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Objective: Research addressing the associations between C‐reactive protein (CRP) and depression among patients with stable coronary heart disease (CHD) has produced inconsistent results. This might be attributable to varying associations of CRP with specific depression symptom profiles. We responded to this challenge using various network analysis techniques. Methods: A total of 967 outpatients with documented CHD were drawn from the baseline cross‐sectional data of the Heart and Soul Study. We first estimated mixed graphical models that included CRP and individual depression symptoms, before and after adjusting for relevant covariates, to explore whether CRP is correlated with specific facets of depression. We also investigated whether CRP levels moderated the associations between specific depression symptoms using moderated network models. Finally, we performed a network comparison test and compared the symptom network properties between non‐elevated and elevated CRP groups. Results: In the network model without covariates, CRP was positively associated with fatigue, appetite changes, and psychomotor problems. CRP maintained its negative association with concentration difficulty regardless of covariate adjustment. Few symptom‐symptom associations, especially those involving appetite changes, were moderated by CRP. Further, the elevated CRP group showed greater overall symptom connectivity as compared to the non‐elevated group. Conclusion: This study segues into CRP‐depression relationship with sophisticated methodology. [ABSTRACT FROM AUTHOR]

Background: Patients with chronic kidney disease (CKD) are at increased risk for heart failure (HF). We aimed to investigate differences in proteins associated with HF hospitalizations among patients with and without CKD in the Heart and Soul Study. Methods and results: We measured 1068 unique plasma proteins from baseline samples of 974 participants in The Heart and Soul Study who were followed for HF hospitalization over a median of 7 years. We sequentially applied forest regression and Cox survival analyses to select prognostic proteins. Among participants with CKD, four proteins were associated with HF at Bonferroni-level significance (p<2.5x10-4): Angiopoietin-2 (HR[95%CI] 1.45[1.33, 1.59]), Spondin-1 (HR[95%CI] 1.13 [1.06, 1.20]), tartrate-resistant acid phosphatase type 5 (HR[95%CI] 0.65[0.53, 0.78]) and neurogenis locus notch homolog protein 1 (NOTCH1) (HR[95%CI] 0.67[0.55, 0.80]). These associations persisted at p<0.01 after adjustment for age, estimated glomerular filtration and history of HF. CKD was a significant interaction term in the associations of NOTCH1 and Spondin-1 with HF. Pathway analysis showed a trend for higher representation of the Cardiac Hypertrophy and Complement/Coagulation pathways among proteins prognostic of HF in the CKD sub-group. Conclusions: These results suggest that markers of heart failure differ between patients with and without CKD. Further research is needed to validate novel markers in cohorts of patients with CKD and adjudicated HF events. [ABSTRACT FROM AUTHOR]

Veterans with PTSD or depression are at increased risk for suicidal ideation. However, few studies have examined that risk in those with comorbid PTSD and depression, instead focusing on these disorders individually. This study investigates the association of suicidal ideation with comorbid PTSD and depression and examines the role of military and psychosocial covariates. We evaluated 746 veterans using the CAPS to assess PTSD and the PHQ-9 to measure depression and suicidal ideation. Covariates were assessed via validated self-report measures. 49% of veterans with comorbid PTSD and depression endorsed suicidal ideation, making them more likely to do so than those with depression alone (34%), PTSD alone (11%), or neither (2%). In multivariate logistic regression models, this association remained significant after controlling for demographics and symptom severity. Anger, hostility, anxiety, alcohol use, optimism and social support did not explain the elevated risk of suicidal ideation in the comorbid group in fully adjusted models. As suicidal ideation is a known risk factor for suicide attempts and completions, veterans with comorbid PTSD and depression represent a vulnerable group who may need more intensive monitoring and treatment to reduce risk of suicide. [ABSTRACT FROM AUTHOR]

Summary Posttraumatic stress disorder (PTSD) is associated with an increased risk of cardiovascular disease and several other chronic illnesses. Alterations in the sympathetic nervous system (SNS) and the hypothalamic–pituitary–adrenal (HPA) axis in PTSD might contribute to these associations but findings regarding SNS and HPA activity in PTSD are heterogeneous. We measured 24-h urinary catecholamines and cortisol in a large cohort of adult outpatients recruited from 2 Veterans Affairs medical centers. 24-h urinary norepinephrine, epinephrine, dopamine and cortisol were measured by tandem mass spectrometry. Lifetime and current PTSD were assessed with the Clinician Administered PTSD Scale using DSM-IV-TR criteria. Out of 613 participants, 199 (32.5%) had current PTSD, 100 (16.3%) had lifetime but not current PTSD, and 314 (51.2%) never had PTSD. Patients with current PTSD had significantly higher norepinephrine secretion compared to those without PTSD. Patients in the lifetime PTSD group exhibited lower cortisol values compared to those without PTSD. Participants who never had PTSD showed the lowest norepinephrine and the highest cortisol values. All results remained stable when controlling for potentially confounding variables. This study provides evidence for increased norepinephrine secretion and decreased cortisol in PTSD. Future longitudinal studies are needed to determine whether these changes contribute to adverse health outcomes in patients with PTSD. [ABSTRACT FROM AUTHOR]

Higher levels of physical activity are associated with lower rates of coronary heart disease (CHD). Previous studies have suggested that this is due partly to lower levels of inflammation and insulin resistance. The aim of this study was to determine whether physical activity level was associated with inflammation or insulin resistance during a 5-year period in outpatients with known CHD. A total of 656 participants from the Heart and Soul Study, a prospective cohort study of outpatients with documented CHD, were evaluated. Self-reported physical activity frequency was assessed at baseline and after 5 years of follow-up. Participants were classified as low versus high activity at each visit, yielding 4 physical activity groups: stable low activity, decreasing activity (high at baseline to low at year 5), increasing activity (low at baseline to high at year 5), and stable high activity. Year 5 markers of inflammation (C-reactive protein [CRP], interleukin-6, and fibrinogen) and insulin resistance (insulin, glucose, and glycated hemoglobin) were compared across the 4 activity groups. After 5 years of follow-up, higher activity was associated with lower mean levels of all biomarkers. In the fully adjusted regression models, CRP, interleukin-6, and glucose remained independently associated with physical activity frequency (log CRP, p for trend across activity groups = 0.03; log interleukin-6, p for trend = 0.01; log glucose, p for trend = 0.003). Subjects with stable high activity typically had the lowest levels of biomarkers. In conclusion, in this novel population of outpatients with known CHD followed for 5 years, higher physical activity frequency was independently associated with lower levels of CRP, interleukin-6, and glucose. [ABSTRACT FROM AUTHOR]

A growing body of evidence supports an association between vitamin D and cardiovascular disease. However, the mechanisms underlying this association are unknown. From 2000 to 2002, we identified 946 participants with stable cardiovascular disease in San Francisco, California, and followed them prospectively for cardiovascular events (heart failure, myocardial infarction, stroke, or cardiovascular death). We then examined the extent to which the association was attenuated by adjustment for poor health behaviors, comorbid health conditions, and potential biological mediators. During a median follow-up period of 8.0 years (through August 24, 2012), 323 subjects (34.1%) experienced a cardiovascular event. Following adjustment for sociodemographic factors, season of blood measurement, health behaviors, and comorbid conditions, 25-hydroxyvitamin D levels under 20 ng/mL remained independently associated with cardiovascular events (hazard ratio = 1.30, 95% confidence interval: 1.01, 1.67). However, after further adjustment for potential biological mediators, the independent association was no longer present (hazard ratio = 1.11, 95% confidence interval: 0.85, 1.44). Parathyroid hormone, a potentially modifiable biological factor downstream from 25-hydroxyvitamin D, was responsible for the majority of this attenuation. These findings highlight the need for randomized controlled trials to determine whether vitamin D supplementation in persons with deficiency could be beneficial for the primary or secondary prevention of cardiovascular events. [ABSTRACT FROM PUBLISHER]

The article discusses the diagnosis and treatment of depression using the case of a 52-year-old man with depressive symptoms and comorbid medical conditions. A first-person description is presented by the patient regarding his emotions and his certainty that he was suffering from really severe depression. Evidence concerning appropriate depression diagnosis and screening is considered. The importance of patient self-management, team-based care and pharmacotherapy is also addressed.

Objectives: The purpose of this research was to evaluate the relationship between cognitive and somatic depressive symptoms and cardiovascular prognosis. Background: Depression in patients with stable coronary heart disease (CHD) is associated with poor cardiac prognosis. Whether certain depressive symptoms are more cardiotoxic than others is unknown. Methods: In the Heart and Soul Study, 1,019 patients with stable CHD were assessed using the Patient Health Questionnaire to determine the presence of the 9 depressive symptoms included in the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition. The mean age of the patients was 67 years, and 82% were men. A comparison was made on a new cardiovascular event (myocardial infarction, stroke, transient ischemic attack, or congestive heart failure) or death (mean follow-up duration 6.1 ± 2.0 years) on the basis of cognitive and somatic sum scores and for patients with or without each of those specific depressive symptoms. Demographic characteristics, cardiac risk factors, and cardiac medications were controlled for. Results: After adjustment for demographic data and cardiac risk factors, each somatic symptom was associated with 14% greater risk for events (hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.05 to 1.24; p = 0.002). Fatigue (HR: 1.34; 95% CI: 1.07 to 1.67; p = 0.01), appetite problems (HR: 1.46; 95% CI: 1.12 to 1.91; p = 0.005), and sleeping difficulties (HR: 1.26; 95% CI: 1.00 to 1.58; p = 0.05) were most strongly predictive of cardiovascular events. In contrast, cognitive symptoms (HR: 1.08; 95% CI: 0.99 to 1.17; p = 0.09) were not significantly associated with cardiovascular events. Conclusions: In patients with stable CHD, somatic symptoms of depression were more strongly predictive of cardiovascular events than cognitive symptoms, although the CIs surrounding these estimates had substantial overlap. These findings are highly consistent with those of previous studies. Further research is needed to understand the pathophysiological processes by which somatic depressive symptoms contribute to prognosis in patients with CHD. [Copyright &y& Elsevier]

The article presents a prospective cohort study designed to determine why depressive symptoms are associated with an increased risk of cardiovascular events. Potential biological and behavioral mediators were investigated. Smoking and alcohol use, medication adherence, and physical activity were assessed. Participants were followed up for reports on hospitalization for heart trouble. Outcome events included heart failure, stroke, myocardial infarction, transient ischemic attack, or death. Researchers found that behavioral factors, especially inactivity, accounted for the association between depressive symptoms and adverse cardiovascular events.

Background: Depression and inflammation independently predict adverse cardiovascular outcomes in patients with coronary heart disease (CHD). Depression has been associated with elevated levels of inflammation in otherwise healthy patients without known CHD. However, studies investigating the link between depression and inflammation in patients with established CHD have produced inconclusive results. Methods: We sought to examine the association of major depression with inflammation in 984 outpatients with established CHD from the Heart and Soul Study. We assessed current major depression with the Computerized Diagnostic Interview Schedule and collected venous blood samples for measurement of five inflammatory biomarkers (white blood cell count, CD40 ligand, C-reactive protein [CRP], fibrinogen, and interleukin-6 [IL-6]). We used multivariate analysis of variance to examine the association of current depression with inflammatory markers, adjusted for potential confounding variables. Results: Of the 984 participants, 217 (22%) had current major depression. Depression was not associated with increased levels of any inflammatory marker. Contrary to our hypothesis, depression was associated with lower levels of CRP (p = .09), fibrinogen (p = .006), and IL-6 (p = .007) in both unadjusted and adjusted models. Conclusions: We found no evidence that current depression is associated with greater inflammation in outpatients with CHD. Inflammation is unlikely to explain the adverse cardiovascular outcomes associated with depression in patients with established CHD. [Copyright &y& Elsevier]

Major depressive disorder is a risk factor for the development of incident coronary heart disease events in healthy patients and for adverse cardiovascular outcomes in patients with established heart disease. Depression is present in 1 of 5 outpatients with coronary heart disease and in 1 of 3 outpatients with congestive heart failure, yet the majority of cases are not recognized or appropriately treated. It is not known whether treating depression improves cardiovascular outcomes, but antidepressant treatment with selective serotonin reuptake inhibitors is generally safe, alleviates depression, and improves quality of life. This article evaluates the importance of major depression in patients with cardiovascular disease, and provides practical guidance for identifying and treating this disorder. [ABSTRACT FROM AUTHOR]

Background: The effect of mild chronic kidney disease (CKD) on depression, stress, quality of life (QOL), and health status is not well understood. We compared these outcomes in subjects with and without CKD. Methods: We performed a cross-sectional study of 967 outpatients enrolled in the Heart and Soul Study. CKD was defined as a measured creatinine clearance <60 ml/min. Outcome measures included depressive symptoms measured using the Patient Health Questionnaire (PHQ), stress measured using the Perceived Stress Scale (PSS), and QOL and overall health rated as excellent, very good, good, fair, or poor. Results: The prevalence of depressive symptoms (17 vs. 19%, p = 0.4) or perceived stress (11 vs. 16%, p = 0.09) did not vary significantly by CKD. The prevalence of fair or poor QOL was not significantly different in subjects with CKD, compared with those without CKD (24 vs. 23%, p = 0.65). Age-adjusted analyses revealed a significant association of CKD with QOL (p = 0.003), however, this association no longer reached statistical significance after adjustment for confounders (p = 0.06). Subjects with CKD were more likely to report poor or fair overall health than subjects without CKD (42 vs. 34%, p = 0.03). After multivariate adjustment, CKD remained significantly associated with worse overall health (OR = 1.65, 95% CI 1.21–2.24, p = 0.001), and modestly associated with QOL (OR = 1.31, 95% CI 0.99–1.75, p = 0.06), but had no association with depression (p = 0.48) or stress (p = 0.24). Conclusion: In this study of persons with coronary artery disease, subjects with CKD had reduced overall health and modestly reduced QOL; however, mental health was similar in those with and without CKD. These findings suggest that self- assessed overall health may decline at earlier stages of renal dysfunction than mental health outcomes or QOL. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Most studies examining the relation between depression and bone mineral density (BMD) have been limited to psychiatric patients or to community-dwelling, older women. We conducted a cross-sectional and prospective cohort study to determine whether depressive symptoms are associated with low BMD in community-dwelling, older men. We recruited 515 men 50 years of age or older from population-based listings of age-eligible men. Participants completed the Geriatric Depression Scale (short form) and were considered depressed if they scored 6 or more out of 15 possible points. BMD was measured in the spine and hip using dual energy x-ray absorptiometry in all participants, and again an average of 3.6 years later in a random subset of 100 participants. The prevalence of depressive symptoms (GDS = 6) was 3.1% (16 of 515). We found no difference in mean BMD or mean percent change in BMD per year of the hip and lumbar spine in men who had 6 or more depressive symptoms compared with men who reported 5 or fewer symptoms of depression. These findings suggest that depressive symptoms are not associated with BMD in community-dwelling, older men. [ABSTRACT FROM AUTHOR]

Background: Previous studies have suggested an association between depression and low socioeconomic status, but few have empirically examined the effect of depressive symptoms on income and employment over time. Objective: To determine whether depressive symptoms are associated with subsequent unemployment or loss of family income. Methods: We performed a prospective cohort study of 5115 adults aged 18 to 30 years. These participants included approximately equal numbers of African Americans and whites and men and women from 4 cities in the United States who completed the 1990-1991 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study. For this analysis, we included 2334 participants who were employed full or part time and who reported an annual family income of $25 000 or more. Participants completed the Center for Epidemiologic Studies Depression Scale and were considered to have depressive symptoms if they scored 16 or higher on the 60-point scale. We evaluated self-reported unemployment and annual family income during 5 years of follow-up. Results: Thirty-three percent (118/354) of participants with depressive symptoms (Center for Epidemiologic Studies Depression Scale score ≥16) in 1990-1991 and 21% (335/1581) of participants without substantial depressive symptoms (Center for Epidemiologic Studies Depression Scale score <16) reported new unemployment during the subsequent 5 years (odds ratio, 1.9; 95% confidence interval, 1.4-2.4; P<.001). This association remained strong after adjusting for potential confounding variables, including marital status, education, history of unemployment, current part-time (vs full-time) employment, and cigarette smoking (odds ratio, 1.6; 95% confidence interval, 1.2-2.0; P = .001). Seventeen percent (62/371) of participants with depressive symptoms and 7% (113/1631) of participants without substantial depressive symptoms in 1990-1991 reported that their family income had decreased below $25... [ABSTRACT FROM AUTHOR]

Background: Results of previous studies have suggested that involvement in religious activities may be associated with lower rates of smoking. We sought to determine whether frequent attendance at religious services is associated with less smoking among young adults. Methods: This prospective cohort study of 4569 adults aged 20 to 32 years included approximately equal numbers of blacks and whites and men and women from 4 cities in the United States who attended the 1987/1988 examination of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Frequency of attendance at religious services and denominational affiliation were determined by self-report questionnaire in 1987/ 1988. Cigarette smoking was determined by interview at this time and again 3 years later. Results: Of 4544 participants who completed the tobacco questionnaire in 1987/1988, 34% (891/2598) who attended religious services less than once per month or never and 23% (451/1946) who attended religious services at least once per month reported current smoking (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.52.0; P <.001). This association between less frequent attendance at religious services and current smoking was found in most denominations and remained significant after adjusting for potential confounding variables (OR, 1.5; 95% CI, 1.3-1.8; P<.001). During 3-year followup, nonsmokers who reported little or no religious involvement had an increased risk of smoking initiation (adjusted OR, 1.9; 95% CI, 1.3-2.7; P<.001). Conclusions: Young adults who attend religious services have lower rates of current and subsequent cigarette smoking. The potential health benefits associated with religious involvement deserve further study. [ABSTRACT FROM AUTHOR]

Background: Evidence regarding the effect of postmenopausal estrogen therapy on mood is limited.Methods: To determine whether postmenopausal estrogen therapy is associated with fewer depressive symptoms in elderly women, we conducted a cross-sectional study of 6, 602 white women ages 71 years or older who were recruited from population-based listings in Baltimore, Md; Minneapolis, Minn; Portland, Ore; and the Monongahela Valley, Pa. Use of estrogen and progestin was determined by interview. Participants completed the Geriatric Depression Scale short form (GDS) and were considered depressed if they reported 6 or more of 15 possible symptoms of depression.Results: A total of 6.3% (72/1,150) of current estrogen users, 7.2% (142/1,964) of past estrogen users, and 9.0% (313/3,488) of never users reported 6 or more symptoms of depression (P =.004). Current estrogen users had a decreased risk of reporting 6 or more depressive symptoms, compared with not current (past or never) users of estrogen (odds ratio [OR], 0.7; 95% CI, 0.5 to 0.9; P =.01], adjusted for living alone, bilateral oophorectomy, current smoking, physical activity, social network, self-perceived health, cognitive function, functional status, and antidepressant use. However, excluding women who use estrogen or progestin alone, we were unable to find an association between current use of combined estrogen plus progestin therapy and depressive symptoms (adjusted OR, 0.8; 95% CI, 0.5 to 1.4; P =.5).Conclusions: This cross-sectional study found that current use of unopposed estrogen was associated with a decreased risk of depressive symptoms in older women. Additional studies are needed to understand the effect of combined estrogen and progestin therapy on the prevalence of depressive symptoms in older women. [ABSTRACT FROM AUTHOR]

Objective: To determine the effect of case-finding for depression on frequency of depression diagnoses, prescriptions for antidepressant medications, prevalence of depression, and health care utilization during 2 years of follow-up in elderly primary care patients.Design: Randomized controlled trial.Setting: Thirteen primary care medical clinics at the Kaiser Permanente Medical Center, an HMO in Oakland, Calif, were randomly assigned to intervention conditions (7 clinics) or control conditions (6 clinics).Participants: A total of 2,346 patients aged 65 years or older who were attending appointments at these clinics and completed the 15-item Geriatric Depression Scale (GDS). GDS scores of 6 or more were considered suggestive of depression.Interventions: Primary care physicians in the intervention clinics were notified of their patients' GDS scores. We suggested that participants with severe depressive symptoms (GDS score >/= 11) be referred to the Psychiatry Department and participants with mild to moderate depressive symptoms (GDS score of 6 -10) be evaluated and treated by the primary care physician. Intervention group participants with GDS scores suggestive of depression were also offered a series of organized educational group sessions on coping with depression led by a psychiatric nurse. Primary care physicians in the control clinics were not notified of their patients' GDS scores or advised of the availability of the patient education program (usual care). Participants were followed for 2 years.Measurements and Main Results: Physician diagnosis of depression, prescriptions for antidepressant medications, prevalence of depression as measured by the GDS at 2-year follow-up, and health care utilization were determined. A total of 331 participants (14%) had GDS scores suggestive of depression (GDS >/= 6) at baseline, including 162 in the intervention group and 169 in the control group. During the 2-year follow-up period, 56 (35%) of the intervention participants and 58 (34%) of the control participants received a physician diagnosis of depression (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.6 to 1.6; P =.96). Prescriptions for antidepressants were received by 59 (36%) of the intervention participants and 72 (43%) of the control participants (OR, 0.8; 95% CI, 0.5 to 1.2; P =.3). Two-year follow-up GDS scores were available for 206 participants (69% of survivors): at that time, 41 (42%) of the 97 intervention participants and 54 (50%) of the 109 control participants had GDS scores suggestive of depression (OR, 0.7; 95% CI, 0.4 to 1.3; P =.3). Comparing participants in the intervention and control groups, there were no significant differences in mean GDS change scores (-2.4 +/- SD 3.7 vs -2.1 SD +/- 3.6; P =.5) at the 2-year follow-up, nor were there significant differences in mean number of clinic visits (1.8 +/- SD 3.1 vs 1.6 +/- SD 2.8; P =.5) or mean number of hospitalizations (1.1 +/- SD 1.6 vs 1.0 +/- SD 1.4; P =.8) during the 2-year period. In participants with initial GDS scores > 11, there was a mean change in GDS score of -5.6 +/- SD 3.9 for intervention participants (n = 13) and -3.4 +/- SD 4.5 for control participants (n = 21). Adjusting for differences in baseline characteristics between groups did not affect results.Conclusions: We were unable to demonstrate any benefit from case-finding for depression during 2 years of follow-up in elderly primary care patients. Studies are needed to determine whether case-finding combined with more intensive patient education and follow-up will improve outcomes of primary care patients with depression. [ABSTRACT FROM AUTHOR]

Reports on a prospective cohort study on the association of depression with falls, low bone density and risk of fracture, among elderly white women in the United States. Prevalence of depression; Bone mineral density; Risk for falling among depressed women; Occurrence of nonvertebral and vertebral fractures.

Presents the results of a study comparing the use of aspirin alone and with heparin in treating unstable angina and the risk of myocardial infarction and death. Evidence that most patients should be treated with a combination of heparin and aspirin; Information about ischemic pain and revascularization procedures; Findings of this meta-analysis of six randomized controlled trials.

Describes a study on the relationship between mortality and depressive symptoms in elderly women. Characteristics of the women in the study; Variation in mortality in women with no depressive symptoms; Factors attributed to causes of mortality; Details on the prevalence of depression; When mortality rates in women with and without depression diverged; In-depth look at the results of the study.

There is considerable controversy about whether patients with cardiovascular disease should be screened for depression. Depression is known to be associated with increased morbidity and mortality, but screening by itself does not improve either depression or cardiovascular outcomes. Nonetheless, depression deserves treatment regardless of its cardiovascular effects, and screening plus collaborative care is cost effective in primary care settings. Thus, patients with cardiovascular disease should receive routine screening for depression by primary care providers in the context of a collaborative care treatment program. [Copyright &y& Elsevier]

The article presents information on the causes of coronary heart disease (CHD). A research study conducted a few years earlier showed that typical heart disease patient is a keen and ambitious man. Time urgency and hostility are major causes CHD. Anger, anxiety and depression are some psychological factors that increase the risk of CHD with adverse outcomes among patients with established CHD. Psychological factors were stronger risk factors for incident myocardial infarction than diabetes, smoking, hypertension and obesity reveals a recent study of more than 25,000 patients from 52 countries.

Veteran access to sleep medicine is of paramount importance to the Veterans Health Administration (VA). To increase access, VA has created community referral policies and programs, as well as telehealth programs. In 2017, the Office of Rural Health (ORH) funded a TeleSleep initiative focused on reaching rural Veterans with unmet sleep needs. ORH provided 3-6 years of funding to help 19 hubs support 98 spoke sites serving rural Veterans. As ORH funding concluded, each hub identified its path to sustainment. This case study follows one TeleSleep hub in VA's western geographic region as it transitioned from ORH funding sustainment as a regional Sleep Clinical Resource Hub. This case study describes the real-world process of adaptation in care delivery strategies. One key area of adaptation revolved around whether to deliver care via the patient's home facility or the provider's home facility. In early 2021, the TeleSleep team implemented an innovative provider transfer model, where temporary reinforcements from the TeleSleep hub increased the workforce capacity of spoke sites, similar to the concept of locum tenens. In this provider transfer model, TeleSleep clinicians scheduled, documented, and billed for each encounter at the Veteran's home facility. Positioning TeleSleep clinicians as local providers facilitated communication and referrals and promoted continuity and quality of care for Veterans in their home facility. This provider transfer model reduced the administrative burden of providers and schedulers and supported patient-side-only documentation of care. While this mirrors current locum tenens practice, transferring providers did not fit VA's financial model as implemented by the western region's Sleep Clinical Resource Hub. Therefore, in December 2021, VA aligned TeleSleep with VA's preferred practice of patient rather than provider transfers. In the patient transfer model, providers schedule and document in both the provider and patient electronic health records, and bill in the provider's facility. However, reflecting on this period of innovation, TeleSleep team members concluded that the provider transfer model could improve patient safety and care coordination while reducing the administrative burden of frontline clinicians. Further research and development are needed to align the provider transfer model with VA's financial model. [ABSTRACT FROM AUTHOR]

The relationship between alcohol consumption and mortality generally exhibits a U-shaped curve. The longevity observed with moderate alcohol consumption may be explained by other confounding factors, and, if such a relationship is present, the mechanism is not well understood. Indeed, the optimal amount of alcohol consumption for health has yet to be determined. Leukocyte telomere length is an emerging quantifiable marker of biological age and health, and a shorter telomere length is a predictor of increased mortality. Because leukocyte telomere length is a quantifiable and objectively measurable biomarker of aging, we sought to identify the amount of alcohol consumption associated with the longest telomere length and least telomere length attrition. Among over 2,000 participants from two distinct cohort studies, we found no pattern of alcohol consumption that was associated with longer telomere length or less telomere length attrition over time. Binge drinking may reduce telomere length. Using telomere length as a marker of age and health, these data fail to demonstrate any benefits of alcohol consumption, even when consumed in moderation. [ABSTRACT FROM AUTHOR]

Objective Data Sources and Study Setting Study Design Data Collection Methods Principal Findings Conclusions To develop, deploy, and evaluate a national, electronic health record (EHR)‐based dashboard to support safe prescribing of biologic and targeted synthetic disease‐modifying agents (b/tsDMARDs) in the United States Veterans Affairs Healthcare System (VA).We extracted and displayed hepatitis B (HBV), hepatitis C (HCV), and tuberculosis (TB) screening data from the EHR for users of b/tsDMARDs using PowerBI (Microsoft) and deployed the dashboard to VA facilities across the United States in 2022; we observed facilities for 44 weeks post‐deployment.We examined the association between dashboard engagement by healthcare personnel and the percentage of patients with all screenings complete (HBV, HCV, and TB) at the facility level using an interrupted time series. Based on frequency of sessions, facilities were grouped into high‐ and low/none‐engagement categories. We modeled changes in complete screening pre‐ and post‐deployment of the dashboard.All VA facilities were eligible for inclusion; excluded facilities participated in design of the dashboard or had <20 patients receiving b/tsDMARDs. Session counts from facility personnel were captured using PowerBI audit log data. Outcomes were assessed weekly based on EHR data extracted via the dashboard itself.Totally 117 facilities (serving a total of 41,224 Veterans prescribed b/tsDMARDs) were included. Before dashboard deployment, across all facilities, 61.5% of patients had all screenings complete, which improved to 66.3% over the course of the study period. The largest improvement (15 percentage points, 60.3%–75.3%) occurred among facilities with high engagement (post‐intervention difference in outcome between high and low/none‐engagement groups was 0.17 percentage points (pp) per week, 95% confidence interval (0.04 pp, 0.30 pp); p = 0.01).We observed significant improvements in screening for latent infections among facilities with high engagement with the dashboard, compared with those with fewer sessions. [ABSTRACT FROM AUTHOR]

Background: Remote monitoring (RM) of pacemakers and implantable cardioverter‐defibrillators (ICDs) is a Class 1, Level of Evidence A recommendation because of its multitude of clinical benefits. However, RM adherence rates are suboptimal, precluding patients from achieving these benefits. There is a need for direct‐to‐patient efforts to improve adherence. Methods: In this national randomized, controlled trial conducted in the Veterans Health Administration (VHA), 2120 patients with a pacemaker or ICD who had not sent an RM transmission for ≥1 year (and usually ≥3 years) while under VHA care for their device were randomly assigned to be mailed a postcard (n = 1076) or a detailed letter (n = 1044). The postcard described what RM does and its key benefits (reduced mortality and fewer in‐person visits). The letter provided a similar message but included more details about RM benefits and the process. The primary outcome was an RM transmission sent within 90 days of mailing, and a secondary outcome was an RM transmission sent within 365 days. Results: The primary outcome was achieved in 121 (11.3%) in the postcard and 96 patients (9.2%) in the letter group (p =.12). The secondary outcome was achieved in 266 (24.7%) and 239 (22.9%), respectively (p =.32). Conclusions: This randomized trial showed no significant difference in the proportion of chronically non‐adherent patients who sent an RM transmission after receiving a low‐cost postcard or a detailed, higher‐cost letter encouraging their participation in RM. However, as only a minority of patients responded to either, further work is needed to engage patients in the life‐saving benefits of RM. [ABSTRACT FROM AUTHOR]

Introduction: Cardiac rehabilitation (CR) remains underutilized in patients with ischemic heart disease (IHD). Home-based CR (CR) has been promulgated as a model of delivery that may improve participation, but its impact on functional status is unclear. Hypothesis: We sought to compare change in 6-minute-walk-distance (6MWD) among patients enrolled in home-based vs. facility-based CR after myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery. Methods: We evaluated change in 6MWD among 231 Veterans with IHD via home-based vs. facility-based CR after an IHD event. Between 9/2015 and 9/2017, all eligible patients enrolling in home-based (San Francisco VA) or facility-based CR (VA Ann Arbor and VA Pittsburgh) were invited to participate. 6MWD was assessed at baseline, 3-, and 6-months. Results: Median baseline 6MWD were similar in 116 patients who completed home-based vs. facility-based CR (1155 vs. 1160 ft, p=0.52). Median time from referral to enrollment was shorter for home-based vs. facility-based CR (14 vs. 42 days, p<0.001). At 3 months, patients participating in home-based CR demonstrated greater increase in 6MWD (324 vs. 128 feet; p<0.001). After adjusting for demographics, comorbidities, and clinical indication, the mean 3-month change in 6MWD remained significantly greater (330 feet vs. 127 feet; p<0.001). However, the difference was no longer statistically significant at 6 months of follow-up (295 vs. 191 feet; p=0.10). Conclusions: Participants in home-based CR experienced faster time to enrollment and greater 3-month increases in 6MWD than those in facility-based CR, but differences were no longer significant at 6 months. The early superiority of HBCR may relate to shorter delay from referral to participation. Both groups demonstrated similar safety and efficacy. These findings suggest that among selected patients who cannot attend facility-based CR, home-based CR may provide a reasonable alternative. [ABSTRACT FROM AUTHOR]

Background: Vital signs are routinely measured from patients presenting to the emergency department (ED), but how they predict clinical outcomes like hospitalization is unclear.Objectives: To evaluate how pulse, respiratory rate, temperature, and mean arterial pressure (MAP) at ED presentation predicted probability of hospitalization, transfer to another center, or death in the ED (as a composite outcome) vs. other ED dispositions (discharged, eloped, and sent to observation or labor and delivery), and to assess the performance of different modeling strategies, specifically, models including flexible forms of vital signs (as restricted cubic splines) vs. linear forms (untransformed numeric variables) vs. binary transformations (vital signs values categorized simply as normal or abnormal).Methods: We analyzed the data of 12,660 adults presenting for medical illnesses to the ED at the University of California, San Francisco Medical Center, San Francisco, California, throughout 2014. We used flexible forms of vital signs data at presentation (pulse, temperature, respiratory rate, and MAP) to predict ED disposition (admitted, transferred, or died, vs. other ED dispositions) and to guide binary transformation of vital signs. We compared performance of models including vital signs as flexible terms, binary transformations, or linear terms.Results: A model including flexible forms of vital signs and age to predict the outcome had good calibration and moderate discrimination (C-statistic = 71.2, 95% confidence interval [CI] 70.0-72.4). Binary transformation of vital signs had minimal impact on performance (C-statistic = 71.3, 95% CI 70.2-72.5). A model with linear forms was less calibrated and had slightly reduced discrimination (C-statistic = 70.3, 95% CI 69.1-71.5).Conclusions: Findings suggest that flexible modeling of vital signs may better reflect their association with clinical outcomes. Future studies to evaluate how vital signs could assist clinical decision-making in acute care settings are suggested. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about population-level trends in rates of cardiovascular hospitalizations among U.S. Veterans. Recent adoption of a centralized Corporate Data Warehouse in the Veterans Health Administration (VHA) provides a new opportunity to evaluate trends in national rates of hospitalization among Veterans. We sought to determine the leading causes of cardiovascular (CV) hospitalization, and to compare national rates of CV hospitalization by age, gender, race, ethnicity, geographical distribution and year, among U.S. Veterans. Methods: We evaluated the electronic health records of all Veterans ≥18 years old that accessed VA healthcare services between January 1 2010 and December 31 2014. Among these 9,066,693 patients, we identified the 5 leading causes of CV hospitalization and compared rates of hospitalization by age, gender, race, ethnicity, geographical distribution and year. Results: The top 5 causes of CV hospitalization in VA hospitals were: chest pain (3.23 per 1,000 Veterans per year), coronary arteriosclerosis in native artery (2.36), congestive heart failure (1.82), atrial fibrillation (1.34) and acute sub-endocardial infarction (0.99). Overall, the rate of Veterans hospitalized for one or more of these CV conditions decreased over time, from 9.9 per 1000 Veterans in 2010 to 8.3 per 1000 Veterans in 2014. The odds of hospitalization due to any of the 5 conditions were higher in men vs. women (OR 1.73, p<0.0001), in urban vs. rural areas (OR 1.15, p<0.0001), and in the Southeast vs. Pacific regions (OR 1.08, p<0.0001). As compared with Whites, odds of CV hospitalization were higher in Blacks (OR 1.34, p<0.0001) but lower in Asians (OR 0.50, p<0.0001). Racial, geographic and temporal differences in rates of hospitalization were also observed for each of the individual CV conditions. Conclusions: Among U.S. Veterans enrolled in the VA healthcare system, there is substantial variation in rates of CV hospitalization by age, gender, race, geographical distribution and year. [ABSTRACT FROM AUTHOR]

The article presents a response from Doctor Christine C. Welles, et al. to comments made by Doctors A.L.C. Schneider and E.D. Michos on a study by Welles' group about the relationship between Vitamin D and cardiovascular disease. The comments prompted the study authors to reanalyze their data and adjust for 3 categories of race or ethnicity, along with an adjustment for the season of drawing blood samples. The authors noted that the adjustments did not appreciably alter the original results.

Background: The incidence of mortality five years after the onset of symptomatic heart failure is about 50%. Lifestyle behaviors differ substantially and likely lead to prognostic differences. Aims: We sought to determine the factors associated with all-cause mortality in patients with heart failure, particularly the impact of a sedentary lifestyle on mortality. Methods: This is a secondary analysis of a randomized controlled trial (REMOTE-HF) to improve self-care through education and counseling (N=602). We conducted an unadjusted Cox proportional hazards regression analysis with sedentary lifestyle as a predictor of mortality, then added depressive symptoms as a confounder. A Kaplan–Meier survival analysis assessed time to event comparing sedentary lifestyle. Cox models included variables of clinical relevance as well as all significant variables from baseline characteristics associated with all-cause mortality. Results: The mean ± SD age was 66 ± 12.4 years, 41% were women, and 90% were of white race. There were 125 all-cause deaths over 24 months. Sedentary lifestyle was associated with a 75% increase in the expected hazard of all-cause mortality (hazards ratio 1.75; p = 0.003; 95% CI 1.21–2.54) after adjusting for moderate to severe depressive symptoms. Two Cox models showed an 89 and 95% increase, respectively, in all-cause mortality in sedentary participants holding all other variables constant. Conclusions: Sedentary lifestyle is strongly associated with all-cause mortality, independent of having moderate to severe depressive symptoms. Clinicians and researchers have an important role in promoting sustained and safe physical activity to improve survival. Other important modifiable targets to improve survival include depressive symptoms, low literacy, and low body mass index. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique Identifier: NCT00415545 [ABSTRACT FROM AUTHOR]

The authors reflect on the benefits of depression treatment to patients with cardiovascular diseases. They mention the Project Coronary Psychological Evaluation Studies (COPES) which proves the benefits of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care model to patients with acute coronary syndrome (ACS). They believe that depression screening improves the cardiovascular outcomes of patients leading a better emotional health and physical functioning.

Background: Remote monitoring (RM) of pacemakers and implantable cardioverter-defibrillators (ICDs) reduces morbidity and mortality. However, many patients are not adherent to RM. Objective: To test the effect of informational postcards on RM adherence. Design/Patients: Stepped-wedge randomized controlled trial among Veterans with pacemakers and ICDs. Intervention: In wave 1, Veterans who had sent at least 1 transmission within the past 2 years but had become non-adherent were randomly assigned to receive a postcard or no postcard. Those receiving postcards were randomized to 1 of 2 messages: (1) a"warning" postcard describing risks of non-adherence or (2) an "encouraging" postcard describing benefits of adherence. In wave 2, Veterans who had either not received a postcard in wave 1 or had since become non-adherent were mailed a postcard (again, randomized to 1 of 2 messages). Patients who did not send an RM transmission within 1 month were mailed a second, identical postcard. Main Measures: Transmission within 70 days. Key Results: Overall, 6351 Veterans were included. In waves 1 and 2, postcards were mailed to 5657 Veterans (2821 "warning" messages and 2836 "encouraging" messages). Wave 1 included 2178 Veterans as controls (i.e., not mailed a postcard), some of whom received a postcard in wave 2 if they remained non-adherent. In wave 2, 3473 postcards were sent. Of the 5657 patients mailed a postcard, 2756 (48.7%) sent an RM transmission within 70 days, compared to 530 (24.3%) of 2178 controls (absolute difference 24.4%, 95% confidence interval [CI] 22.2%, 26.6%). Of those who sent a transmission, 71.8% did so after the first postcard. Transmission rates at 70 days did not significantly differ between "warning" and "encouraging" messages (odds ratio 1.04, 95% CI 0.92, 1.18). Conclusions: Informational postcards led to a 24.4% absolute increase in adherence at 70 days among Veterans with pacemakers and ICDs who were non-adherent to RM. [ABSTRACT FROM AUTHOR]

Highlights • Lower cortisol levels predict a poorer clinical course of PTSD. • Elevated WBC, CRP, fibrinogen and ESR predict a poorer clinical course of PTSD. • Elevated WBC, CRP and fibrinogen predict a poorer clinical course of depression. Abstract Background Prior research has focused largely on the pro-inflammatory states of PTSD and depression, with few studies evaluating the direction of inflammation's association with these disorders. To clarify whether inflammation plays a role in the development of PTSD or depression, we assessed the predictive value of inflammatory biomarkers on the courses of these conditions in a cohort of Veterans. Methods This research was part of the Mind Your Heart Study, a prospective cohort study designed to examine PTSD-related health outcomes. Between 2008 and 2010, 746 San Francisco area Veterans Administration patients were enrolled. At baseline, inflammatory biomarkers were measured from fasting morning venous blood draws, and cortisol and catecholamine levels were measured from 24-hour urine samples. PTSD was diagnosed using the PTSD Checklist at baseline and annual follow-up. Depression was evaluated using the 9-item Patient Health Questionnaire at baseline and follow-up. Ordinal logistic regression models were used to assess the predictive value of baseline biomarker levels on clinically relevant courses of PTSD and depression categorized and ordered as none, resolved, developed, and chronic. Results After adjustment for age and sex, elevated levels of white blood cell count (OR = 1.27(1.10–1.47), p = 0.001), C-reactive protein (OR = 1.20(1.04–1.39), p = 0.02), fibrinogen (OR = 1.19(1.03–1.38), p = 0.02), and ESR (OR = 1.17(1.00–1.36, p = 0.05), and decreased levels of urine cortisol (OR = 0.84(0.71–0.99), p = 0.04) were significant predictors of poorer courses of PTSD. Elevated levels of WBC count (OR = 1.31(1.14–1.50), p < 0.001), CRP (OR = 1.24(1.07–1.43), p = 0.003), fibrinogen (OR = 1.26(1.09–1.46), p = 0.002), and catecholamines (OR = 1.17(1.01–1.36), p = 0.04) were significant predictors of poorer courses of depression. After additionally controlling for physical activity, elevated WBC count (p = 0.002) and decreased levels of urine cortisol (p = 0.05) remained significant predictors of PTSD course, and elevated WBC count (p = 0.001), CRP (p = 0.03), and fibrinogen (p = 0.02) remained significant predictors of depression course. After adjusting for all significant variables, elevated WBC count (p = 0.02) was a significant predictor of a poorer course of PTSD, and elevated WBC count (p = 0.04) and platelet count (p = 0.03) were significant predictors of a poorer course of depression. Conclusions Increased levels of several inflammatory biomarkers were associated with significantly increased odds of clinically worse courses of PTSD and depression. Inflammation may be a target for prevention and treatment of these mental health disorders. [ABSTRACT FROM AUTHOR]

A response to a letter to the editor about the article "Vitamin D Deficiency and Cardiovascular Events in Patients With Coronary Heart Disease: Data From the Heart and Soul Study," which appeared in the previous issue is presented.

Two antifibrotic medications, pirfenidone and nintedanib, are approved for the treatment of idiopathic pulmonary fibrosis (IPF). Little is known about their real-world adoption. What are the real-world antifibrotic utilization rates and factors associated with uptake among a national cohort of veterans with IPF? This study identified veterans with IPF who received care either provided by the Veterans Affairs (VA) Healthcare System or non-VA care paid for by the VA. Patients who had filled at least one antifibrotic prescription through the VA pharmacy or Medicare Part D between October 15, 2014, and December 31, 2019, were identified. Hierarchical logistic regression models were used to examine factors associated with antifibrotic uptake, accounting for comorbidities, facility clustering, and follow-up time. Fine-Gray models were used to evaluate antifibrotic use by demographic factors, accounting for the competing risk of death. Among 14,792 veterans with IPF, 17% received antifibrotics. There were significant disparities in adoption, with lower uptake associated with female sex (adjusted OR, 0.41; 95% CI, 0.27-0.63; P <.001), Black race (adjusted OR, 0.60; 95% CI, 0.49-0.73; P <.001), and rural residence (adjusted OR, 0.88; 95% CI, 0.80-0.97; P =.012). Veterans who received their index diagnosis of IPF outside the VA were less likely to receive antifibrotic therapy (adjusted OR, 0.15; 95% CI, 0.10-0.22; P <.001). This study is the first to evaluate the real-world adoption of antifibrotic medications among veterans with IPF. Overall uptake was low, and there were significant disparities in use. Interventions to address these issues deserve further investigation. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers. Objective: The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented. Design: Retrospective, observational, utilizing administrative data. Subjects: VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT). Main Measures: Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service. Key Results: In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices. Conclusions: Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources. [ABSTRACT FROM AUTHOR]

Mary A. Whooley responds to a letter to the editor about her article "Depressive Symptoms, Homocysteine Concentration and Cardiovascular Events in Patients With Coronary Heart Disease" in a previous issue.

Presents a letter to the editor in reply to reader response to an article about the Seattle Angina Questionnaire and quality of life in cardiac patients.