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Post-traumatic stress disorder (PTSD) is associated with an increased risk for physical illnesses and early mortality. However, we do not know if it also increases the risk for adverse outcomes of coronavirus disease 2019 (COVID-19). In this retrospective cohort study, we examined associations of PTSD and other psychiatric disorders with risk for hospitalization and death in the 60 days following a COVID-19 infection in 228,367 U.S. Department of Veteran Affairs (VA) patients who tested positive for COVID-19 between February 2020 and August 2021 (age m = 60.6, 89.5% male). Generalized linear models estimated associations of PTSD and other psychiatric disorders with outcomes following a positive SARS-CoV-2 test, adjusting for socio-demographic, medical, and behavioral factors. Among 228,367 VA patients, 25.6% had PTSD, and 28.2% had a psychiatric disorder other than PTSD. In the 60 days following a positive COVID-19 test, 15% of patients were hospitalized, and 6% died. Patients with PTSD had an increased risk for both hospitalization (adjusted relative risk, ARR = 1.18, 95% CI 1.15-1.21) and death (ARR = 1.13, 95% CI 1.08-1.19) relative to those with no psychiatric disorders, adjusting for socio-demographics. Estimates remained significant when models were additionally adjusted for medical comorbidities and smoking. Patients with other psychiatric disorders also had an increased risk of adverse COVID-19 outcomes, with larger effect sizes than PTSD in older (≥65 years) but not younger patients. In this large-scale study of VA patients, individuals with PTSD, and other psychiatric disorders, had heightened vulnerability to severe adverse outcomes of COVID-19; thus, individuals with PTSD should also be considered at higher risk for severe COVID-19 outcomes, and potentially prioritized for vaccination, screening, and early treatment intervention for COVID-19.

BackgroundThe relationship between vitamin D status and COVID-19-related clinical outcomes is controversial. Prior studies have been conducted in smaller, single-site, or homogeneous populations limiting adjustments for social determinants of health (race/ethnicity and poverty) common to both vitamin D deficiency and COVID-19 outcomes.ObjectiveTo evaluate the dose-response relationship between continuous 25(OH)D and risk for COVID-19-related hospitalization and mortality after adjusting for covariates associated with both vitamin D deficiency and COVID-19 outcomes.DesignRetrospective cohort study.PatientsVeteran patients receiving care in US Department of Veteran Affairs (VA) health care facilities with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test and a blood 25(OH)D test between February 20, 2020, and November 8, 2020, followed for up to 60 days.Main measuresExposure was blood 25(OH)D concentration ascertained closest to and within 15 to 90 days preceding an index positive SARS-CoV-2 test. Co-primary study outcomes were COVID-19-related inpatient hospitalization requiring airborne, droplet, contact, or other isolation and mortality ascertained within 60 days of an index positive SARS-CoV-2 test.Key resultsOf 4,599 veterans with a positive SARS-CoV-2 test, vitamin D deficiency (< 20 ng/mL) was identified in 665 (14.5%); 964 (21.0%) were hospitalized; and 340 (7.4%) died. After adjusting for all covariates, including race/ethnicity and poverty, there was a significant independent inverse dose-response relationship between increasing continuous 25(OH)D concentrations (from 15 to 60 ng/mL) and decreasing probability of COVID-19-related hospitalization (from 24.1 to 18.7%, p=0.009) and mortality (from 10.4 to 5.7%, p=0.001). In modeling 25(OH)D as a log-transformed continuous variable, the greatest risk for hospitalization and death was observed at lower 25(OH)D concentrations.ConclusionsContinuous blood 25(OH)D concentrations are independently associated with COVID-19-related hospitalization and mortality in an inverse dose-response relationship in this large racially and ethnically diverse cohort of VA patients. Randomized controlled trials are needed to evaluate the impact of vitamin D supplementation on COVID-19-related outcomes.

PurposeTo determine the effectiveness of telephone motivational coaching delivered by veteran peers to improve mental health (MH) treatment engagement among veterans.MethodsVeterans receiving primary care from primarily rural VA community-based outpatient clinics were enrolled. Veterans not engaged in MH treatment screening positive for ≥1 MH problem(s) were randomized to receive veteran peer-delivered feedback on MH screen results and referrals plus 4 sessions of telephone motivational coaching (intervention) versus veteran peer-delivered MH results and referrals without motivational coaching (control). Blinded telephone assessments were conducted at baseline, 8, 16, and 32 weeks. Cox proportional hazard models compared MH clinician-directed treatment initiation between groups; descriptive analyses compared MH treatment retention, changes in MH symptoms, quality of life, and self-care.FindingsAmong 272 veterans screening positive for ≥1 MH problem(s), 45% who received veteran peer telephone motivational coaching versus 46% of control participants initiated MH treatment (primary outcome) (hazard ratio: 1.09, 95% CI: 0.76-1.57), representing no between-group differences. In contrast, veterans receiving veteran peer motivational coaching achieved significantly greater improvements in depression, posttraumatic stress disorder and cannabis use scores, quality of life domains, and adoption of some self-care strategies than controls (secondary outcomes). Qualitative data revealed that veterans who received veteran peer motivational coaching may no longer have perceived a need for MH treatment.ConclusionsAmong veterans with MH problems using predominantly rural VA community clinics, telephone peer motivational coaching did not enhance MH treatment engagement, but instead had positive effects on MH symptoms, quality of life indicators, and use of self-care strategies.

PurposeTo examine the impact of a pilot VA Whole Health Coaching program, including whether and how the program helps veterans improve their health and quality of life.InterventionWhole Health Coaching is a structured program to support veterans in making healthy behavior changes to promote holistic well-being.DesignThis mixed-methods quality-improvement evaluation combined surveys (pre- and post-coaching) with follow-up qualitative interviews.SettingThe setting was a large VA healthcare system, encompassing a medical center and six community-based clinics in Northern California.Participants65 veterans completed surveys at both time points; 42 completed qualitative interviews.MethodTelephone surveys administered at baseline and 3 months assessed global health (PROMIS-10), perceived stress (PSS-4), and perceived health competency (PHCS-2). Pre- and post-scores were compared using t-tests. A subsample of participants completed a qualitative interview evaluating program experience, goal attainment, and the coaching relationship.ResultsSurveys showed significant improvements over baseline in mental health (p = 0.006; d = 0.36), stress (p = 0.003; d = -0.38), and perceived health competence (p = 0.01; d = 0.35). Interviewees were highly satisfied with their coaching experience, describing both effective program components and improvement opportunities.ConclusionWhole Health Coaching can help participants make meaningful progress toward health goals, reduce stress, and improve quality of life. The Whole Health model's emphasis on holistic self-assessment; patient-driven goal-setting; supportive, non-judgmental inquiry; and mindful awareness contributed to program success and enhanced participants' experience.

BackgroundLittle is known about the COVID-19 pandemic's impact on US military veterans' health, wellbeing, and care engagement. Healthcare systems like VA need additional information about the pandemic's biopsychosocial impacts and how a Whole Health approach may help to address them.ObjectiveTo examine how the pandemic has affected veterans' health, wellbeing, and engagement in the VA Whole Health System of Care.MethodWe conducted qualitative interviews with 40 veterans at a large multicampus VA healthcare system during the pandemic. Informed by a Whole Health approach, interviews used open-ended questions to holistically explore pandemic impacts on mental and physical health, healthcare access and engagement, social support, coping strategies, and use of VA healthcare and wellness services. Interviews were conducted by telephone, audio-recorded, and analyzed using a matrix-based technique. Interviews were supplemented by an original survey assessing pandemic impacts; descriptive frequencies were calculated to describe and characterize the interviewed sample.Interview resultsNearly, all participating veterans described significant pandemic impacts on their wellbeing, especially loneliness and sorrow stemming from isolation and disruptions to ordinary routines. These emotional impacts-sometimes combined with new constraints on care access and personal mobility-disrupted veterans' health plans and sometimes deterred engagement in both routine and wellness care. Veterans already struggling with chronic mental and physical health conditions and those who experienced transitions or losses during the pandemic described the most severe impacts on their wellbeing. Virtual VA wellness services, especially health coaching and mind-body wellness groups, were a key source of support and connection for those who engaged in them.ConclusionWe discuss the implications of our findings for care systems attempting to implement a Whole Health System of Care, including how they can address postpandemic barriers to engagement in healthcare and wellness programs, and how wellness programs can be leveraged to support those most at risk after the COVID-19 pandemic and in future crises.

BackgroundThe Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. wHOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care.DesignwHOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis.SummaryThis trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel.

Background: Psychiatric disorders may be a risk factor for long COVID, broadly defined as COVID-19 conditions continuing three months post-acute infection. In US Veterans with high psychiatric burden, we examined associations between psychiatric disorders and clinical diagnosis of long COVID. Methods: We conducted a retrospective cohort study using health records from VA patients with a positive SARS-CoV-2 test from February 2020 to February 2023. Generalized linear models estimated associations between any psychiatric disorder and likelihood of subsequent diagnosis with long COVID (i.e. two or more long COVID clinical codes). Models were adjusted for socio-demographic, medical, and behavioral factors. Secondary models examined individual psychiatric disorders and age-stratified associations. Results: Among 660 217 VA patients with positive SARS-CoV-2 tests, 56.3% had at least one psychiatric disorder diagnosis and 1.4% were diagnosed with long COVID. Individuals with any psychiatric disorder had higher risk for long COVID diagnosis in models adjusted for socio-demographic factors, vaccination status, smoking, and medical comorbidities (relative risk, RR = 1.28, 95% CI 1.21–1.35), with the strongest associations in younger individuals. Considering specific disorders, depressive, anxiety, and stress-related disorders were associated with increased risk for long COVID diagnoses (RRs = 1.36–1.48), but associations were in the opposite direction for substance use and psychotic disorders (RRs = 0.78–0.88). Conclusions: Psychiatric disorder diagnoses were associated with increased long COVID diagnosis risk in VA patients, with the strongest associations observed in younger individuals. Improved surveillance, treatment, and prevention for COVID-19 and its long-term sequelae should be considered for individuals with psychiatric conditions. [ABSTRACT FROM AUTHOR]

ObjectiveTo determine the prevalence and correlates of lower urinary tract symptoms (LUTS) among returned Iraq and Afghanistan veterans; in particular its association with mental health diagnoses and medication use.MethodsWe performed a retrospective cohort study of Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs health care. Mental health diagnoses were defined by International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes from medical records. LUTS was defined by ICD-9-CM code, use of prescription medication for LUTS, or procedure for LUTS. We determined the independent association of mental health diagnoses and LUTS after adjusting for sociodemographic and military service characteristics, comorbidities, and medications.ResultsOf 519,189 veterans, 88% were men and the mean age was 31.8 years (standard deviation ± 9.3). The overall prevalence of LUTS was 2.2% (11,237/519,189). Veterans with post-traumatic stress disorder (PTSD) were significantly more likely to have a LUTS diagnosis, prescription, or related procedure (3.5%) compared with veterans with no mental health diagnoses (1.3%) or a mental health diagnosis other than PTSD (3.1%, P

IntroductionMental health disorders are prevalent in the United States, Iraq, and Afghanistan war veterans. Mental illness, including posttraumatic stress disorder (PTSD) with or without psychiatric medications, can increase the risk for male sexual dysfunction, threatening quality of life.AimsWe sought to determine the prevalence and correlates of sexual dysfunction among male Iraq and Afghanistan veterans.MethodsWe performed a retrospective cohort study of 405,275 male Iraq and Afghanistan veterans who were new users of U.S. Department of Veterans Affairs healthcare from October 7, 2001 to September 30, 2009 and had 2-year follow-up.Main outcome measuresWe determined the independent association of mental health diagnoses and sexual dysfunction after adjusting for sociodemographic and military service characteristics, comorbidities, and medications.ResultsVeterans with PTSD were more likely to have a sexual dysfunction diagnosis, be prescribed medications for sexual dysfunction, or both (10.6%), compared with veterans having a mental diagnosis other than PTSD (7.2%), or no mental health diagnosis (2.3%). In a fully adjusted model, PTSD increased the risk of sexual dysfunction by more than threefold (adjusted risk ratio = 3.61, 95% CI = 3.48-3.75). Veterans with mental health disorders, particularly PTSD, were at the highest risk of sexual dysfunction when prescribed psychiatric medications (adjusted risk ratio = 4.59, 95% CI = 4.41-4.77).ConclusionsAmong U.S. combat veterans, mental health disorders, particularly PTSD, increased the risk of sexual dysfunction independent of the use of psychiatric medications.

BackgroundObesity is a growing public health concern and is becoming an epidemic among veterans in the post-deployment period.ObjectiveTo explore the relationship between body mass index (BMI) and posttraumatic stress disorder (PTSD) in a large cohort of Iraq and Afghanistan veterans, and to evaluate trajectories of change in BMI over 3 years.DesignRetrospective, longitudinal cohort analysis of veterans' health recordsParticipantsA total of 496,722 veterans (59,790 female and 436,932 male veterans) whose height and weight were recorded at the Department of Veterans Affairs (VA) healthcare system at least once after the end of their last deployment and whose first post-deployment outpatient encounter at the VA was at least 1 year prior to the end of the study period (December 31, 2011).Main measuresBMI, mental health diagnoses.Key resultsSeventy-five percent of Iraq and Afghanistan veterans were either overweight or obese at baseline. Four trajectories were observed: "stable overweight" represented the largest class; followed by "stable obese;" "overweight/obese gaining;" and "obese losing." During the 3-year ascertainment period, those with PTSD and depression in particular were at the greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight. Adjustment for demographics and antipsychotic medication attenuated the relationship between BMI and certain mental health diagnoses. Although BMI trajectories were similar in men and women, some gender differences were observed. For example, the risk of being in the persistently obese class in men was highest for those with PTSD, whereas for women, the risk was highest among those with depression.ConclusionsThe growing number of overweight or obese returning veterans is a concerning problem for clinicians who work with these patients. Successful intervention to reduce the prevalence of obesity will require integrated efforts from primary care and mental health to treat underlying mental health causes and assist with engagement in weight loss programs.

BackgroundAn increasing number of women serve in the military and are exposed to trauma during service that can lead to mental health problems. Understanding how these mental health problems affect reproductive and physical health outcomes will inform interventions to improve care for women veterans.MethodsWe analyzed national Department of Veterans Affairs (VA) data from women Iraq and Afghanistan veterans who were new users of VA healthcare from October 7, 2001, through December 31, 2010 (n = 71,504). We used ICD-9 codes to categorize veterans into five groups by mental health diagnoses (MH Dx): Those with no MH Dx, posttraumatic stress disorder (PTSD), depression, comorbid PTSD and depression, and a MH Dx other than PTSD and depression. We determined the association between mental health category and reproductive and other physical health outcomes defined by ICD-9 codes. Categories included sexually transmitted infections, other infections (e.g., urinary tract infections), pain-related conditions (e.g., dysmenorrhea and dsypareunia), and other conditions (e.g., polycystic ovarian syndrome, infertility, sexual dysfunction). Models were adjusted for sociodemographic and military service factors.ResultsThere were 31,481 patients (44%) who received at least one mental health diagnosis. Women veterans with any mental health diagnosis had significantly higher prevalences of nearly all categories of reproductive and physical disease diagnoses (p < .0001 for adjusted prevalences). There was a trend of increasing prevalence of disease outcomes in women with PTSD, depression, and comorbid PTSD and depression (p for trend

Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients’ use of non-mental health medical services and the impact of mental disorders on utilization.To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans’ first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.Veterans with mental disorders had 42–146% greater utilization than those without mental disorders, depending on the service category (all P

Objectives. We sought to investigate longitudinal trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans. Methods. We determined the prevalence and predictors of mental health diagnoses among 289328 Iraq and Afghanistan veterans entering Veterans Affairs (VA) health care from 2002 to 2008 using national VA data. Results. Of 289328 Iraq and Afghanistan veterans, 106726 (36.9%) received mental health diagnoses; 62929 (21.8%) were diagnosed with posttraumatic stress disorder (PTSD) and 50432 (17.4%) with depression. Adjusted 2-year prevalence rates of PTSD increased 4 to 7 times after the invasion of Iraq. Active duty veterans younger than 25 years had higher rates of PTSD and alcohol and drug use disorder diagnoses compared with active duty veterans older than 40 years (adjusted relative risk=2.0 and 4.9, respectively). Women were at higher risk for depression than were men, but men had over twice the risk for drug use disorders. Greater combat exposure was associated with higher risk for PTSD. Conclusions. Mental health diagnoses increased substantially after the start of the Iraq War among specific subgroups of returned veterans entering VA health care. Early targeted interventions may prevent chronic mental illness. (doi:10.2105/AJPH.2008.150284)

Objectives. We sought to determine whether chronic conditions and functional limitations are equally predictive of mortality among older adults. Methods. Participants in the 1998 wave of the Health and Retirement Study (N = 19430) were divided into groups by decades of age, and their vital status in 2004 was determined. We used multivariate Cox regression to determine the ability of chronic conditions and functional limitations to predict mortality. Results. As age increased, the ability of chronic conditions to predict mortality declined rapidly, whereas the ability of functional limitations to predict mortality declined more slowly. In younger participants (aged 50-59 years), chronic conditions were stronger predictors of death than were functional limitations (Harrell C statistic 0.78 vs. 0.73; P=.001). In older participants (aged 90-99 years), functional limitations were stronger predictors of death than were chronic conditions (Harrell C statistic 0.67 vs. 0.61; P=.004). Conclusions. The importance of chronic conditions as a predictor of death declined rapidly with increasing age. Therefore, risk-adjustment models that only consider comorbidities when comparing mortality rates across providers may be inadequate for adults older than 80 years.

Objectives. We sought to evaluate outcomes of the Veterans Administration (VA) Afghan and Iraq Post-Deployment Screen for mental health symptoms. Methods. Veterans Administration clinicians were encouraged to refer Iraq or Afghanistan veterans who screened positive for posttraumatic stress disorder, depression, or high-risk alcohol use to a VA mental health clinic. Multivariate methods were used to determine predictors of screening, the proportions who screened positive for particular mental health problems, and predictors of VA mental health clinic attendance. Results. Among 750 Iraq and Afghanistan veterans who were referred to a VA medical center and 5 associated community clinics, 338 underwent postdeployment screening; 233 (69%) screened positive for mental health problems. Having been seen in primary care (adjusted odd ratio [AOR]=13.3; 95% confidence interval [CI]=8.31, 21.3) and at a VA community clinic (AOR=3.28; 95% CI=2.03, 5.28) predicted screening. African American veterans were less likely to have been screened than were White veterans (AOR =0.45; 95% CI =0.22, 0.91). Of 233 veterans who screened positive, 170 (73%) completed a mental health follow-up visit. Conclusions. A substantial proportion of veterans met screening criteria for co-occurring mental health problems, suggesting that the VA screens may help overcome a 'don't ask, don't tell' climate that surrounds stigmatized mental illness. Based on data from 1 VA facility, VA postdeployment screening increases mental health clinic attendance among Iraq and Afghanistan veterans. (Am J Public Health. 2008;98:714-720. doi: 10.2105/AJPH.2007.115519)

Escherichia coli strain MG1655 was chosen for sequencing because the few mutations it carries (ilvG rfb-50 rph-1) were considered innocuous. However, it has a number of growth defects. Internal pyrimidine starvation due to polarity of the rph-1 allele on pyrE was problematic in continuous culture. Moreover, the isolate of MG1655 obtained from the E. coli Genetic Stock Center also carries a large deletion around the fnr (fumaratenitrate respiration) regulatory gene. Although studies on DNA microarrays revealed apparent cross-regulation of gene expression between galactose and lactose metabolism in the Stock Center isolate of MG1655, this was due to the occurrence of mutations that increased lacY expression and suppressed slow growth on galactose. The explanation for apparent cross-regulation between galactose and N-acetylglucosamine metabolism was similar. By contrast, cross-regulation between lactose and maltose metabolism appeared to be due to generation of internal maltosaccharides in lactose-grown cells and may be physiologically significant. Lactose is of restricted distribution: it is normally found together with maltosaccharides, which are starch degradation products, in the mammalian intestine. Strains designated MG1655 and obtained from other sources differed from the Stock Center isolate and each other in several respects. We confirmed that use of other E. coli strains with MG1655-based DNA microarrays works well, and hence these arrays can be used to study any strain of interest. The responses to nitrogen limitation of two urinary tract isolates and an intestinal commensal strain isolated recently from humans were remarkably similar to those of MG1655.

Background: The relationship between vitamin D status and COVID-19-related clinical outcomes is controversial. Prior studies have been conducted in smaller, single-site, or homogeneous populations limiting adjustments for social determinants of health (race/ethnicity and poverty) common to both vitamin D deficiency and COVID-19 outcomes. Objective: To evaluate the dose-response relationship between continuous 25(OH)D and risk for COVID-19-related hospitalization and mortality after adjusting for covariates associated with both vitamin D deficiency and COVID-19 outcomes. Design: Retrospective cohort study. Patients: Veteran patients receiving care in US Department of Veteran Affairs (VA) health care facilities with a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test and a blood 25(OH)D test between February 20, 2020, and November 8, 2020, followed for up to 60 days. Main Measures: Exposure was blood 25(OH)D concentration ascertained closest to and within 15 to 90 days preceding an index positive SARS-CoV-2 test. Co-primary study outcomes were COVID-19-related inpatient hospitalization requiring airborne, droplet, contact, or other isolation and mortality ascertained within 60 days of an index positive SARS-CoV-2 test. Key Results: Of 4,599 veterans with a positive SARS-CoV-2 test, vitamin D deficiency (< 20 ng/mL) was identified in 665 (14.5%); 964 (21.0%) were hospitalized; and 340 (7.4%) died. After adjusting for all covariates, including race/ethnicity and poverty, there was a significant independent inverse dose-response relationship between increasing continuous 25(OH)D concentrations (from 15 to 60 ng/mL) and decreasing probability of COVID-19-related hospitalization (from 24.1 to 18.7%, p=0.009) and mortality (from 10.4 to 5.7%, p=0.001). In modeling 25(OH)D as a log-transformed continuous variable, the greatest risk for hospitalization and death was observed at lower 25(OH)D concentrations. Conclusions: Continuous blood 25(OH)D concentrations are independently associated with COVID-19-related hospitalization and mortality in an inverse dose-response relationship in this large racially and ethnically diverse cohort of VA patients. Randomized controlled trials are needed to evaluate the impact of vitamin D supplementation on COVID-19-related outcomes. [ABSTRACT FROM AUTHOR]