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OBJECTIVE: To compare health care system problems or “hassles” experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non‐VA community providers. DATA SOURCES: We collected survey data in 2017‐2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States. STUDY DESIGN: We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans’ experience of hassles (dependent variable), source of health care, self‐rated physical and mental health, and sociodemographics. DATA COLLECTION: Participants responded to mailed surveys by mail, telephone, or online. PRINCIPAL FINDINGS: The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self‐rated physical and mental health, zero‐inflated negative binominal regression indicated that dual care users experienced more hassles than VA‐only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P

BACKGROUND: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed. OBJECTIVE: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA). DESIGN: Qualitative study using semi-structured formative evaluation interviews. PARTICIPANTS: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems. INTERVENTIONS: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients’ experience of care coordination within VA primary care and between PACT and other outpatient and community settings. APPROACH: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers. KEY RESULTS: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs. CONCLUSION: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-04967-y) contains supplementary material, which is available to authorized users.

Comparison of cardiovascular disease (CVD) risk calculators in Latinx majority populations living with HIV can assist clinicians in selecting a calculator and interpreting results. 10-year CVD risks were estimated for 652 patients seen ≥ 2 times over 12 months in a public clinic using three risk calculators: Atherosclerotic CVD risk Calculator (ASCVD), Framingham Risk Calculator (FRC), and Data Collection on Adverse Effects of Anti-HIV Drugs Study (D:A:D) Calculator. Median estimated 10-year CVD risk in this population was highest using FRC (11%), followed by D:A:D (10%), and lowest with ASCVD (5%; p

Demand for building competencies in implementation research (IR) outstrips supply of training programs, calling for a paradigm shift. We used a bootstrap approach to leverage external resources and create IR capacity through a novel 2-day training for faculty scientists across the four Texas Clinical & Translational Science Awards (CTSAs). The Workshop combined internal and external expertise, targeted nationally established IR competencies, incorporated new National Institutes of Health/National Cancer Institute OpenAccess online resources, employed well-known adult education principles, and measured impact. CTSA leader buy-in was reflected in financial support. Evaluation showed increased self-reported IR competency; statewide initiatives expanded. The project demonstrated that, even with limited onsite expertise, it was possible to bootstrap resources and build IR capacity de novo in the CTSA community.

BACKGROUND: Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE: The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN: Multi-site, cluster-randomized QI initiative. PARTICIPANTS: Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS: We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES: We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects. KEY RESULTS: N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1–2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (− 0.42 (− 0.76, − 0.08) non-coached; − 0.40 (− 0.75, − 0.06) coached). However, the DiD (0.02 (− 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION: Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03063294 SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06926-y.

The Institute of Medicine (IOM) suggests that linkages between primary care practices and community-based resources can improve health in lower income and minority patients, but examples of these are rare. We conducted a prospective, mixed-methods observational study to identify indicators of primary care–community linkage associated with the frequency of visits to community-based senior centers and improvements in diabetes-related outcomes among 149 new senior center members (72% Hispanic). We used semistructured interviews at baseline and 9-month follow-up, obtaining visit frequency from member software and clinical assessments including hemoglobin A1c (HbA1c) from colocated primary care clinics. Members’ discussion of their activities with their primary care providers (PCPs) was associated with increased visits to the senior centers, as well as diabetes-related improvements. Direct feedback from the senior centers to their PCPs was desired by the majority of members and may help to reinforce use of community resources for self-management support.

Implementation of the Veterans Choice Program (VCP) allows Veterans to receive care paid for by the Department of Veterans Affairs (VA) in community settings. However, the quality of that care is unknown, particularly for complex conditions such as posttraumatic stress disorder (PTSD). A cross-sectional survey was conducted of 668 community primary care and mental health providers in Texas and Vermont to describe use of guideline-recommended treatments (GRTs) for PTSD. Relatively, few providers reported using guideline-recommended psychotherapy or prescribing practices. More than half of psychotherapists reported the use of at least one guideline-recommended psychotherapy for PTSD, but fewer reported the use of core treatment components, prior training in the GRT(s) they use, or adherence to a treatment manual. Suboptimal prescribing for PTSD patients was reported more commonly than optimal prescribing. Findings raise critical questions regarding how to ensure veterans seeking PTSD care in community settings receive psychotherapy and/or prescribing consistent with clinical practice guidelines.

This work focuses on the hygrothermal behavior of three external thermal insulation systems: one ETICS including EPS insulation and two ventilated cladding systems including either mineral or biobased insulation. These systems were applied on a rendered hollow concrete wall and tested simultaneously between two climatic chambers. Thermocouples, humidity sensors and heat flux sensors allow investigating the hygrothermal behavior of the retrofitted wall at different stages: just after the application of insulations systems, during safe and critical use. The measured data are compared to numerical results obtained by solving a heat and moisture transfer model. Results highlight the key role of adhesive on ETICS, which provides a significant moisture source during the application and forms an additional moisture transfer resistance within the wall. Results on ventilated cladding systems show that using biobased insulation may delay and even prevent the risk of interstitial condensation. The comparison between numerical and experimental results is satisfying for temperature and heat flow density, but underline the sensitivity of relative humidity to the sorption capacity of hygroscopic building materials. In addition, the systems design has a great influence on the condensation risks.

The Institute of Medicine has noted that there is great potential to leverage the infrastructure of community resources to improve health outcomes in lower income and minority patients through primary care-public health linkages, but examples of these are rare. We conducted a prospective, mixed methods observational study to identify indicators of primary care-community linkage associated with frequency of visits to community-based, multi-purpose senior centers and improvements in diabetes-related outcomes among 149 newly enrolled senior center members (72% Hispanic). We used semi-structured interviews at baseline and 9-months follow-up to ascertain patient characteristics and experiences, obtaining visit frequency from senior center software and measures of Hemoglobin A1c (HbA1c) and BMI from co-located primary care clinics. In multivariable linear regression, patients’ discussion of senior center activities with their primary care providers (PCPs) (t=2.15, p=0.03), but not source of primary care (t= -0.48, p=0.63) or referral status (t= -0.86, p=0.39), was significantly associated with frequency of visits after controlling for sociodemographic characteristics, travel distance from home to senior center, disease burden, diabetes status, and sedentary behavior. Members’ discussion of senior center activities with their PCPs was significantly associated with reductions of 0.57% in HbA1c (p=0.005) and 0.68 kg/m2 in BMI (p=0.046) at follow-up, controlling for baseline covariates and number of senior center visits. In addition, the majority of these patients wanted direct feedback from the senior centers to their PCPs, which may help reinforce use of community-based resources to support self-management among aging patients, including minorities, with diabetes or other chronic conditions.

Introduction Among US veterans, posttraumatic stress disorder (PTSD) is a high-prevalence condition; more than a million veterans of all combat eras are service-connected for this condition. Research on factors driving veterans’ decision-making regarding preferred setting for PTSD care has been limited. The purpose of this study was to understand factors associated with preferences for setting of future PTSD care among veterans service-connected for PTSD. Materials and Methods We conducted a cross-sectional mailed survey among veterans with service connection for PTSD in Texas and Vermont identified from the Veterans Services Network Corporate Mini Master File (VETSNET). Survey items were intended to elucidate PTSD healthcare decision-making and queried utilization, perceived need for care, and satisfaction and preferences for VA, community, and/or military setting for receipt of future PTSD care. Logistic regression was used to identify factors associated with preference for care setting. UT Health San Antonio’s Institutional Review Board determined this quality improvement project to be non-research. Results Veterans (n = 2,327) were surveyed with an overall response rate of 37.1%. Most veterans (72.4%) identified VA as a preferred site for their future PTSD care; a substantial, but smaller, number of veterans identified being interested in receiving care in community (39.9%) and military (12.7%) settings. Factors associated with preferences for future care setting included demographics (e.g., ethnicity, income), availability of healthcare coverage, prior experiences of care, and attitudes related to perceived quality of care and trust in VA. Conclusions These findings suggest that it is important to retain foundational mental health services within VA, as well as to continue to invest in building provider and network capacity in community settings, to ensure alignment with veteran preferences for care setting.

Promising practices for the coordination of chronic care exist, but how to select and share these practices to support quality improvement within a healthcare system is uncertain. This study describes an approach for selecting high-quality tools for an online care coordination toolkit to be used in Veterans Health Administration (VA) primary care practices. We evaluated tools in three steps: (1) an initial screening to identify tools relevant to care coordination in VA primary care, (2) a two-clinician expert review process assessing tool characteristics (e.g. frequency of problem addressed, linkage to patients' experience of care, effect on practice workflow, and sustainability with existing resources) and assigning each tool a summary rating, and (3) semi-structured interviews with VA patients and frontline clinicians and staff. Of 300 potentially relevant tools identified by searching online resources, 65, 38, and 18 remained after steps one, two and three, respectively. The 18 tools cover five topics: managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, agenda setting, patient pre-visit packet, and provider contact information for patients. The final toolkit provides access to the 18 tools, as well as detailed information about tools' expected benefits, and resources required for tool implementation. Future care coordination efforts can benefit from systematically reviewing available tools to identify those that are high quality and relevant.

Aims: To examine providers’ behavioral intention toward the utilization of genomic services at the Veterans Health Administration (VHA; Washington, DC, USA) through the lens of the ‘Theory of Planned Behavior’. The theory of planned behavior posits that individuals’ behaviors (using genomic services) are driven by their behavioral intentions. Behavioral intentions is a function of: first, behavioral beliefs; second, normative beliefs, and third; control beliefs. Materials & methods: Semi-structured interviews were conducted with 20 providers working in different units at the South Texas Veterans Health Care System (STVHCS; TX USA). The interviews focused on assessing providers’ behavioral beliefs, normative beliefs and control beliefs regarding the delivery of genomic medicine at the STVHCS. Interview materials were tape recorded, transcribed and the content was analyzed using qualitative methods. Results: All participating providers perceived genomic medicine to be an important area in medicine (behavioral beliefs). They agreed that the VHA has the necessary infrastructure to foster the delivery of genomic services. The majority of participants (n = 18; 90%) agreed that primary care providers will play a major role in delivering genomic services. Providers indicated that referents’ (other providers) opinions about genomic services may affect their decisions about whether to utilize genomic services (normative beliefs). However, most providers (n = 17; 85%) raised concerns about the impact of using genomic services on the process of care (control beliefs). Participants indicated that additional training for providers and patients, and decision support will facilitate the delivery of genomic services (control beliefs). Providers also identified three external barriers: first, uncertainty about genomic findings; second, coordination of care between primary care, specialists and genetic services (system level barriers); and third ethical issues associated with genomic information and services. Conclusion: Our findings highlight several opportunities and challenges related to the delivery of genomic medicine at the VHA. The results suggest that strategies to address providers’ concerns in the control beliefs domain may be necessary to enhance providers’ utilization of genomic services in clinical practice.

Background Successfully transitioning patients from hospital to home is a complex, often uncertain task. Despite significant efforts to improve the effectiveness of care transitions, they remain a challenge across health care systems. The lens of complex adaptive systems (CAS) provides a theoretical approach for studying care transition interventions, with potential implications for intervention effectiveness. The aim of this study is to examine whether care transition interventions that are congruent with the complexity of the processes and conditions they are trying to improve will have better outcomes. Methods We identified a convenience sample of high-quality care transition intervention studies included in a care transition synthesis report by Kansagara and colleagues. After excluding studies that did not meet our criteria, we scored each study based on (1) the presence or absence of 5 CAS characteristics (learning, interconnections, self-organization, co-evolution, and emergence), as well as system-level interdependencies (resources and processes) in the intervention design, and (2) scored study readmission-related outcomes for effectiveness. Results Forty-four of the 154 reviewed articles met our inclusion criteria; these studies reported on 46 interventions. Nearly all the interventions involved a change in interconnections between people compared with care as usual (96% of interventions), and added resources (98%) and processes (98%). Most contained elements impacting learning (67%) and self-organization (69%). No intervention reflected either co-evolution or emergence. Almost 40% of interventions were rated as effective in terms of impact on hospital readmissions. Chi square testing for an association between outcomes and CAS characteristics was not significant for learning or self-organization, however interventions rated as effective were significantly more likely to have both of these characteristics (78%) than interventions rated as having no effect (32%, p = 0.005). Conclusions Interventions with components that influenced learning and self-organization were associated with a significant improvement in hospital readmissions-related outcomes. Learning alone might be necessary but not be sufficient for improving transitions. However, building self-organization into the intervention might help people effectively respond to problems and adapt in uncertain situations to reduce the likelihood of readmission. Electronic supplementary material The online version of this article (10.1186/s12913-018-3712-7) contains supplementary material, which is available to authorized users.

Introduction Effective delivery of healthcare in complex systems requires managing interdependencies between professions and organisational units. Reducing 30-day hospital readmissions may be one of the most complex tasks that a healthcare system can undertake. We propose that these less than optimal outcomes are related to difficulties managing the complex interdependencies among organisational units and to a lack of effective sensemaking among individuals and organisational units regarding how best to coordinate patient needs. Methods and analysis This is a mixed method, multistepped study. We will conduct in-depth qualitative organisational case studies in 10 Veterans Health Administration facilities (6 with improving and 4 with worsening readmission rates), focusing on relationships, sensemaking and improvisation around care transition processes intended to reduce early readmissions. Data will be gathered through multiple methods (eg, chart reviews, surveys, interviews, observations) and analysed using analytic memos, qualitative coding and statistical analyses. We will construct an agent-based model based on those results to explore the influence of sensemaking and specific care transition processes on early readmissions. Ethics and dissemination Ethical approval has been obtained through the Institutional Review Board of the University of Texas Health Science Center at San Antonio (approval number: 14–258 hour). We will disseminate our findings in manuscripts in peer-reviewed journals, professional conferences and through short reports back to participating entities and stakeholders.

This study provides an overview on the impacts of climate change on agricultural water management, including agricultural water requirement, water availability and water quality, and the transition of those impacts to crop yield, agricultural land suitability and livestock production systems, considering both long-term trends of climate and extreme climatic events. A synthesis of findings from local, regional, and global studies guides this article's discussion of scientifically based information, implications for managing the risk of water scarcity and food insecurity, and future research. Negative and positive climate change impacts occurring at the local scale may counteract each other at the global scale (e.g., those on irrigation requirement and arable land availability); the impacts from the various factors can be counter-balanced too (e.g., CO2 and water deficit impact on crop yield). Meanwhile, the shocks at the local and regional levels have been or will be caused by water quantity and quality problems and are pressing concerns for decision making. Although uncertainty in climate change predictions remains a critical issue for decision making, certain knowledge about the impact on crop production has been obtained from historical data. Finally, future research needs to focus on gaining a more detailed understanding of climate change (especially extreme events), climate change impacts, both natural and social response mechanisms, and adaptation measures of agricultural water management. More focus should be laid on improving impact assessment via the various methods such as retrospective analysis, monitoring, prediction, and strategic risk management. Moreover, planned adaptations in agricultural water management will be needed to facilitate more consistent and more effective responses to climate change, with consideration of the linkage with nonagricultural water uses. WIREs Water 2015, 2:439–455. doi: 10.1002/wat2.1089 This article is categorized under: Engineering Water > Planning Water Science of Water > Water and Environmental Change

A l’initiative de la ville d’Orleans, il a ete developpe puis applique sur le perimetre de protection eloignee des captages alimentant la ville (Val d’Orleans au sud de la Loire) un modele numerique innovant permettant de correler et de prevoir, en fonction des pratiques phytosanitaires agricoles, la nature et les quantites de pesticides transferes jusqu’aux captages. L’application, baptisee Phyto’Scope, a ete construite en couplant un modele de transfert dans le sol realise par Footways avec un modele de transfert dans le sous-sol elabore par Geo-Hyd. Une premiere phase a consiste a recueillir les donnees necessaires au parametrage des modeles : distribution spatiale et type de cultures, pratiques phytosanitaires, climatologie, pedologie, hydrogeologie. D’un point de vue quantitatif, la modelisation dans le sol montre que sur 4 t/an de substances actives appliquees, 43 kg seulement percolent vers le soussol et donc vers la nappe. D’un point de vue qualitatif, la modelisation dans le sous-sol permet d’observer que sur 121 substances appliquees, dix molecules sont restituees par infiltration. Les donnees issues du modele « sol » alimentent un maillage de 250 m × 250 m sur tout le perimetre. Le modele a permis de tracer une carte des temps de sejour et des vitesses de transfert, une carte des secteurs les plus sensibles et de prevoir les concentrations finales dans les eaux prelevees aux captages. Le metazachlore (au travers de ses deux principaux metabolites) est la molecule la plus transferee et peut depasser des concentrations superieures a 0,1 g/L. Les analyses realisees par la suite dans la ressource ont corrobore ce resultat. Le bon comportement du modele et sa relative facilite de mise en oeuvre permettent d’envisager son utilisation a des fins predictives ou de sensibilisation, puis de proposer dans un second temps des outils et actions d’animation pour une utilisation des produits phytosanitaires en adequation avec la protection de la ressource en eau.

Significant changes in national health policy, like the Veterans Choice Act, have created growing opportunities for veterans to receive care outside of the Veterans Administration (VA), yet little is known about the attitudes and practices in PTSD care of community providers, particularly their use of evidence-based psychotherapies (EBPs). The authors assessed psychotherapy practices of community providers serving veterans with PTSD in Texas. They surveyed Texas mental health providers regarding their patient population, practice setting, and posttraumatic stress disorder (PTSD)-related screening, assessment, and treatment practices. They identified providers from state licensing board rosters and included a stratified sample of social workers, marriage and family therapists, and professional counselors (500 each), all psychologists with available email addresses (n = 3,986), and 106 providers known to have completed state-sponsored training for 1 of the EBPs for PTSD, cognitive processing therapy. Four hundred sixty-three eligible respondents returned surveys (15% response rate). Providers reported treating a mean of 7.9 veterans with PTSD in the past year (range = 0-200; SD = 20.5), using a variety of therapeutic approaches for PTSD. Only 15.0% of providers reported regularly conducting psychotherapy for PTSD following a treatment manual, and fewer than half reported any use of EBPs for PTSD with patients. Although many veterans are receiving treatment for PTSD in the community, many community-based mental health providers in Texas do not consistently use recommended treatments for PTSD. These findings may suggest an important opportunity for VA to engage and partner with community providers to achieve high-quality care for veterans. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

International audience; Objectives: Clustered cases of urogenital schistosomiasis were reported in April 2014 among French and German tourists linked to exposure in the Cavu River, Southern Corsica, France, between 2011 and 2013. We set up national surveillance for autochthonous urogenital schistosomiasis to document the largest possible number of cases in order to identify potential sites of transmission and to determine the extent of the outbreak in France and Corsica.Methods:The early response consisted mostly of prohibiting swimming in the river, performing a nationwide serologic screening of all persons exposed to the river between 2011 and 2013 and treating confirmed cases. Physicians were asked to report all patients with one or more positive antischistosome serologic test. Cases were defined as occurring in a resident of France with serologic evidence of schistosomiasis or schistosome eggs in urine and no history of contact with freshwater in known endemic areas. We documented symptoms as well as place and time of exposure to freshwater for all subjects. To estimate the outbreak size, we modelled the effect of the 2014 nationwide screening on the 2011–2015 time series of serodiagnosed schistosomiasis cases using log-linear autoregression.Results: In 2014, a total of 106 autochthonous cases were reported, including 35 symptomatic infections. All patients had swum in the Cavu during summer 2013. Over 30 000 persons were likely screened for autochthonous schistosomiasis. The model-estimated outbreak size was 338 cases, including 36 serodiagnosed in 2015.Conclusions: Besides the 2013 outbreak, there is evidence of small-scale transmission in 2015 in Corsica. Early detection and control of recurrences requires raising community and medical awareness.

Thrombotic microangiopathy (TMA) is one of the hallmark vascular lesions of antiphospholipid syndrome nephropathy (APSN). These lesions are at high risk of recurrence after kidney transplantation. The complement pathway is thought to be active in this process. We used eculizumab to treat three consecutive kidney transplant recipients with posttransplant TMA due to APSN recurrence that was resistant to plasmapheresis and explored the complement deposition and apoptotic and vascular cell markers on the sequential transplant biopsies. Treatment with eculizumab resulted in a rapid and dramatic improvement of the graft function in all three patients and in improvement of the TMA lesions within the graft. None of these patients had TMA flares after eculizumab was withdrawn. At the time of TMA diagnosis, immunofluorescence studies revealed intense C5b-9 and C4d depositions at the endothelial cell surface of the injured vessels. Moreover, C5b-9 colocalized with vessels exhibiting a high rate of apoptotic cells. Examination of sequential biopsies during eculizumab therapy showed that TMA lesions, C4d and apoptotic markers were rapidly cleared but the C5b-9 deposits persisted for several months as a footprint of the TMA. Finally, we noticed that complement inhibition did not prevent the development of the chronic vascular changes associated with APSN. Eculizumab seems to be an efficient method for treating severe forms of posttransplant TMA due to APSN recurrence. Terminal complement inhibition does not prevent the development of chronic APSN.

To evaluate the clinical utility of a new scale assessing Self-Efficacy for Life Tasks (SELT), we examined whether SELT was associated with postdeployment symptoms among male U.S. veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). A total of 41 OEF/OIF veterans completed the SELT scale and measures of post-traumatic stress disorder (PTSD), anxiety, depression, combat exposure, postdeployment social support, and stressful life events. SELT emerged as significantly associated with PTSD, depression, and anxiety, and remained significant following adjustment for stress exposures and social support. The SELT scale may aid in assessing functional concerns following reintegration and targeting therapy to address veterans’ individual life challenges.

Background: In 2014, the Department of Veterans Affairs (VA) implemented the Veterans Choice Program (VCP) to provide reimbursement for community-based care to eligible veterans. Inadequate networks of participating providers may impact the utility of VCP for veterans with posttraumatic stress disorder (PTSD), a complex condition occurring at lower frequency among civilians. Objectives: To compare characteristics and attitudes of community-based primary care and mental health providers reporting interest or no interest in VCP participation during early implementation; and to examine perceptions and experiences of VCP among “early adopters.” Research Design: Cross-sectional surveys with 2 samples: a stratified random sample of mental health and primary care prescribers and psychotherapists drawn from state licensing boards (Community Sample); and a stratified random sample of prescribers and psychotherapists identified as VCP-authorized providers (VCP-Authorized). Subjects: Five hundred fifty-three respondents in the Community Sample and 115 in the VCP-Authorized (total, n=668; 21.1% response). Measures: Surveys assessed provider and practice characteristics, attitudes to VA and VCP, and experiences and satisfaction with the VCP; an open-ended survey item assessed providers’ reasons for interest or lack of interest in VCP participation. Results: Few providers reported VCP participation during this period. Interest in VCP participation was associated across provider groups with factors including being a veteran and receiving VA reimbursement; currently providing treatment for PTSD was associated with interest in VCP participation among psychotherapists, but not prescribers. Conclusions: Developing networks of VCP providers to serve Veterans with PTSD is likely to require targeting more receptive provider groups, reducing barriers to participation, and more effectively communicating the value of VCP participation to providers.

To identify and validate trajectories of comorbidity associated with traumatic brain injury in male and female Iraq and Afghanistan war Veterans (IAV).Derivation and validation cohorts were compiled of IAV who entered the Department of Veterans Affairs (VA) care and received 3 years of VA care between 2002-2011. Chronic disease and comorbidities associated with deployment including TBI were identified using diagnosis codes. A latent class analysis (LCA) of longitudinal comorbidity data was used to identify trajectories of comorbidity.LCA revealed five trajectories that were similar for women and men: (1) Healthy, (2) Chronic Disease, (3) Mental Health, (4) Pain and (5) Polytrauma Clinical Triad (PCT: pain, mental health and TBI). Two additional classes found in men were 6) Minor Chronic and 7) PCT with chronic disease. Among these gender-stratified trajectories, it was found that women were more likely to experience headache (Pain trajectory) and depression (Mental Health trajectory), while men were more likely to experience lower back pain (Pain trajectory) and substance use disorder (Mental Health trajectory). The probability of TBI was highest in the PCT-related trajectories, with significantly lower probabilities in other trajectories.It was found that TBI was most common in PCT-related trajectories, indicating that TBI is commonly comorbid with pain and mental health conditions for both men and women. The relatively young age of this cohort raises important questions regarding how disease burden, including the possibility of neurodegenerative sequelae, will accrue alongside normal age-related decline in individuals with TBI. Additional 'big data' methods and a longer observation period may allow the development of predictive models to identify individuals with TBI that are at-risk for adverse outcomes.

Obesity is an increasing problem in the USA, and research into the association between obesity and pneumonia has yielded conflicting results. Using Department of Veterans Affairs administrative data from fiscal years 2002-2006, we examined a cohort of patients hospitalised with a discharge diagnosis of pneumonia. Body mass index was categorised as underweight (

Cost burdens represent a significant barrier to medication adherence among chronically ill patients, yet financial pressures may be mitigated by clinical or organizational factors, such as treatment aligned with the Chronic Care Model (CCM). This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden.Surveys were administered to patients at 40 small community-based primary care practices. Medication adherence was assessed using the 4-item Morisky scale, while five cost-related items documented recent pharmacy restrictions. CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care (PACIC). Nested random effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden.Of 1823 respondents reporting diabetes and other chronic diseases, one-quarter endorsed intrapersonal adherence barriers, while 23% restricted medication due of cost. Controlling for age and health status, the relationship between medication cost and CCM with adherence was significant; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior.Patients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden. Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence.

This paper describes the development and preliminary validation of a scale to assess perceived self-efficacy to complete culturally and age-appropriate life tasks (SelfEfficacy for Life Tasks, or SELT) among male veterans of Afghanistan (Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF). The SELT scale was developed for this population in a multistage process that included: 1) semistructured interviews inquiring about expectations of self among OEF/OIF veterans; 2) content analysis to inductively derive a list of priority life tasks; 3) item development; 4) field-testing; and 5) preliminary instrument validation. Forty-one veterans completed the final instrument along with measures of anxiety and depression symptoms, positive and negative social support, and postdeployment life stressors. We tested two scoring methods, one using a simple mean and one a weighted mean. Using either scoring method, SELT had statistically significant negative correlations with anxiety, depression, and being separated from partner, as well as strong positive correlations with postdeployment social support. These findings support the construct validity of the SELT scale in the population of male OEF/OIF veterans. Future research examining the relationship between SELT and long-term outcomes using longitudinal designs will be needed to assess predictive validity.

In response to dramatic increases in obesity prevalence, clinical guidelines urge health care providers to prevent and treat obesity more aggressively.To describe the proportion of obese primary care patients receiving obesity care over a 5-year period and identify factors predicting receipt of care.Retrospective cohort study utilizing VHA administrative data from 6 of 21 VA administrative regions.Veterans seen in primary care in FY2002 with a body mass index (BMI)or =30 kg/m(2) based on heights and weights recorded in the electronic medical record (EMR), survival through FY2006, and active care (1 or more visits in at least 3 follow-up years FY2003-2006).Receipt of outpatient visits for individual or group education or instruction in nutrition, exercise, or weight management; receipt of prescriptions for any FDA-approved medications for weight reduction; and receipt of bariatric surgery.Of 933,084 (88.6%) of 1,053,228 primary care patients who had recorded heights and weights allowing calculation of BMI, 330,802 (35.5%) met criteria for obesity. Among obese patients who survived and received active care (N = 264,667), 53.5% had a recorded obesity diagnosis, 34.1% received at least one outpatient visit for obesity-related education or counseling, 0.4% received weight-loss medications, and 0.2% had bariatric surgery between FY2002-FY2006. In multivariable analysis, patients older than 65 years (OR = 0.62; 95% CI: 0.60-0.64) were less likely to receive obesity-related education, whereas those prescribed 5-7 or 8 or more medication classes (OR = 1.41; 1.38-1.45; OR = 1.94; 1.88-2.00, respectively) or diagnosed with obesity (OR = 4.0; 3.92-4.08) or diabetes (OR = 2.23; 2.18-2.27) were more likely to receive obesity-related education.Substantial numbers of VHA primary care patients did not have sufficient height or weight data recorded to calculate BMI or have recorded obesity diagnoses when warranted. Receipt of obesity education varied by sociodemographic and clinical factors; providers may need to be cognizant of these when engaging patients in treatment.

Objective: Communicating genetic research results to participants presents ethical challenges. Our objectives were to examine participants’ preferences in receiving future genetic research results and to compare preferences reported by veteran and nonveterans participants. Methods: Secondary analysis was performed on data collected in 2000–2004 from 1,575 consent forms signed by Mexican-American participants enrolled in 2 genetic family studies (GFS) in San Antonio: The Family Investigation of Nephropathy and Diabetes (FIND) and the Extended FIND (EFIND). The consent forms for these studies contained multiple-choice questions to examine participants’ preferences about receiving their (1) clinical lab results and (2) future genetic research results. The FIND and EFIND databases had information on subjects’ demographic characteristics and some selected clinical variables. We identified veterans using the Veterans Health Administration’s (VHA’s) centralized data repository. We compared veterans’ and nonveterans’ preferences using Student’s t test for continuous variables and χ2 test for discrete variables. A logistic regression analyzed subjects’ preference for receiving their research results, controlling for other socio-demographic and clinical variables. Results: The sample included 275 (18%) veterans and 1,247 (82%) nonveterans. Our results indicated a strong desire among the majority of participants 1,445 (95%) in getting their clinical lab research results. Likewise, 93% expressed interest in being informed about their future genetic results. There was no significant difference in veterans’ and nonveterans’ preference to disclosure of the research results (χ2 test; p > 0.05). Regression analysis showed no significant relationship (p = 0.449) between the outcome (receiving research results) and veterans’ responses after controlling for demographics and educational levels. Conclusion: Participants believed they would prefer receiving their genetic research results. Veterans are similar to nonveterans in their preferences. Offering genetic research results to participants should be based on well defined and structured plans to enhance interpretation of genetic data.

Objectives To compare the clinical outcomes of young-old patients (aged 60–74 years) and old-old patients (aged 75 years and older) who received collaborative care management for depression. Design Multisite randomized clinical trial. Setting Eighteen primary care clinics from eight healthcare organizations. Participants Nine hundred six patients (N = 606 young-old; N=300 old-old) with major depression and/or dysthymia who were randomized to receive collaborative care in the Improving Mood: Promoting Access to Collaborative Treatment trial. Intervention Patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician. Measurements Young-old and old-old patients were compared on process of care and outcome variables. Process of care was determined by the type of treatment and level of care received. Clinical outcomes included Symptom Checklist (SCL)-20 depression scores, treatment response (defined as a ≥50% decrease in the SCL-20 score from baseline), and complete remission (defined as a SCL-20 score Results The process of care variables did not significantly differ between the two age groups. Young-old patients had similar treatment responses at initial follow-up (3 months) but were significantly more likely to respond to treatment and meet complete remission criteria than old-old patients at 6-, 12-, 18-, and 24-months. Conclusions Young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission in the long run.

Nephrotoxicity of calcineurin inhibitors (CNIs) is an acute, reversible and chronic, irreversible pathology. Histologically, acute nephrotoxicity manifests as hemodynamic modifications caused by vasoconstriction of the essentially afferent arterioles resulting in a drop in the glomerular filtration rate. Chronic nephrotoxicity is characterized by arteriolar hyalinosis resulting in a variety of tubulointerstitial and glomerular lesions with an essentially ischemic mechanism. However, these histological lesions, whether chronic or acute, are not specific of CNI toxicity and can be seen in the course of many pathological circumstances in kidney transplantation. This absence of specificity makes the histological diagnosis of CNI nephrotoxicity difficult. In addition, the individual risk of developing CNI nephrotoxicity, difficult to predict based solely on the pharmacokinetic parameters of systemic CNI exposure, also involves local exposure (CNI concentrations in the graft) modulated by several, notably pharmacogenetic factors. The difficulty of diagnosing CNI nephrotoxicity and the interindividual variability of its risk require development of new diagnostic tools so that the patients at highest risk of developing severe CNI nephrotoxicity lesions, in whom minimization protocols would produce the best risk-benefit ratio, can be identified.

Resume La biopsie renale est un outil precieux utilise pour la surveillance des greffons et la gestion de leur survie. Depuis 1993, grâce aux recherches realisees sur des tissus biopsiques qui ont permis de distinguer les differents types de rejet et de trouver des marqueurs de rejet reversible ou irreversible, une classification des lesions renales a ete mise en place, la classification de Banff, regulierement mise a jour depuis. La derniere en date (2005) definit le rejet chronique medie par anticorps, abandonne le terme de nephropathie d’allogreffe et decrit une nouvelle classe avec la fibrose interstitielle et atrophie tubulaire (FI/AT). Les biopsies systematiques ou de depistage permettent de reveler des lesions de rejet infraclinique avant toute degradation de la fonction renale, de mieux comprendre la physiopathologie de la nephropathie d’allogreffe, de preciser le diagnostic, mais aussi de reveler d’autres lesions plus specifiques pouvant beneficier d’un traitement. Elles ont cependant leurs limites avec les difficultes d’interpretation, les risques qu’elles font encourir au patient et leur cout.

Uranium monocarbide (UC) or ternary alloys are considered to be possible candidates for future nuclear fuels. Although the crystallographic and electronic structure of UC has been addressed in past investigations, discrepancies in the literature data have fostered a new investigation of the UC phase. We report here a reinvestigation of the UC phase by complementary X-ray spectroscopy and quantum chemical calculations. A combination of X-ray powder diffraction and extended X-ray absorption fine structure analysis at the uranium LIII edge led to the crystallographic determination of the UC phase of the NaCl type. For electronic structure investigation, a combination of uranium X-ray absorption near-edge spectroscopy at the LIII edge and at the NIV,V edges with quantum chemical calculations allowed us to define the evolution of the metal charge in comparison with metallic uranium on the one hand and uranium dioxide on the other hand.