VA Eastern Kansas Health Care System

Serum concentration of hepatic enzymes are linked to liver dysfunction, metabolic and cardiovascular diseases. We perform genetic analysis on serum levels of alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) using data on 437,438 UK Biobank participants. Replication in 315,572 individuals from European descent from the Million Veteran Program, Rotterdam Study and Lifeline study confirms 517 liver enzyme SNPs. Genetic risk score analysis using the identified SNPs is strongly associated with serum activity of liver enzymes in two independent European descent studies (The Airwave Health Monitoring study and the Northern Finland Birth Cohort 1966). Gene-set enrichment analysis using the identified SNPs highlights involvement in liver development and function, lipid metabolism, insulin resistance, and vascular formation. Mendelian randomization analysis shows association of liver enzyme variants with coronary heart disease and ischemic stroke. Genetic risk score for elevated serum activity of liver enzymes is associated with higher fat percentage of body, trunk, and liver and body mass index. Our study highlights the role of molecular pathways regulated by the liver in metabolic disorders and cardiovascular disease.

Adults aged 55 to 80 years participated voluntarily in a wait-list control study during in-patient physical therapy following first stroke. All participants (N = 15) received conventional physical therapy gait training throughout 30 treatment sessions. Rhythmic auditory stimulation (RAS)-enhanced gait training was nested within conventional treatments in three conditions: (1) RAS throughout 30 treatments (N = 5); (2) RAS in the last 20 treatments (N = 5); and (3) RAS in the last 10 treatments (N = 5). Cadence and balance outcome measurements were taken at baseline, and following 10, 20, and 30 treatment sessions. Improvements across time were statistically significant in all conditions for one-limb stance, cadence, velocity, stride length, and posture head tilt with no statistically significant improvements for the Timed Up and Go Test and the Functional Reach Test. Statistically significant gains were made in the one-limb stance and cadence with earlier implementations of RAS. Results of the study demonstrate the feasibility of RAS to enhance gait training that warrants further investigation of the protocol to demonstrate the effects of RAS in stroke rehabilitation.

Financial support provided by the Craig H. Neilsen Foundation.© Copyright 2020, Paralyzed Veterans of AmericaThese guidelines have been prepared based on scientific and professional information ava...

BACKGROUND: There is evidence that low-level alcohol use, drinking 1 to 2 drinks on occasion, is protective for cardiovascular disease, but increases the risk of cancer. Synthesizing the overall impact of low-level alcohol use on health is therefore complex. The objective of this paper was to examine the association between frequency of low-level drinking and mortality. METHODS: Two data sets with self-reported alcohol use and mortality follow-up were analyzed: 340,668 individuals from the National Health Interview Survey (NHIS) and 93,653 individuals from the Veterans Health Administration (VA) outpatient medical records. Survival analyses were conducted to evaluate the association between low-level drinking frequency and mortality. RESULTS: The minimum risk drinking frequency among those who drink 1 to 2 drinks per occasion was found to be 3.2 times weekly in the NHIS data, based on a continuous measure of drinking frequency, and 2 to 3 times weekly in the VA data. Relative to these individuals with minimum risk, individuals who drink 7 times weekly had an adjusted hazard ratio (HR) of all-cause mortality of 1.23 (p < 0.0001) in the NHIS data, and individuals who drink 4 to 7 times weekly in the VA data also had an adjusted HR of 1.23 (p = 0.01). Secondary analyses in the NHIS data showed that the minimum risk was drinking 4 times weekly for cardiovascular mortality, and drinking monthly or less for cancer mortality. The associations were consistent in stratified analyses of men, women, and never smokers. CONCLUSIONS: The minimum risk of low-level drinking frequency for all-cause mortality appears to be approximately 3 occasions weekly. The robustness of this finding is highlighted in 2 distinctly different data sets: a large epidemiological data set and a data set of veterans sampled from an outpatient clinic. Daily drinking, even at low levels, is detrimental to one's health.

The Long Form and the Short Form of the Geriatric Depression Scale (GDS) were compared in a VA nursing home population. The study had two phases. In the first phase, 86 geriatric male veterans were administered the Long Form of the GDS at intake. The Long Form was rescored on the Short Form and a scatterplot was constructed. The Short Form of the GDS consistently identified 94% of the participants using the Long Form as the standard. In the second phase of the study, 31 veterans were administered both the Long Form and the Short Form of the GDS in alternating order during their intake or annual screening assessment. A scatterplot showed the Short Form to consistently identify 100% of the participants using the Long Form as the standard.

Objective: The aim of this study was to examine major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) diagnosed at age < 55 as predictors, and sex and race as potential moderators, of dementia and other forms of cognitive impairment. Method: Veterans ( N = 4,800) aged ⩾ 56 years were grouped by psychiatric history, sex, and race. Hierarchical and stepwise regression were employed to determine significant predictors. Results: MDD and PTSD were associated with almost double the risk for developing dementia or cognitive impairment at age ⩾ 56. Sex, as a moderator, had small effects whereas race increased the risk almost twofold for Black veterans, given the presence of MDD history. Discussion: MDD and PTSD act as significant risk factors for dementia and other forms of cognitive impairment, and Black veterans, given a history of MDD, may be at an increased risk. An important endeavor for future research is to examine how this risk may vary across dementia subtypes and related conditions.

STUDY OBJECTIVE: To compare the effectiveness of weight-management medications used to assist with weight loss in real-world clinical practice in the Veterans Health Administration (VHA). DESIGN: Retrospective, multicenter, observational cohort study. DATA SOURCE: National VA Corporate Data Warehouse. PATIENTS: or greater who had an initial fill for a study medication (orlistat [6153 patients], phentermine [304 patients], lorcaserin [298 patients], or phentermine-topiramate extended release [233 patients]) or participation in the VA's MOVE! weight-management program with at least three total visits in a clinic coded as a MOVE clinic in the subsequent 24 weeks (59,047 patients) between January 1, 2012, and July 1, 2016. MEASUREMENTS AND MAIN RESULTS: , high-density and low-density lipoprotein cholesterol and triglyceride levels; and percentage of patients who achieved at least a 5% and 10% weight loss at 6 months from baseline in each group after at least 20 weeks. For the primary outcome, the percentage decrease in weight from baseline after at least 20 weeks in the lorcaserin, phentermine-topiramate, phentermine, orlistat, and MOVE! groups were 3.6%, 4.1%, 3.6%, 2.1%, and 1.6%, respectively (phentermine-topiramate group vs. MOVE! group, p<0.05). Achievement of at least a 5% weight loss after at least 20 weeks differed significantly among groups, ranging from 26.2% for the MOVE! Program only group to 40.3% for patients in the phentermine-topiramate group. CONCLUSION: In the VA population, the effectiveness of four available weight-management medications was similar. Patients receiving phentermine-topiramate had a greater proportion of weight loss after at least 20 weeks compared with those solely enrolled in the VA's MOVE! weight-management program.

The purpose of this investigation is to provide descriptive information on veteran response styles for a variety of VA referral types using the Minnesota Multiphasic Personality Inventory (MMPI)-2-Restructured Form (MMPI-2-RF), which has well-supported protocol validity scales. The sample included 17,640 veterans who were administered the MMPI-2-RF between when it was introduced to the VA system in 2013 until May 31, 2015 at any VA in the United States. This study examines frequencies of protocol invalidity based on the MMPI-2-RF's validity scales and provides comprehensive descriptive findings on validity scale scores within the VA. Three distinct trends can be seen. First, a majority of the sample did not elevate any of the validity scales beyond their recommended interpretive cut-scores, indicating that scores on the substantive scales would be deemed valid and interpretable in those cases. Second, elevation rates are higher for the overreporting scales in comparison to the underreporting and non-content-based invalid responding scales. Lastly, a majority of those with an elevation on one overreporting validity indicator also had an elevation on at least one other overreporting scale. Implications for practice and the utility of the MMPI-2-RF within the VA are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

This special issue highlights new research in psychological assessment and measurement-based care. Psychological assessment has historically been central to the field of psychology. Measurement-based care, considered an evidence-based practice, is a special type of applied psychological assessment in which patient-reported outcome measures are used to track progress in care as part of a clinical process. We discuss how the knowledge from these two distinct but related fields can synergistically advance mental health treatment. The articles in this special issue demonstrate ways to practically implement measurement-based care, the application of measurement-based care in special populations, as well as feature advances in psychological assessment that support the practice of measurement-based care. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The authors investigated counselor trainees' levels of cognitive complexity and sociopolitical advocacy as predictors of universal‐diverse orientation (UDO). Participants included 120 master's‐ and doctoral‐level trainees from 4 midwestern counseling psychology programs. Results revealed that, after accounting for multicultural social desirability and training experience, actual time spent engaging in sociopolitical advocacy activities uniquely predicted 1 subscale of UDO. Los autores investigaron los niveles de complejidad cognitiva y defensoría sociopolítica de los consejeros en formación como indicadores de predicción de su orientación universal‐diversa (UDO, por sus siglas en inglés). Entre los participantes había 120 estudiantes de maestríay doctorado de 4 programas de psicología clínica en el Medio Oeste de EE.UU. Los resultados revelaron que, después de tomar en cuenta el atractivo social multicultural y la experiencia en formación, el tiempo real dedicado a la participación en actividades de defensoría sociopolítica solo predijo 1 sub‐escala de UDO.

AIMS: This study used a person-centered approach to test whether drinking motive typologies could be identified. DESIGN: Longitudinal study of college students within the intensive multivariate prospective alcohol college-transitions (IMPACTS) data set. SETTING: University campus in the United States. PARTICIPANTS: University students (baseline n reporting alcohol motives = 2158; baseline age = 18.60 years old). MEASUREMENTS: The drinking motives questionnaire-revised (DMQ-R). FINDINGS: Using Steinley & Brusco's cluster analysis approach [based on the theoretical ratio expected between the within sum of squares and the total sum of squares when the data are divided into two clusters when no cluster structure is present; the cut-off for the ratio is 0.25 for uniform (multivariate uniform) distributions and 0.36 for normal (multivariate normal) distributions], we examined whether there was evidence for distinct clusters of individuals that differed on their overall level of motives to drink. We tested the fit of a one-group (cluster) solution compared to multi-cluster solutions. Both cross-sectionally and prospectively, the data could not be partitioned into two or more clusters [regardless of whether the cut-off assuming a multivariate uniform distribution (i.e. 0.25) or the more liberal multivariate normal distribution (i.e., 0.36) was used]. These findings showed that enhancement and coping drinkers do not form two distinct groups but, rather, these motives exist on a continuum such that individuals who are high in one internal motive tend to be high in the other motive. CONCLUSIONS: Coping and enhancement drinkers do not form two distinct groups. Variable-centered approaches to drinking motives may be a better alternative to classifying all drinkers as either enhancement or coping drinkers for both clinical and research endeavors.

The present study assessed the relationship between numbing and three associated conditions of alexithymia, apathy, and depression, utilizing data collected on 353 Vietnam combat veterans diagnosed with Posttraumatic Stress Disorder from in- and out-patient settings and an outreach center at various Department of Veterans Affairs Medical centers. All subjects completed four self-report measures: the Glover Numbing Scale, the Beck Depression Inventory, the Apathy Evaluation Scale, and the Toronto Alexithymia Scale-20. The correlation matrix indicated that scores on the four measures were moderately to highly correlated. Principal components analysis with a varimax rotation indicated a five-factor solution that provided evidence for the factorial validity of each of the constructs assessed. Results of the factor analysis of items from the four measures were consistent with numbing being a separate and distinct construct from alexithymia, apathy, and depression. In general, results indicated that all constructs measured were separate and distinct from one another.

This report describes a case of burn injury following exposure to sulfur mustard, a chemical agent used in war. A review of the diagnostic characteristics, clinical manifestations, and therapeutic measures used to treat this uncommon, yet extremely toxic, entity is presented. The aim of this report is to highlight the importance of considering this diagnosis in any war victim, especially during these unfortunate times of rising terrorist activities.

BACKGROUND: Minimal information exists concerning the use and liability of electronic medical record (EMR) metadata. STUDY DESIGN: We performed a retrospective review of Vista Imaging (VI) metadata concerning when and which images residents and medical students on a surgery service actually visualized; and the laws governing e-discovery were reviewed. RESULTS: During a 5-month period, PGY III surgery residents logged in to VI 191+/-18.3 times; PGY II surgery residents logged in 164+/-34.3 times; and PGY I surgery residents logged in 92.0+/-14.8 times. Family practice residents logged in 21.0+/-4.6 times, and medical students logged in 32.0+/-5.7 times (p < 0.01). Surgery residents logged about once a day (1.0+/-0.06 log-ins/day); family practice residents (0.2+/-0.2 log-ins/day) and medical students (0.3+/-0.1 log-ins/day) logged about only once a week. CT scans were the most frequently viewed image: surgery residents viewed CT scans during 81.9+/-14.9% of Vista Imaging sessions to view 69.3+/-36.5 images (range 1 to 863 images); family practice residents viewed CT scans during 58.0+/-43.8% of Vista Imaging sessions to view 19.3+/-22.8 images (range 1 to 112 images); and medical students viewed CT scans during 89.8+/-30.3% of Vista Imaging sessions to view 24.4+/-6.3 images (range 1 to 95 images). Changes in the Federal Rules of Civil Procedure and the need to authenticate electronic medical records will mean more metadata will be discovered during litigation. CONCLUSIONS: Electronic medical records metadata allow for creation of detailed physician profiles and will likely be used increasingly to discredit physicians during medical malpractice litigation.

We investigated the validity and screening effectiveness of the PHQ-2 and PHQ-9 scores in 229 college students in a cross-sectional design. PHQ associations with Minnesota Multiphasic Personality Inventory-3 internalizing scales suggest PHQ scores are effective screening tools for college students and may aid in effective triage and service needs.

PURPOSE: Patients with cirrhosis needing anticoagulation therapy have historically been prescribed warfarin. New retrospective research has concluded that in patients with cirrhosis direct oral anticoagulants (DOACs) have similar or lower bleeding rates compared with that of warfarin. This study compares the safety and efficacy of DOACs with that of warfarin in patients with cirrhosis. METHODS: A retrospective chart review was conducted in adult patients with cirrhosis taking either apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin. Exclusion criteria consisted of patients prescribed triple antithrombotic therapy (dual antiplatelet therapy plus an anticoagulant) and indications other than nonvalvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). The primary endpoint was all-cause bleeding, and the secondary endpoints were failed efficacy and major bleeding as defined by the International Society on Thrombosis and Haemostasis in 2005. Failed efficacy was a combination endpoint including the development of VTE, stroke, myocardial infarction and/or death. Patient data were collected from the Computerized Patient Record System from October 31, 2014 to October 31, 2018. RESULTS: = .9). Subgroup analysis of allcause bleeding did not identify any significant trends between groups. CONCLUSIONS: There were no statistically significant differences identified between the rates of all-cause bleeding, major bleeding, and failed efficacy between the DOACs and warfarin groups. DOACs may be a safe alternative to warfarin in patients with cirrhosis requiring anticoagulation for NVAF or VTE, but large randomized trials are required to confirm these results.

Litigation after cybersurgery, i.e. remote robotic surgery, will be complex. In addition to being able to sue physicians and hospitals, patients who sustain an adverse outcome after cybersurgery will have the potential to sue the robotic manufacturer and the telecommunications company. Moreover, cybersurgery litigation will involve laws that are generally unfamiliar to healthcare providers. Accordingly, this article examines a lawsuit involving a robotic surgical instrument as a model to suggest where liability traps may arise during the delivery of cybersurgery.

With almost 90% of Americans expressing a desire to age in place in their home, many health systems and communities are challenged to provide the right resources, at the right time, to support What Matters to older adults. In the Department of Veterans Affairs (VA), approximately 50% of Veterans enrolled in VA health care are aged 65 and older, driving an imperative to provide timely, Age-Friendly care through a broad continuum of services. VA has taken a multifaceted approach to shift Long-Term Services and Supports to promote aging in place through innovation pilots, expansion of Home and Community Based Services (HCBS) and adoption of Age-Friendly Health Systems (AFHS) practices [or "framework"]. VA is spreading geriatrics knowledge throughout the clinician and trainee workforce, improving skills and practices across all disciplines and care settings. The framework of AFHS creates a shared language to support transitions across ambulatory, hospital, emergency department, home care, and nursing home settings. Through these efforts, VA is reimagining geriatrics, providing an example of the type of care all older adults want and deserve. Since March 2020, 375 care settings across 132/139 (95%) VA parent facilities have earned AFHS recognition. By incorporating AFHS into the infrastructure of the healthcare system, clinicians are prepared to address What Matters across clinical settings and address common geriatric syndromes. Leaders in a variety of health systems can learn from VA efforts to provide a continuum of Age-Friendly programs and services that promote independence, function, well-being and aging in place.

The prevalence of experiencing sexual assault is alarmingly high among Transgender and Gender Diverse people (TGD; people whose gender identities and/or expressions are not traditionally associated with their sex assigned at birth) and is associated with various mental health sequalae. Perceived social support has been shown to abate the negative outcomes of sexual assault among cisgender individuals, yet little is known about this association among TGD people, especially which provider of support (i.e., family, friends, or significant others) may be most beneficial. To that end, 191 TGD adults were recruited through Amazon’s Mechanical Turk to examine perceived social support as a potential moderator of the association between sexual assault victimization and post-sexual assault trauma symptomology. Results showed an interaction trending toward significance between sexual assault and support from a significant other. Decomposition of this interaction demonstrated that sexual assault was associated with post-assault trauma symptoms when support from a significant other was low (ß = .25, p < .05) but not high (ß = .10, p = .089). The interaction between sexual assault and perceived social support was not significant for perceived support from friends ( p = .133) or family ( p = .954). Findings highlight the need for additional research on perceived social support as a potential buffering mechanism between sexual assault and post-assault symptomology in TGD people.

Introduction: This study examines the utility of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) validity scales to detect invalid responding within a sample of active duty United States Army soldiers referred for neuropsychological evaluations.Method: This study examines the relationship between performance validity testing and performance on the MMPI-2-RF over-reporting scales. Specifically, mean differences between those who passed (n = 152; 75.6%) or failed (n = 49; 24.4%) performance validity testing were compared. Receiver operator characteristic analyzes were also conducted to expand available information on the MMPI-2-RF over-reporting sensitivity and specificity in an Army sample.Results: This study has two distinct findings. First, effect size differences between those passing and failing performance validity testing are classified as small to medium in magnitude (ranging from d = . 30/g = .32 on F-r to d = .66/g = .73 on RBS). Second, over-reporting scales have higher specificity and poorer sensitivity. Likewise, performance of the over-reporting scales suggests that those who exceeding recommended cut scores are likely to have failed extra-test performance validity measures.Conclusion: These findings suggest that many who fail external performance measures may be undetected on the MMPI-2-RF over-reporting scales and that those exceeding recommended cut scores are likely to have failed extra-test performance validity testing. Implications for research on, and practice with, the MMPI-2-RF in military populations are discussed.