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Background: Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk. Methods: Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012–2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis. Results: A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR] = 1.47, 95% CI: 1.33–1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR = 6.01, 95% CI: 3.73–9.68), and other significant subtypes included head and neck (aHR = 3.55, 95% CI: 2.74–4.62) and lung cancer (aHR = 2.35, 95% CI: 1.85–3.00). Cancer stages 3 (aHR = 2.36, 95% CI: 1.80–3.11) and 4 (aHR = 3.53, 95% CI: 2.81–4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3–6‐ and 6–12‐month periods following diagnosis. Conclusion: Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer. [ABSTRACT FROM AUTHOR]

Introduction: Little is known regarding long‐term mortality outcomes after non‐fatal suicide attempts among Veterans Health Administration (VHA) patients, which may inform services delivery and program evaluation. Methods: For 4,601,081 Veterans with 2005 VHA encounters, we assessed unadjusted and age‐adjusted all‐cause and cause‐specific mortality through 2017, overall and for Veterans with (N = 8243) versus without (N = 4,592,838) 2005 VHA suicide attempt documentation. Standardized mortality ratios compared mortality rates by suicide attempt status. Multivariable proportional hazards regression models assessed age‐ and gender‐adjusted mortality risk. Results: Among Veteran VHA users with non‐fatal suicide attempt diagnoses, 1.6% died of suicide, 4.6% of non‐suicide external causes, and 30.7% of any cause. In age‐ and gender‐adjusted analyses, Veterans who attempted suicide had increased suicide (hazard ratio [HR] = 4.52, 95% confidence interval [CI] = 3.82–5.36), non‐suicide external cause (HR = 3.75, 95% CI = 3.38–4.17), and all‐cause (separate due to non‐proportional hazards: 2006, HR = 2.05, 95% CI = 1.81–2.31; 2007–2017, HR = 1.72, 95% CI = 1.65–1.80) mortality through 2017. Conclusion: Over 12 years, Veteran VHA patients with non‐fatal suicide attempt diagnoses had increased risk of suicide, non‐suicide external cause, and all‐cause mortality. Over 98% of Veteran VHA users who had a diagnosed non‐fatal attempt did not die by suicide, highlighting additional program evaluation outcomes and opportunities to support physical and mental health. [ABSTRACT FROM AUTHOR]

Introduction: Veterans who receive Veterans Health Administration (VHA) Home Based Primary Care (HBPC) services and those discharged from VHA Community Living Centers (CLC) may be at increased risk of suicide. No studies to date have assessed suicide risks among HBPC patients. This study examined suicide risks among recipients of VHA HBPC services and following discharge from VHA CLCs, as compared to other Veteran VHA users. Methods: We identified three cohorts of 2013 Veteran VHA patients: 47,842 HBPC users, 17,725 with live discharges from CLCs, and 5,554,635 other VHA users. Using proportional hazards regression, we assessed risk of suicide through 2016. Results: Overall, HBPC recipients did not differ from the other cohorts in suicide risk. Although in unadjusted analyses CLC discharged patients had greater suicide risk than the general VHA patient cohort (hazard ratio (HR) = 1.73, 95% confidence interval = 1.25–2.41), this became nonsignificant when controlling for diagnoses. Conclusions: Overall findings did not identify differential suicide risk among VHA HBPC recipients in 2013, when compared to other Veteran VHA patient cohorts. Veterans discharged from VHA CLCs have increased mental health morbidity, which was associated with increased suicide risk. [ABSTRACT FROM AUTHOR]

Objectives: To assess outcomes for Veterans Health Administration (VHA) patients following calls to the Veterans Crisis Line (VCL). Methods: 158,927 VHA patients had an initial VCL call in 2010–2015 with documented identifiers. Multivariable proportional hazards regressions assessed risks of suicide and suicide‐related behavior through 12 months. Covariates included age, sex, region, mental health encounters in the prior year, time of day, weekday/weekend status, call outcome, and responder determination of caller risk. Results: Annualized suicide rates per 100,000 within 1, 3, 6, and 12 months were 797, 520, 387, and 298, respectively. Average age was 49.9 (SD = 15.2), 86.5% were male, 68.6% received mental health encounters in the prior year, and 5.9% had calls categorized as at high risk. Adjusting for covariates, suicide risk was greater among male callers and those with calls categorized as at high or moderate risk. Conclusions: Veterans Crisis Line serves a high‐risk population at a critical time. Rates were particularly high within one month and remained substantially elevated through 12 months. Findings have directly informed ongoing efforts to enhance coordination between VCL and VHA to support suicide prevention. [ABSTRACT FROM AUTHOR]

Objectives: Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users.Methods: Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators.Results: Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality.Conclusions: Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities. [ABSTRACT FROM AUTHOR]

Background and Objectives: The purpose of this study is to assess trends in opioid-involved overdose mortality among US Veterans.Methods: Age-adjusted drug overdose mortality rates, overall and by opioid subtype, were assessed from National Death Index data for US Veterans; statistical significance of trends was assessed for 2010 to 2015 and 2015 to 2016.Results: Veteran age-adjusted overdose mortality rates increased 23.7% from 2010 to 2015 (19.7-24.4 of 100 000) and a further 20.4% through 2016 (29.3 of 100 000). Opioid involvement increased from 51.3% in 2010 to 62.1% in 2016, as opioid overdose rates increased from 10.9 to 19.5 of 100 000. Overdose mortality varied substantially by opioid subtype and demographics.Conclusions and Scientific Significance: This report provides the first-ever description of trends and characteristics of overdose mortality and opioid-involved deaths among US Veterans of military service for the period 2010 to 2016. With the exception of female Veterans and Veterans in Western States, it has been found that trends in Veteran overdose mortality paralleled rising rates of drug overdose observed in the United States more broadly. Published 2020. This article is a U.S. Government work and is in the public domain in the USA. (Am J Addict 2020;00:00-00). [ABSTRACT FROM AUTHOR]

Objective: To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD).Data Sources: A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249).Study Design: We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership.Data Extraction Methods: We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase.Principal Findings: The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma.Conclusions: Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits. [ABSTRACT FROM AUTHOR]

Aims: To evaluate treatment satisfaction in patients with type 2 diabetes (T2D) not adequately controlled by metformin, randomized to ITCA 650 (continuous exenatide in osmotic mini‐pump) vs twice‐daily exenatide injections (Ex‐BID). Materials and methods: The Diabetes Medication Satisfaction Tool (DM‐SAT) was administered and assessments were made at baseline, Week 8 and Week 20 during a 24‐week open‐label phase 2 trial. In Stage I (Weeks 1‐12), 155 patients, comprising the ITT population, were randomized to 3 groups: ITCA 650 20 μg/day, ITCA 650 40 μg/day and Ex‐BID 10 μg BID. In Stage II (Weeks 13‐24), ITCA 650 groups were re‐randomized to either remain on the Stage I dose or receive a higher dose. Patients treated with Ex‐BID were randomized to 40 or 60 μg/day ITCA 650. Results: Patients using ITCA 650 reported significant increases in overall treatment satisfaction by Week 8 vs those using Ex‐BID (P < .01), despite similar clinical efficacy and overall rates of nausea. During Stage II, further improvement in HbA1c and weight were seen after 3‐fold dose escalation of ITCA 650 and treatment satisfaction was maintained. When patients using Ex‐BID were switched to ITCA 650, treatment satisfaction increased and reached levels similar to those initially treated with ITCA 650. Neither GI side effects of nausea and/or vomiting, nor the procedure to sub‐dermally place ITCA 650, significantly impacted treatment satisfaction scores. Conclusion: ITCA 650 added to metformin for patients with T2D, and for those who switched to ITCA 650 from Ex‐BID, meaningfully improved glucose control and significantly increased overall treatment satisfaction. [ABSTRACT FROM AUTHOR]

Objectives The US Veterans Health Administration (VHA) has begun using predictive modeling to identify Veterans at high suicide risk to target care. Initial analyses are reported here. Methods A penalized logistic regression model was compared with an earlier proof-of-concept logistic model. Exploratory analyses then considered commonly-used machine learning algorithms. Analyses were based on electronic medical records for all 6,360 individuals classified in the National Death Index as having died by suicide in fiscal years 2009-2011 who used VHA services the year of their death or prior year and a 1% probability sample of time-matched VHA service users alive at the index date ( n = 2,112,008). Results A penalized logistic model with 61 predictors had sensitivity comparable to the proof-of-concept model (which had 381 predictors) at target thresholds. The machine learning algorithms had relatively similar sensitivities, the highest being for Bayesian additive regression trees, with 10.7% of suicides occurred among the 1.0% of Veterans with highest predicted risk and 28.1% among the 5.0% of with highest predicted risk. Conclusions Based on these results, VHA is using penalized logistic regression in initial intervention implementation. The paper concludes with a discussion of other practical issues that might be explored to increase model performance. [ABSTRACT FROM AUTHOR]

Background and Aims Limited information is available regarding links between specific substance use disorders (SUDs) and suicide mortality; however, the preliminary evidence that is available suggests that suicide risk associated with SUDs may differ for men and women. This study aimed to estimate associations between SUDs and suicide for men and women receiving Veterans Health Administration (VHA) care. Design A cohort study using national administrative health records. Setting National VHA system, USA. Participants All VHA users in fiscal year (FY) 2005 who were alive at the beginning of FY 2006 ( n = 4 863 086). Measurements The primary outcome of suicide mortality was assessed via FY 2006-2011 National Death Index (NDI) records. Current SUD diagnoses were the primary predictors of interest, and were assessed via FY 2004-2005 VHA National Patient Care Database (NPCD) records. Findings In unadjusted analyses, a diagnosis of any current SUD and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders were all associated significantly with increased risk of suicide for both males and females [hazard ratios (HRs)] ranging from 1.35 for cocaine use disorder to 4.74 for sedative use disorder for men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder for women]. Further, the HR estimates for the relations between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men ( P < 0.05). After adjustment for other factors, most notably comorbid psychiatric diagnoses, associations linking SUDs with suicide were attenuated markedly and the greater suicide risk among females was observed for only any SUD and opioid use disorder ( P < 0.05). Conclusions Current substance use disorders (SUDs) signal increased suicide risk, especially among women, and may be important markers to consider including in suicide risk assessment strategies. None the less, other co-occurring psychiatric disorders may partially explain associations between SUDs and suicide, as well as the observed excess suicide risk associated with SUDs among women. [ABSTRACT FROM AUTHOR]

Objectives Associations between BMI and suicide risks and methods for individuals receiving care in the Veterans Health Administration (VHA) health system were evaluated. Design and Methods For 4,005,640 patients in fiscal years 2001-2002, multivariable survival analyses assessed associations between BMI and suicide, through FY2009. Covariates included demographics, psychiatric, and nonpsychiatric diagnoses, receipt of VHA mental health encounters, and regional network. Among suicide decedents, multivariable Generalized Estimating Equations (GEE) regression examined associations between BMI and suicide method. Results 1.3% of patients were underweight, 24.3% normal weight, 40.6% overweight, and 33.8% obese. Underweight was associated with increased suicide risk (adjusted hazard ratio [AHR] = 1.17, 95% CI: 1.01, 1.36) compared to normal. Overweight and obese status were associated with lower risk (AHR = 0.78, 95% CI: 0.74, 0.82; AHR = 0.63, 95% CI: 0.60, 0.66, respectively). Among suicide decedents, high lethality methods were most common among underweight and least common among obese individuals. Adjusting for covariates, BMI was not associated with method lethality, yet some associations were observed between BMI and specific methods. Conclusion Among VHA patients, BMI was negatively associated with suicide risks. These differences may partly relate to choice of suicide method. Low BMI offers an additional resource for clinical suicide risk assessments. [ABSTRACT FROM AUTHOR]

Background and aims Tobacco use may be a risk factor for suicide mortality; however, prior research has produced equivocal findings and has been limited by relatively small sample sizes to study the rare event of suicide, as well as a lack of adjustment for other important factors, including psychiatric illness. We estimate the predictive association between tobacco use disorder and the risk of suicide mortality, adjusting for other important variables. Design A prospective cohort study. Setting The United States Veterans Health Administration ( VHA). Participants All individuals who received VHA services in fiscal year (FY) 2005 and were alive at the start of FY 2006 ( n = 4 863 086). Measurements Tobacco use disorder was assessed via FYs 2004-05 VHA National Patient Care Database records. The outcome of suicide mortality was assessed during the follow-up interval from the beginning of FY 2006 to the end of FY 2008 using National Death Index records. Findings Of the 4 863 086 individuals in the study, 4823 died by suicide during the follow-up interval. In the unadjusted model, tobacco use disorder was associated with an increased risk of suicide [hazard ratio (HR) = 1.88; 95% confidence interval (CI) = 1.76, 2.02]. After adjustment for model covariates, the association remained statistically significant, although attenuated (HR = 1.36, 95% CI = 1.27, 1.46). Conclusions Tobacco use disorder may confer a modest excess risk of death by suicide. Psychiatric disorders may partially explain the relationship between tobacco use disorder and suicide. [ABSTRACT FROM AUTHOR]

Objective To assess, during a period of decreasing psychiatric inpatient utilization, cost savings from Assertive Community Treatment ( ACT) programs for individuals with severe mental illnesses. Data Source U.S. Department of Veterans Affairs' ( VA) national administrative data for entrants into ACT programs. Study Design An observational study of the effects of ACT enrollment on mental health inpatient utilization and costs in the first 12 months following enrollment. ACT enrollees ( N = 2010) were propensity score matched to ACT-eligible non-enrollees ( N = 4020). An instrumental variables generalized linear regression approach was used to estimate enrollment effects. Results Instrumental variables estimates indicate that between FY2001 and FY2004, entry into ACT resulted in a net increase of $4529 in VA costs. Trends in inpatient use among ACT program entrants suggest this effect remained stable after FY2004. However, eligibility for ACT declined 37 percent, because fewer patients met an eligibility standard based on high prior psychiatric inpatient use. Conclusions Savings from ACT programs depend on new enrollees' intensity of psychiatric inpatient utilization prior to entering the ACT program. Although a program eligibility standard based on prior psychiatric inpatient use helped to sustain the savings from VA ACT programs, over time, it also resulted in an unintended narrowing of program eligibility. [ABSTRACT FROM AUTHOR]

To assess whether distance to services or diagnosis at a hospital-based medical center compared with a community clinic influences the receipt of psychotherapy versus pharmacotherapy for depression. Veterans Affairs (VA) administrative data for 132,329 depressed veterans between October 2003 and September 2004. Multivariable logistic and multinomial regression models were used to examine the relationship between distance to the nearest mental health facility and the facility of initial depression diagnosis on receipt of any and adequate psychotherapy and/or pharmacotherapy, adjusted for patient characteristics. Compared with those living within 30 miles of the nearest mental health treatment facility, depressed patients living between 30 and 60 miles away had a decreased likelihood of receiving psychotherapy (OR=0.71; 95 percent CI: 0.66, 0.76) and a greater likelihood of receiving antidepressant treatment (OR=1.27; 95 percent CI: 1.22, 1.33). Initial diagnosis at a small community clinic compared with a VA medical center was not associated with a difference in receipt of any psychotherapy (OR=0.95; 95 percent CI: 0.83, 1.09), but it was associated with decreased likelihood of receiving eight or more psychotherapy visits (OR=0.46; 95 percent CI: 0.35, 0.61) or any antidepressant treatment (OR=0.69; 95 percent CI: 0.63, 0.75). The VA and similar health systems should make efforts to insure adequate psychotherapy is provided to patients who initiate treatment at small community clinics and provide psychotherapy alternatives that may be less sensitive to travel barriers for patients living remote distances from mental health treatment. Extending services to small community clinics that support antidepressant treatment should also be considered. [ABSTRACT FROM AUTHOR]

Objective. To assess the relationship between closer monitoring of depressed patients during high-risk treatment periods and death from suicide, using two analytic approaches. Data Source. VA patients receiving depression treatment between 1999 and 2004. Study Design. First, a case–control design was used, adjusting for age, gender, and high-risk days (1,032 cases and 2,058 controls). Second, an instrumental variable (IV) approach ( N=714,106) was used, with IVs of (1) average monitoring rates in the VA facility of most use and (2) monitoring rates of VA facilities weighted inversely by distance from patients' residences. Principal Findings. The case–control approach indicated a modest increase in suicide risk with each additional visit (odds ratio=1.02; 95 percent confidence interval=1.002, 1.04). The “facility used” IV estimate indicated near zero change in risk (0.0008 percent increase; p=.97) with each additional visit, while the distance-weighted IV estimate indicated a 0.032 percent decrease in risk ( p=.29). An alternative analysis assuming a threshold effect of ≥4 visits during high-risk periods also showed a decrease (0.15 percent; p=.08) using the distance IV. Conclusions. The IV approach appeared to address the selection bias more appropriately than the case–control analysis. Neither analysis clearly indicated that closer monitoring during high-risk periods was significantly associated with reduced suicide risks, but the distance-weighted IV estimate suggested a potentially protective effect. [ABSTRACT FROM AUTHOR]

OBJECTIVES Naturalistic studies comparing differences in risks across antidepressant agents must take into account factors which influence selection of specific agents and may be associated with outcomes. We examined predictors of antidepressant choice among VA patients treated for depression. METHODS Retrospective cohort study of VA patients with depression diagnoses and a new start of one of the seven most commonly prescribed antidepressant agents between 1 April 1999 and 30 September 2004 ( n = 502 179). We examined the relationship between patient and facility characteristics and new starts of bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine. We also examined factors associated with new starts only among patients starting selective serotonin reuptake inhibitors (SSRIs). RESULTS Thirty-three percent of patients starting mirtazapine had at least three outpatient mental health visits in the prior year, compared to ≤24% of patients prescribed other antidepressants. Patients starting mirtazapine were also most likely to have received at least two other psychotropic medications in the prior year. Of the four SSRIs, 40% of the patients receiving sertraline and only 31% of those receiving fluoxetine were 65 years or older. A comorbid anxiety disorder (other than post-traumatic stress disorder) was diagnosed in 21% of paroxetine patients compared with ≤15% of other SSRI patients. CONCLUSION Choice of antidepressant medication for depressed VA patients was associated with important differences in demographic and clinical variables, including psychiatric illness severity, older age, and likelihood of a comorbid anxiety disorder. These findings emphasize the importance of controlling for selection bias when using observational data to compare risks from or effect of mental health treatments. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This exploratory case study examines the challenges faced by the Norwegian Book Clubs, a well-established company in a small country's book distribution sector, and the company's strategic responses to the challenge of industry deregulation and related threat of foreign competition. The theoretical argument of the study is shaped by the “liability of foreignness” hypothesis (Hymer, 1976) but takes the perspective of the indigenous market player. This theoretical lens is supplemented with insights on entry deterrent strategies from industrial organization (Bain, 1956). Case findings suggest industry incumbents can reinforce their “local player advantage” through simultaneously strengthening their organizational capabilities, increasing their positional advantages in the domestic market, and enhancing their local embeddedness. The authors further find that market characteristics and government regulations significantly affect the relationship between company strategic responses and the local player's advantage. Implications for theory, managerial practice, and public policy are discussed. © 2009 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Over recent decades a structural transformation has affected agriculture in the frontier areas of Malaysian Borneo and Outer Island Indonesia with the rapid conversion of agricultural lands, fallows, and formerly forested areas into oil palm. These frontiers have similar positions in the international political economy of oil palm and have complementary resource endowments. In both cases, state planners face the common challenges of finding a disciplined labour force, delivering land for estate development, maintaining local legitimacy, and dealing with local contestation. Yet there are significant differences in systems of governance and policy frameworks regarding land, shifting capacity of state actors to facilitate the transformation of these agrarian frontiers, and changing degrees of local, national and international contestation. Considering the generic and the specific elements at play in each case, this paper argues that analogous policy narratives have shaped the ways in which landholders have been engaged in the process of oil palm expansion in Malaysia and Indonesia. In both cases, with the shift from state-led to neoliberal governance approaches to agricultural development, the ‘frontier’ has been created and transformed through policy narratives that facilitate the conversion of whole landscapes into oil palm. This has been achieved by obscuring indigenous forms of agriculture and land tenure, while creating reserves of available ‘state’ or ‘idle’ customary land, and counterpoising smallholder ‘marginality’ and ‘backwardness’ to the modernity of contemporary estate agriculture. [ABSTRACT FROM AUTHOR]

The 2004 Indian Ocean tsunami brought Aceh's long-drawn separatist conflict back to international attention. Yet, the precise way in which the different aspects of the conflict entangled with resource-related grievances have remained poorly understood. Taking a political ecology approach, this paper sets out to understand the role of natural resource grievances within the complex and shifting set of mutually implicated factors leading to and sustaining the conflict from the early days of Indonesia's independence. The paper argues that the management of Aceh's natural resources – especially the rich gas and oil reserves – was not the sole or primary causal factor. Rather, state managed exploitation of natural resources had a demonstration effect, exemplifying other grievances and supporting the articulation of a separatist discourse naturalizing ‘Acehnese’ conceptualizations of resource entitlement. Comparing Aceh with other separatist conflicts, the paper suggests that, as conflict unfolds at the intersection of a shifting set of concerns, it is increasingly difficult to separate the underlying issues of identity, resource entitlements and human rights. [ABSTRACT FROM AUTHOR]

The article discusses the occurrence and uncertainty of source-specific Bacteroides and Escherichia coli in a mixed land-use karstic watershed in Tennessee. According to the authors, source-specific total Bacteroides and bovine-specific Bacteroides can be used to better understand hydrologic influences on bacterial delivery and persistence of Escherichia coli densities and loads. Bioassays and multivariate cluster analyses helped to build a conceptual model for separating pure runoff-dominated persistence versus potential groundwater-dominated responses.

Objectives: There have been few comprehensive studies of nutrition and exercise behaviors among patients with bipolar disorder (BPD). Based on a national sample of patients receiving care in the Veterans Affairs (VA) health care system, we compared nutrition and exercise behaviors among individuals diagnosed with BPD, others diagnosed with schizophrenia, and others who did not receive diagnoses of serious mental illness (SMI). Methods: We conducted a cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in fiscal year (FY) 1999 and who either received a diagnosis of BPD (n = 2,032) or schizophrenia (n = 1,895), or were included in a random sample of non-SMI VA patients (n = 3,065). We compared nutrition and exercise behaviors using multivariable logistic regression, controlling for patient socio-economic and clinical factors, and adjusting for patients clustered by site using generalized estimating equations. Results: Patients with BPD were more likely to report poor exercise habits, including infrequent walking (odds ratio, OR = 1.33, p < 0.001) or strength exercises (OR = 1.28, p < 0.001) than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than two daily meals (OR = 1.32, p < 0.001) and having difficulty obtaining or cooking food (OR = 1.48, p < 0.001). Patients with BPD were also more likely to report having gained ≥10 pounds in the past 6 months (OR = 1.59, p < 0.001) and were the least likely to report that their health care provider discussed their eating habits (OR = 0.84, p < 0.05) or physical activity (OR = 0.81, p < 0.01). Conclusions: Greater efforts are needed to reduce the risk of poor nutrition and exercise habits among patients diagnosed with BPD. [ABSTRACT FROM AUTHOR]

Objective. We examine the impact of two dimensions of access—geographic accessibility and availability—on VA health system and mental health treatment retention among patients with serious mental illness (SMI). Methods. Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using county-level VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored. Results. There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant. Conclusions. Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention. [ABSTRACT FROM AUTHOR]

Objectives: We evaluated patient and medication treatment factors associated with self-reported oral health status in patients diagnosed with serious mental illness (SMI) in a large, national sample of patients in the Veterans Affairs (VA) health system.Methods: 4,769 patients (mean age = 55, 7.8 percent women) were included from the VA's 1999 National Psychosis Registry (NPR) for whom the oral health information gathered by the VA's Large Health Survey of Veterans was available. Current (1999) psychotropic medication data were ascertained from the NPR. Multivariable logistic regression analyses were used to determine the patient factors (e.g., sociodemographic, enabling, and treatment factors) associated with poor or fair overall dental health, and with having tooth or mouth problems that made it difficult to eat.Results: While 61.0 percent of persons with SMI self-reported fair to poor dental health, 34.1 percent reported that oral health problems made it difficult for them to eat. Patients who were not employed, experiencing financial strain, who smoked, who were prescribed tricyclic antidepressants, or prescribed selective serotonin reuptake inhibitors were more likely to report poor or fair dental health. These variables were also associated with having tooth or mouth problems.Conclusions: Suboptimal oral health was self-reported with substantial prevalence among patients with SMI, a problematic finding given its consequences for general health, social functioning, and quality of life. Greater efforts are needed to improve oral health outcomes among patients with SMI by facilitating access to dental care and addressing mutable factors such as smoking and medication side effects. [ABSTRACT FROM AUTHOR]

To examine primary care physician (PCP) contributions toward racial and sex differences in the diagnosis and treatment of late-life depression.Survey using a computerized instrument incorporating video interviews and text, with volunteer PCPs randomly assigned to one of four standardized video vignettes of an elderly patient depicting late-life depression. Vignettes differed only in the patient/actor's race (white/African-American) or sex.American Academy of Family Physicians meeting, San Diego, California, 2002.One hundred seventy-eight U.S.-practicing postresidency PCPs who were asked to participate in a clinical decision-making study.The computerized survey instrument assessed PCPs' diagnoses, first-line treatment and management recommendations, and judgment of personal characteristics/behaviors for the patients in the vignettes.Eighty-five percent of all PCPs correctly diagnosed the elderly patient(s) with major depression. There were no significant differences in the diagnosis of depression, treatment recommendations, or PCP assessment of most patient characteristics by the race or sex of the patient/actor in the vignette, but PCP characteristics, most notably the location of medical school training (U.S. vs international), affected the likelihood of a depression diagnosis and treatment recommendations.Given standardized symptom-pictures, PCPs are just as likely to diagnose and treat depression in African-American as in white older people, suggesting that bias based simply on apparent patient race is not a likely explanation for the lower rates of depression diagnosis and treatment in older African Americans. PCPs who have trained at international medical schools may benefit from targeted training initiatives on the diagnosis and treatment of late-life depression. [ABSTRACT FROM AUTHOR]

The transport, retention, and release of hydrophobic and hydrophilic polystyrene latex microsphere colloids were examined in 0.5-cm-thick, 26-cm-long slab chambers filled with either regular (hydrophilic) or weakly water-repellent sand. The water-repellent sand consisted of a mixture of 0.4% strongly water-repellent grains with unmodified regular sand for the remainder. The concentration of colloids in the outflow water was measured at the same time as the pore-scale distribution of colloids was recorded in still and video images. Although the type of sand affected the flow pattern in the top of the chamber, it did not affect the breakthrough for the same type of colloids. More hydrophilic colloids were eluted in the drainage water than hydrophobic colloids. Images showed that there was a greater retention of the hydrophobic colloids due to strongly attractive hydrophobic interaction forces between colloids and subsequent filtering of colloidal aggregates in the narrow passages between grains. Once filtered, these aggregates then served as preferred sites for attachment of other hydrophobic colloids. The hydrophilic colloids were retained primarily in a thin film of water at the edge of the menisci, the air-water-solid (AWS) interface. Centrifugal motion within the pendular rings observed in the videos contributed to movement of the colloids toward the AWS interface, where colloids were retained due to both low laminar flow velocities near the grain surface and straining in the thin water film at the edge of the meniscus. Except near the solid interface, sorption at the air-water (AW) interface was not observed and appeared unimportant to the retention of colloids. The findings form an essential link between colloid retention and transport processes at the interfacial, pore, and Darcy scales. [ABSTRACT FROM AUTHOR]

To determine the prevalence and correlates of behavior problems of residents of Veterans Affairs (VA) nursing homes and to compare residents with serious mental illness (SMI) with other resident groups.This study combined cross-sectional resident assessments with administrative data for all residents in VA nursing homes. Multivariate ordinal logistic regression was used to evaluate associations between resident characteristics and problem behaviors.Nursing home care units in the VA healthcare system.A total of 9,618 nursing home residents assessed as part of the VA's April 2001 national resident census.The Patient Assessment Instrument assessed each resident's verbally disruptive, physically aggressive, and socially inappropriate behaviors in the prior 4 weeks. Functional limitations in eating, mobility, toileting, and transfer were assessed. Diagnoses were evaluated for the stay and up to 6 months before assessment.Almost one-fifth (17.9%) of residents received a diagnosis of SMI. Residents with SMI or dementia had greater behavior problems than residents with neither condition. Residents with SMI (and without dementia) exhibited more verbal disruption than residents with dementia (and without SMI), but the two subgroups did not differ in physically aggressive or socially inappropriate behavior.Many VA nursing home residents have SMI. Their level of behavior problems is comparable with that of residents with dementia. Clinical practice and nursing home staff training must encompass geriatric mental health and behavior management to meet the needs of residents with SMI. [ABSTRACT FROM AUTHOR]

Recent technical advances in combinatorial chemistry, genomics, and proteomics have made available large databases of biological and chemical information that have the potential to dramatically improve our understanding of cancer biology at the molecular level. Such an understanding of cancer biology could have a substantial impact on how we detect, diagnose, and manage cancer cases in the clinical setting. One of the biggest challenges facing clinical oncologists is how to extract clinically useful knowledge from the overwhelming amount of raw molecular data that are currently available, In this paper, we discuss how the exploratory data analysis techniques of machine learning and high-dimensional visualization can be applied to extract clinically useful knowledge from a heterogeneous assortment of molecular data. After an introductory overview of machine learning and visualization techniques, we describe two proprietary algorithms (PURS and RadVizTM) that we have found to be useful in the exploratory analysis of large biological data sets. We next illustrate, by way of three examples, the applicability of these techniques to cancer detection, diagnosis, and management using three very different types of molecular data. We first discuss the use of our exploratory analysis techniques on proteomic mass spectroscopy data for the detection of ovarian cancer. Next, we discuss the diagnostic use of these techniques on gene expression data to differentiate between squamous and adenocarcinoma of the lung. Finally, we illustrate the use of such techniques in selecting from a database of chemical compounds those most effective in managing patients with melanoma versus leukemia. [ABSTRACT FROM AUTHOR]

Passive monitoring of polychlorinated biphenyls (PCB) using semipermeable membrane devices (SPMD) was employed to evaluate the contribution of point and nonpoint sources to the flux of PCB in a drainage system encompassing three U.S. Department of Energy (U.S. DOE) industrial and research facilities in eastern Tennessee, USA. Polychlorinated biphenyls concentrations were highest at outfalls containing process waste from the DOE industrial facilities. The significance of these releases was evaluated by calculating the PCB flux (mass per unit time) at different monitoring locations. The flux was calculated from the timeintegrated estimates of the aqueous concentrations of PCB and estimates of the volumetric flow rates of discharges and receiving streams during the deployment period. The DOE discharges accounted for most of the flux of PCB entering the Clinch River from the DOE drainage areas, but these sources constituted only 10% of the flux in the Clinch River about the DOE sources. Principal components analysis was helpful in attributing sources of PCB. In a stream receiving multiple inputs of PCB, congener profiles from upstream sources and discrete discharges were consistent with a mixture of those congener profiles in the downstream receiving water. In another stream with a single upstream source of PCB, changes in PCB flux and congener profiles suggested an apparent steady-state distribution between dissolved PCB and PCB adsorbed to organic matter on the streambed. The flux of dissolved PCB along different stream reaches reflected changes in the sediment organic content. Subtle alterations in congener profiles moving downstream suggested preferential desorption of less chlorinated congeners and sorption of more highly chlorinated congeners to sediment. Time-integrated, flux-based monitoring can be useful across a range of spatial scales for evaluating the significance of point and nonpoint contaminant sources and can help identify and prioritize feasible... [ABSTRACT FROM AUTHOR]

Explores the dominant explanations of the failure of forest management in Indonesia within the public discourse from 1966-1998. Historical and institutional causes of the failure of the state property regime; Inequitability of the country's forest policy; Implications of the forest fires of 1997 and 1998.

Purpose Methods Results Conclusions To assess temporal patterns of Veteran suicide deaths from 2001 to 2021.Data from Veterans Affairs (VA) and Department of Defense (DoD) administrative sources and the VA/DoD Mortality Data Repository identified 133,867 Veteran suicides from 2001 to 2021. Incidence Rate Ratios (IRRs) and Joinpoint regression assessed patterns of Veteran suicide across seasons, days of the week, and 14 holidays; overall and by sex and age.Incidence of Veteran suicide was highest in summers and on Mondays. Veteran suicide incidence was lower on six holidays: Martin Luther King Jr. Day (IRR = 0.82, 95% CI = 0.73–0.93), Presidents' Day (IRR = 0.88, 0.78, 0.99), Memorial Day (IRR = 0.89, CI = 0.79–0.99), Labor Day (IRR = 0.88, CI = 0.78–0.98), Thanksgiving (IRR = 0.81, CI = 0.71–0.92), and Christmas (IRR = 0.78, CI = 0.68–0.89). Suicide incidence was elevated on New Year's Day (IRR = 1.17, CI = 1.05–1.31), particularly among Veterans 25–34 years old (IRR = 1.64, CI = 1.19–2.26). An increasing trend in daily average suicides was indicated from December 30th to January 1st (β = 1.79, p < 0.05). Both seasonal and day of the week effects were present in most subpopulations. Holiday effects were most prevalent among men and varied by age.Veteran suicide incidence was elevated in summer months, on Mondays, and on New Year's Day. Temporal patterns differed by sex and age. Findings can inform ongoing Veteran suicide prevention efforts. [ABSTRACT FROM AUTHOR]

This paper reports the variable conditional effects of a person on the heart rate of nine mongrel dogs. There were three experimental procedures: person present and playing a passive role, person present and playing an active role (petting the dog), and person present and serving as a signal for forthcoming electrical stimulation. The order of presentation of these conditions was counterbalanced with dogs assigned randomly to one of three orders of procedures. Each procedure consisted of 50 trials (exposures to a human). On each trial, the person entered the conditioning room and stood motionless for 40 sec. The petting and shock reinforcements occurred 40 sec after the person entered the room, enabling the study of conditional heart rate changes in the interval from appearance of the person to reinforcement. Heart rate changes varied with the "meaning" of the person, and the rates from high to low were in the order: person serving as a signal for subsequent punishment, person alone, and person serving as a signal for subsequent petting. It was stressed that an experimenter could have marked and varied social, psychophysiological effects upon the individuals being studied, and that in any experiment it is necessary to properly evaluate these effects. [ABSTRACT FROM AUTHOR]

Information about several papers discussed at a symposium on integration of arts into the leadership studies is presented. Topics discussed includes art-based initiatives taken for preparing future leaders, usage of poetry and metaphor for enabling leaders to make ethical decisions and role played by arts in teaching a leader about careful observation. The symposium featured several associate professors including Steven Taylor, William Van Buskirk and Michael London.

Leaders today require critical thinking skills and full awareness of the complexities of social and cultural interaction. These may be best taught through the liberal arts. This article examines the use of live dramatic stage performances for teaching and learning contemporary management and leadership lessons, highlighting the value of collaborating across traditional university boundaries through the use of the arts within the management curriculum. We describe the successful working relationships and our effective implementation model with cross-campus colleagues and students in the theater department to integrate live stage plays into our core management and leadership coursework. Students and faculty from both domains have found the activity to be engaging, provocative, relevant, and valuable. A key finding from this work has been how malleable, smooth, and straightforward the process has been to successfully-and powerfully-integrate the arts and humanities directly into management education and leadership development. [ABSTRACT FROM AUTHOR]

In unsaturated porous media, sorption of colloids at the air-water (AW) interface is accepted as a mechanism for controlling colloid retention and mobilization. However, limited actual pore-scale observations of colloid attachment to the AW interface have been made. To further investigate these processes, a real-time pore-scale visualization method was developed. The method builds on the light transmission technique for fingered flow studies in packed-sand infiltration chambers and combines it with high-resolution, electro-optical hardware and public domain imaging software. Infiltration and drainage of suspensions of hydrophilic negatively charged carboxylated latex microspheres provides compelling visual evidence that colloid retention in sandy porous media occurs via trapping in the thin film of water where the AW interface and the solid interface meet, the air-water-solid (AWS) interface. With this modified theory of trapped colloids at the AWS interface, we are able to explain the apparent discrepancy between previous experimental evidence of hydrophilic colloids seemingly partitioning to the AW interface and more recent findings that suggest this type of colloid does not adsorb at the AW interface. [ABSTRACT FROM AUTHOR]

This paper attempts to introduce the work described in this special section on colloid transport within a more general perspective of the evolution of our understanding of the importance of colloids in subsurface systems. The focus will be on the transport of colloidal particles in natural (i.e., chemically and physically heterogeneous) geological settings because the complexity imposed by these situations represents the greatest challenge to current and future understanding. Great progress has been made in addressing many of the key questions related to colloid transport. However, as in most areas of science, increased knowledge also serves to reveal new and more complex challenges that must be addressed. [ABSTRACT FROM AUTHOR]