Spain. As a base for future analyses, we provide a history of the Palomares incident, including the dosimetry and risk analyses carried out to date and the compensation assessments made for veterans. By law, compensation for illnesses attributed to ionizing radiation is based on maximum estimated doses and standard risk coefficients, with considerable benefit of the doubt given to claimants when there is uncertainty. In the Palomares case, alpha activity in urine fell far faster than predicted by plutonium biokinetic excretion models used at the time. Most of the measurements were taken on-site but were disqualified on the grounds that they were "unreasonably high" and because there was a possibility of environmental contamination. Until the end of 2013, the Air Force used low dose estimates derived from environmental measurements carried out well after the cleanup. After these estimates were questioned by Congress, the Air Force adopted higher dose estimates based on plutonium concentration measurements in urine samples collected from 26 veterans after they left Palomares. The Air Force assumed that all other cleanup veterans received lower doses and therefore assigned to them maximum organ doses based on the individual among the 26 with the lowest urine measurements. These resulting maximum organ doses appear to be sufficient to justify compensation to all Palomares veterans with lung and bone cancer and early-onset liver cancer and leukemia but not other radiogenic cancers.


Assuntos
Neoplasias Induzidas por Radiação/etiologia , Doenças Profissionais/etiologia , Exposição Ocupacional/análise , Plutônio/análise , Exposição à Radiação/análise , Cinza Radioativa/análise , Indenização aos Trabalhadores/economia , Humanos , Neoplasias Induzidas por Radiação/economia , Doenças Profissionais/economia , Exposição Ocupacional/efeitos adversos , Plutônio/envenenamento , Doses de Radiação , Exposição à Radiação/efeitos adversos , Cinza Radioativa/efeitos adversos , Liberação Nociva de Radioativos , Radiometria , Medição de Risco/métodos , Espanha , Estados Unidos , Veteranos/estatística & dados numéricos , Indenização aos Trabalhadores/normas
20.
Int J Occup Med Environ Health ; 32(4): 503­526, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31309787

RESUMO

Objectives: Veterans of the 1991 Gulf War (GW) were exposed to a myriad of potentially hazardous chemicals during deployment. Epidemiological data suggest a possible link between chemical exposures and Parkinson's disease (PD); however, there have been no reliable data on the incidence or prevalence of PD among GW veterans to date. This study included the following 2 questions: 1. Do deployed GW veterans display PD-like symptoms? and 2. Is there a relationship between the occurrence and quantity of PD-like symptoms, and the levels of deployment-related exposures in GW veterans? Material and Methods: Self-reports of symptoms and exposures to deployment-related chemicals were filled out by 293 GW veterans, 202 of whom had undergone 3 Tesla volumetric measurements of basal ganglia volumes. Correlation analyses were used to examine the relationship between the frequency of the veterans' self-reported exposures to deployment-related chemicals, motor and non-motor symptoms of PD, and the total basal ganglia volumes. Results: Healthy deployed GW veterans self-reported few PD-like non-motor symptoms and no motor symptoms. In contrast, GW veterans with Gulf War illness (GWI) self-reported more PD-like motor and non-motor symptoms, and more GW-related exposures. Compared to healthy deployed veterans, those with GWI also had lower total basal ganglia volumes. Conclusions: Although little is known about the long-term consequences of GWI, findings from this study suggest that veterans with GWI show more symptoms as those seen in PD/prodromal PD, compared to healthy deployed GW veterans. Int J Occup Med Environ Health. 2019;32(4):503­26


Assuntos
Guerra do Golfo , Exposição Ocupacional/efeitos adversos , Doença de Parkinson/epidemiologia , Veteranos/estatística & dados numéricos , Gânglios da Base/diagnóstico por imagem , Disfunção Cognitiva/epidemiologia , Feminino , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico por imagem , Síndrome do Golfo Pérsico/induzido quimicamente , Síndrome do Golfo Pérsico/epidemiologia , Praguicidas/efeitos adversos , Prevalência , Autorrelato , Tremor/epidemiologia
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