VA Program Research Articles

Testosterone and neurobehavioral outcomes in special operations forces military with multiple mild traumatic brain injury.

U.S. Special Operations Forces (SOF) are at increased risk of multiple mild traumatic brain injury (mmTBI). Testosterone was prescribed for several participants in a VA program designed to address sequelae of mmTBI for SOF. To determine testosterone prevalence in the Palo Alto VA Intensive Evaluation and Treatment Program (IETP) and observe for association between testosterone and neurobehavioral outcomes. A retrospective cohort study included patients in the Palo Alto VA IETP. Sociodemographic data, testosterone blood levels, and neurobehavioral outcomes were collected from medical records. 55 IETP participants were included: six were testosterone users; the rest were classified as non-users. Testosterone use in this population is 11%, higher than reported national averages in the U.S. Of the 6 testosterone users, 2 (33%) had a formal diagnosis of hypogonadism prior to initiation of testosterone. Neurobehavioral outcome scores between testosterone users and non-users failed to show statistically significant differences, except for the PROMIS pain score, which was higher in the testosterone user population. The current study did not find an association between mmTBI, testosterone use, or testosterone level and neurobehavioral outcomes. This study highlights a need to further examine the relationship between hypogonadism, mmTBI, SOF culture around testosterone, and the effects of testosterone use in this population.

Supraventricular arhythmias in women – why do they require more indepth diagnostics? Rationale for project Pol-Ger Rytmia

Available data indicate that the incidence, clinical course, diagnosis and treatment of supraventricular arrhythmias show marked gender-dependent differences. Gender-dependent peculiarities in the electrophysiological properties of the heart and very complex hormonal influences in women are cited as potential reasons for the higher incidence of most arrhythmias in women and the different clinical course. The differences put women at a disadvantage compared to men in the diagnostic and treatment process. To improve this situation, we have proposed and are already running the project “Women’s Heart – a cross-border two-center study of cardiac arrhythmias in women – POL-GER Rytmia”, financed by the European Union under the Interreg VA program.

What We Know About Homeless Veterans With Other-than-honorable and Punitive Discharges: Data From the Grant and Per Diem (GPD) Program.

The U.S. DVA Grant and Per Diem (GPD) program funds community agencies to provide housing and case management services to Veterans experiencing homelessness. GPD is one of the few VA programs that can enroll Veterans with Other-than-Honorable (OTH) military discharges. The characteristics of OTH Veterans and their outcomes in GPD are unknown. We linked the Homeless Operations and Management Evaluation System database and VA Corporate Data Warehouse to identify Veterans with complete GPD enrollment and discharge data between 2018 and 2020. We categorized Veterans into three military discharge groups: Honorable, OTH, or Punitive. We evaluated key GPD process and outcomes measures: days enrolled in GPD, use of VA-funded emergency department care while in GPD, and whether a Veteran was successfully discharged from GPD, their housing status at program exit, employment status at program exit, and connection to mental health and substance abuse treatment at discharge. We conducted multivariable regressions to determine the adjusted association (controlling for demographics and comorbidities) between military discharge status and process and outcome measures. Among 21,646 Veterans in the GPD program, 20,517 (95%) were honorably discharged; 811 (4%) had an OTH discharge; and 318 (1%) had a Punitive discharge. There was no difference in GPD length of enrollment by discharge status. Compared to honorably discharged veterans, OTH and Punitive discharged Veterans were less likely to successfully exit GPD, more likely to be homeless and employed at program exit, and were less likely to have a VA-funded emergency department visit while in GPD and less likely to be connected to mental health care or substance use treatment at program exit. The GPD program serves hundreds of homeless Veterans with OTH and Punitive discharges every year, but they seem to be at greater risk for negative health and psychosocial outcomes and do not have the same access to VA services as other Veterans. These findings may inform policy considerations about expanding VA care and opportunities for community providers to serve Veterans with OTH and Punitive discharges.

Findings from a Peer-Facilitated, Social Isolation Intervention in the Veterans Health Administration Healthcare System: A Mixed-Methods, Pilot Feasibility Study.

Social isolation is a global public health threat. Veterans are particularly at risk for social isolation due to high rates of comorbid physical and mental health problems. Yet, effective interventions are limited. Our primary objective was to assess the feasibility and acceptability of CONNECTED, a novel, transdiagnostic intervention to reduce social isolation that includes individual and group components and is delivered by peers via telehealth. Secondary objectives were to identify appropriate outcome measures and explore preliminary intervention effects. This was a two-phase study. In Phase 1, to evaluate study feasibility, we surveyed 200 veterans to assess prevalence of social isolation and their interest in social connectedness interventions. In Phase 2, we employed a mixed-methods, pre-post study design in which we piloted CONNECTED with 19 veterans through 2 successive cohorts to further assess feasibility, to evaluate acceptability, and to explore preliminary effectiveness. Quantitative analyses involved descriptive and bivariate analyses as well as multivariate modeling. Qualitative interviews were analyzed using thematic analysis. For Phase 1, 39% of veterans surveyed were socially isolated. Participants who were ≤ 55years old, caregivers, and those who experienced unmet social needs were more likely to report social isolation. Over 61% expressed interest in VA programs to reduce social isolation. For Phase 2, the pilot intervention, recruitment rate was 88% and the enrollment rate was 86%. Retention rates for the two cohorts were 80% and 50%, respectively, and satisfaction rates among intervention completers were 100%. Results also showed statistically significant improvements in social isolation (+ 5.91, SD = 4.99; p = .0028), social support (+ 0.74, SD = 1.09; p = .03), anxiety (-3.92, SD = 3.73; p = .003), and depression (-3.83, SD = 3.13; p = .001). Results for the other measures were not statistically significant. CONNECTED is a feasible and acceptable intervention and is likely to be an effective tool to intervene on social isolation among veterans.

MP48-12 ASSESSING THE IMPACT OF VETERANS HEALTH ADMINISTRATION CHOICE LEGISLATION ON TREATMENT OF LOW-RISK PROSTATE CANCER IN RURAL VETERANS

You have accessJournal of UrologyCME1 Apr 2023MP48-12 ASSESSING THE IMPACT OF VETERANS HEALTH ADMINISTRATION CHOICE LEGISLATION ON TREATMENT OF LOW-RISK PROSTATE CANCER IN RURAL VETERANS Bradley Erickson, Richard Hoffman, Jason Wachsmuth, and Mary Vaughan-Sarrazin Bradley EricksonBradley Erickson More articles by this author , Richard HoffmanRichard Hoffman More articles by this author , Jason WachsmuthJason Wachsmuth More articles by this author , and Mary Vaughan-SarrazinMary Vaughan-Sarrazin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003294.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The 2014 Veterans Choice (Choice) Legislation provided unprecedented access to non-Veterans Health Administration (VHA) healthcare facilities for men living > 40 miles from their closest VHA tertiary facility and/or men experiencing wait times for specialized care of > 60 days. The study purpose was to determine how non-VHA care supported by Choice affected receipt of definitive treatment (prostatectomy/radiation therapy) for low-risk prostate cancer (CaP) – a patient group for whom conservative treatment is strongly recommended by guidelines. METHODS: The cohort included 45,685 men diagnosed with CaP from 2015-2018 who regularly used the VHA. We used VHA claims data and the VA Program Integrity Tool to identify care provided inside and outside (Choice funded) of VHA facilities, respectively. The primary outcomes were 1) definitive CaP care for Grade Group 1 (GG1; Gleason 3+3 or less) CaP and 2) definitive care for men diagnosed at age >70 with PSA < 10 ng/mL. We used multivariable modeling to determine the relationships between patient, facility, tumor characteristics, and biopsy location with receipt of definitive care. RESULTS: We identified 10,499 (23%) men in the cohort with GG1 disease, of which 4097 (39%) underwent definitive treatment (Table). Definitive treatment among GG1 was predicted by lower age (RR 0.98), higher PSA (RR 1.53), Black (non-Hispanic) race (RR 1.1), distance from tertiary VHA (40-90 miles RR 1.15; > 90 miles RR 1.11) and non-VHA diagnostic biopsy location (RR 1.29). There were 6445 (14%) men with CaP that were older than 70 with PSA <10, of which 3836 (60%) underwent definitive treatment. Definitive treatment was predicted by higher Gleason Grade Group (2/3 RR 2.44; 4/5 RR 2.65), lower age (RR 0.97) and non-VHA diagnostic biopsy location (RR 1.16). CONCLUSIONS: We found significant differences in managing low-risk CaP between Veterans receiving care in the VHA and those using their Choice eligibility to receive outside care. The location of the diagnostic biopsy appears to have the greatest impact on treatment and thus may represent a potential target of intervention to minimize the risk of overtreating Veterans with CaP by decreasing care fragmentation. Source of Funding: U.S. Department of Veterans Affairs Office of Rural Health (OMAT 16010) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e659 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bradley Erickson More articles by this author Richard Hoffman More articles by this author Jason Wachsmuth More articles by this author Mary Vaughan-Sarrazin More articles by this author Expand All Advertisement PDF downloadLoading ...

Utilizing Telehealth to Meet the Needs of Rural Veterans: Introduction the VA's Clinical Resource Hubs Geriatric Mental Health Programs

The Department of Veterans Affairs Clinical Resource Hubs (CRHs) offer a variety of telehealth initiatives designed to expand access to care. Each VA Integrated Service Network (VISN) or region has its own CRH to provide telehealth services to veterans residing in that region. Many older veterans receiving services through the telemental health programs reside in rural areas, with limited access to specialty care. Several CRHs offer geriatric mental health consults to expand older veterans’ access to specialty mental health treatment. By utilizing telehealth consultations, older veterans are able to receive high quality mental health care in their homes or at small local clinics.At this time, the CRHs serving VISN 9 (Tennessee and Kentucky), VISN 23 (North Dakota, South Dakota, Nebraska, Iowa, and Minnesota), VISN 1 (New England), VISN 20 (Washington, Oregon, Idaho and Alaska), and VISN 4 (Pennsylvania) offer specialized geriatric mental health services. All of these CRHs offer consultative care with exception of VISN 20, which offers fully virtual continuity clinics to highly underserviced areas within that region. VISN 23 was the first region to offer such a program and has been in operation through the CRH since 2018 (although its geriatric psychiatrist was providing consultative telehealth services prior to that). VISN 9, VISN 20, and VISN 1 began program development and services in 2021. The programs receive additional support from the VA Office of Rural Health, which has also funded a program evaluation team.Each region's geriatric mental health program has a geriatric psychiatrist as well as additional team members with geriatric specialty experience in various fields such as psychology, pharmacy, neuropsychology, internal medicine, and nursing. Care is provided through a range of modalities, including electronic consultations (e-consults), direct to home video visits, video visits at local clinics and inpatient/residential settings, and telephone evaluations. A range of diagnosis and concerns are addressed including, but not limited to, dementia diagnosis and management, caregiver support, treatment of complex psychiatric conditions in late life, and capacity. Veterans residing in outpatient, inpatient, and VHA residential/long term care settings are all eligible for care through CRH programs. Although these programs share a common goal to expand access to geriatric mental health treatment, each program operates uniquely, with different models of care based on the needs of their region's specific population. Our session will start by highlighting the care offered by CRHs and the VA Office of Rural Health's program evaluation research. The geriatric psychiatrist from VISN 9, VISN 23, and VISN 1 will present the specifics of their program, focusing on program development, types of care provided, and population served.

UNMET NEEDS AND PERCEIVED BARRIERS TO ACCESSING HCBS AMONG CAREGIVERS OF VETERANS OF ALL ERAS

Abstract VA has several HCBS to offset caregiver burden, facilitate caregiving, and enhance Veterans’ home-based care, but they remain underutilized. We aimed to describe: the unmet psychosocial and HCBS needs of caregivers, barriers to accessing services, and gaps in available programs. Twenty-three caregivers participated in a 1-hr semi-structured interview (62.9□13.5y; 74.0% women; 47.8% White; 17.4% Hispanic; 65.2% spouses). Caregivers provided 7.3 hrs of daily care (SD=5.5 hrs, Range=1-24); most had provided care for 1+ year. Barriers to accessing HCBS included: a) disagreement with Veterans regarding service preferences and needs; b) lack of awareness of VA and non-VA programs; c) delays in obtaining services; and d) emotional toll of caregiving on personal health and relationship with the Veteran. The VA may need to invest in advertising existing services, develop strategies to match caregivers with available services when needed, and enhancing mental health and relationship quality for Veterans and caregivers.

Staff and Veteran Perspectives on Residential Treatment Programs' Responses to COVID-19: A Qualitative Study Guided by the WHO's After Action Review Framework.

Healthcare must rapidly and systematically learn from earlier COVID-19 responses to prepare for future crises. This is critical for VA's Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), offering 24/7 care to Veterans for behavioral health and/or homelessness. We adapted the World Health Organization's After Action Review (AAR) to conduct semi-structured small-group discussions with staff from two RRTPs and Veterans who received RRTP care during COVID-19, to examine COVID-19's impact on these programs. Six thematic categories emerged through qualitative analysis (participant-checked and contextualized with additional input from program leadership), representing participants' recommendations including: Keep RRTPs open (especially when alternative programs are inaccessible), convey reasons for COVID-19 precautions and programming changes to Veterans, separate recovery-oriented programming from COVID-19-related information-sharing, ensure Wi-Fi availability for telehealth and communication, provide technology training during orientation, and establish safe procedures for off-site appointments. AAR is easily applicable for organizations to debrief and learn from past experiences.

Undoing the Knots: Five Generations of American Catholic Anti-Blackness by Maureen H. O’Connell

Reviewed by: Undoing the Knots: Five Generations of American Catholic Anti-Blackness by Maureen H. O’Connell James Wolfinger IV In this deeply personal work, Maureen O’Connell explores five generations of her Irish Catholic family’s experience in the United States. O’Connell focuses on how her family strove to make it in America, following a familiar story of poor and often despised Irish immigrants coming to a new land, gaining education and financial stability, and building their churches, homes, and communities. Their advance went hand-in-hand with a growing anti-Blackness that set them apart from, and falsely demonstrated their superiority to, African Americans. For O’Connell, this excavation of her family and her broader [End Page 66] community’s past represents a painful, if illuminating, effort. Undoing the Knots, as much as anything, is a journey of personal discovery and familial reckoning. Throughout the book, O’Connell foregrounds anti-Blackness as a constant theme in the nation’s history, emphasizing how the Catholic Church was embedded in racist practices and sometimes led them. Her exploration of Bishop Francis Patrick Kenrick’s 1840s justification of slavery (78) and Cardinal Dennis Dougherty’s failure to integrate Philadelphia’s Catholic Church a century later (174) illuminate how Catholic leadership neglected to right historic wrongs and too often made matters worse. Parishioners like the O’Connells followed right along, seldom questioning the church’s hierarchy or racial orthodoxy. As a personal and familial exploration of the Catholic Church’s involvement in anti-Blackness, Undoing the Knots offers history with an emotional punch. At the same time, the book raises larger questions about U.S. history and political engagement with which O’Connell could more fully grapple. Scholars have clearly established that the United States was founded on racist and xenophobic assumptions, principles, and policies. Anti-Blackness is the most virulent strain of this thinking, but discrimination harmed many groups, including the Irish. O’Connell claims that “oppression in the United States actually had very little to do with religious identity. It was all about race” (73). The work of John Higham and other scholars going back three generations shows that such a point is, at best, overstated. O’Connell could explain more fully how anti-Catholicism shaped the Irish experience and likely limited their latitude to act in more egalitarian ways. Historians must often rely on subtext and read silences, but that can make interpreting the evidence tricky. O’Connell uses phrases such as “likely developed practices” related to racist views (47), suggests her grandfather’s use of VA and FHA loan programs demonstrate his racism (191–193), and posits that her earliest ancestors participated in the social death of Black people because they were white in a racist country (58) [their “whiteness” in the mid-nineteenth century, by the way, has been a debatable point]. O’Connell hits the theme of anti-Blackness so hard that it leaves little room for people to have other motives for their behavior, to challenge as well as support racism. Are all white people implicated in the same way in the creation and functioning of the nation? Could silence in the record be more positive for some individuals than O’Connell argues? How would we know? Since the book explores an action—undoing the knots of anti-Blackness—what is O’Connell’s path forward, her political strategy? She capably lays out this history, but to what purpose? It is not always [End Page 67] clear if “racial mercy” (168) is a mindset or an actionable plan. What should the church, parishioners, readers of the book do? James Wolfinger St. John’s University Copyright © 2022 American Catholic Historical Society

An Inclusive Approach to Geriatric Specialization: The Society for Post-Acute and LTC Medicine AMDA Certified Medical Director Program as a Model for Association-based Training

This symposium addresses a critical need to grow the field of geriatric expertise by creating multiple learning options that reach clinicians at all phases of practice. The AAGP Strategic Planning meeting of September 2019 articulated several future goals including 1) Develop our own competency-based certificate program and 2) Offering a pathway to clinical expertise for clinicians (Tampi R, et al 2020). The strategic plan also strongly emphasized partnerships with like-minded organizations. This symposium highlights the success of the AMDA Certified Medical Director (CMD) Program. Dr Meenakshi Patel will discuss how AMDA developed the certification; she will review the core curriculum, the development of the initial certification and the subsequent recertification procedures. She will also discuss the advantages of the certification for other providers (e.g., PCPs, NPs). Discussion will address how new geriatric certification programs may supplement training conducted in traditional post-graduate settings and allow for critical workforce growth. Association-based certifications permit inclusivity for providers who are not able to avail themselves of post-graduate fellowships but wish to gain geriatric expertise. The value of “clinical pathways” to expertise will be discussed and stakeholders will be invited to explore ways for the AAGP to help create more diverse learning pathways in geriatric psychiatrySpeaker Meenakshi Patel will discuss the AMDA CMD certification program. She will review the core curriculum, development of the initial certification and subsequent recertification program.Panelists: Dr. Amita Patel will review an AAGP-based geriatric certification that was in development several years ago under her leadership and may be ready for a revitalized effort.Dr. Schultz will discuss possible targeted certifications (e.g., Geriatric Psychopharmacology) and models such as the AACP Board Certification In Community & Public Psychiatry, endorsed by the APA. Other training models (NIH T32, HRSA-based) will be noted.Dr. Lantz: Will address how an AAGP-sponsored certification may complement traditional post-residency fellowship programs in a productive way that meets growing workforce needs.Dr. Padala will discuss new VA programs to share geriatric expertise in case-based “Ask the Expert” and other on-line training formats. Growth in training programs offered by the VA and other healthcare systems will be discussed.The symposium will include audience discussion to begin a planning process that may include stakeholder input from clinicians, educators, association leaders and staff.

Ask The Expert Geriatric Psychiatry: VA program to support clinicians

This symposium addresses a critical need in geriatric psychiatry staffing shortages. The Department of Veterans Affairs is increasingly catering to aging veterans with complex medical and emotional problems. Unfortunately, there is a critical shortage of geriatric psychiatry expertise. The COVID-19 pandemic has further amplified the need for geriatric psychiatry services particularly in rural areas. In an effort to extend the valuable and too-often-scarce resource of geriatric psychiatry expertise, the National Telemental Health Center launched a new consultation service, Ask the Expert program in Geriatric Psychiatry, earlier this year. A team of VA Geriatric Psychiatrists were made available to answer general questions that VA clinicians may have about psychiatric care of older Veterans with potentially complex and interacting psychiatric, medical, neurocognitive, and behavioral care needs. The program aimed to provide a response within 7 days. Providers from the field were encouraged not share any Protected Health Information (PHI) in your questions. The service was not intended to make case-specific clinical recommendations, review patient health records, or respond to psychiatric emergencies.Speaker Prasad Padala will discuss the conceptualization, process of development and the National support needed for actualization of the program. He will also provide an overview of common themes in the questions received so far.Panelists: Dr. Ruchi Aggarwal will review the infrastructure, coverage and day to day operation of the program. She will further discuss the performance of the team.Dr. Donovan Maust will provide illustrative examples of polypharmacy, de-prescription and management of complex medical comorbidities.Dr. Gauri Khatkhate will provide illustrative example for management of neuropsychiatric symptoms of dementia.Dr. Susan Schultz will serve as the discussant and will highlight the need for workforce development in geriatric psychiatry. She will also discuss AAGPs efforts in possible targeted certification (e.g., Geriatric Psychopharmacology) and models by other organizations.The symposium will include audience discussion that may include stakeholder input from clinicians, educators, association leaders and staff.

Impacts of Basic Income on Health and Economic Well-Being: Evidence from the Va's Disability Compensation Program

Impacts of Basic Income on Health and Economic Well-Being: Evidence from the Va's Disability Compensation Program

1197. Development and Implementation of Innovative Syringe Service Programs for Veterans in Rural and Urban Settings

BackgroundSyringe Services Programs (SSPs) is one aspect of a comprehensive Harm Reduction approach necessary to reduce the transmission of blood borne infections including Hepatitis B, Hepatitis C, and HIV. Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that in 2019 that 595,000 veterans engage in opioid misuse with at least 57,000 veterans engaging in heroin. Stigmas to SSP are pervasive in the community and within the government system. Federal law prohibited the use of federal funds to purchase sterile needles or syringes for the purposes of illegal use of drugs by injection. It was officially clarified in May 24, 2021 that the prohibition to purchase syringes does not apply to Veterans Health Administration (VHA). While awaiting approximately 2 years to secure this clarification, syringes were obtained through a community donation. We aim to describe our process including difficulties encountered and data collected for SSP at two locations. Difficulties included developing an anonymous process to track quality, motivating providers to refer, educating highest risk veterans, providing face to face engagement during COVID-19 pandemic and ability to mail Harm Reduction kits containing sterile syringes.Illiana VA Program Information Sheet Orlando VA Program Information Sheet MethodsOf the 140 facilities within VHA, there are currently only two SSPs established, Illiana VA and Orlando VA. A retrospective analysis of Harm Reduction benefits was performed among veterans who engaged with the two SSPs between 2018 to 2021. Orlando VA SSP Intake Process Map Process that veteran undergo when they engage with Orlando VA SSPContents of Standard SSP Kit Distributed to Veterans at Orlando VA ResultsApproximately 3000 syringes were dispensed. Of the 17 veterans, 65% received syringes, 82% received naloxone, 100% engagement in mental health and 94% engagement in substance use disorder clinics. In total, 65% were screened for HIV, 82% for HCV and 29% for sexually transmitted infections. ConclusionThese numbers, while modest, are notable, especially given the financial and organizational barriers that were in place. Furthermore, the COVID-19 pandemic impacted full implementation and outreach. With the recent, official clarification on syringe purchase and support for SSPs, the number of SSPs in the VA will grow, along with opportunity for more robust data collection. The experience of both facilities is a model for programs currently in development and moves us closer to ending the HIV epidemic by 2030.Disclosures All Authors: No reported disclosures

Identification of the characteristics of occlusive myocardial infarction: are there any tell-tale signs?

Abstract Introduction Treatment urgency of myocardial infarction (MI) is currently stratified by ST elevation (STEMI) or lack of ST elevation (NSTEMI) on the electrocardiogram. This categorisation arose from the theory that ST elevation indicated total acute coronary artery occlusion (1). However, one-quarter of all NSTEMI have acute occlusion, have a higher mortality and are potentially missed by this strategy (2). Purpose The study purpose is to identify clinical features that could help distinguish an occlusive MI from non-occlusive MI. Methods The prospectively British Cardiovascular Intervention Society (BCIS) data set was collected from patients undergoing primary cutaneous intervention (dataset) was analysed from the years 2015 to 2019. Data collected included presentation characteristics, co-morbidities, treatments and outcomes. We further undertook latent class analysis, to determine whether distinct patterns of presentation and history are associated with acutely occluded NSTEMI. This methodology proceeds through segmentation of a dataset into clusters (“classes”) based on case similarities for the set of variables or “indicators” of interest; the classes are then statistically analysed to evaluate the differences between them. Results A total of 2025 patients underwent percutaneous coronary intervention (PCI) between 2015 and 2019. Of these, 1412 underwent PCI for MI, 510 had a STEMI, and 263 had occlusive MI on angiogram. STEMI patients tended to be younger (66 vs 67; p=0.045), in shock (6.1% vs 1.9%; p&amp;lt;0.001), have cardiac arrest (5.7% vs 1.2%; p&amp;lt;0.001), less co-morbidities, increased left ventricular ejection fraction (LVEF) (&amp;lt;30% 11.8% vs 4.7%; p&amp;lt;0.001, increased short-term mortality (3.5% vs 0.7%; p&amp;lt;0.001) and increased emergency PCI (55.9% vs 6.9%; p&amp;lt;0.001) and thrombolysis (32.7% vs 2.5%; p&amp;lt;0.001),. Occlusive MI patients tended to have ST elevation (63.5% vs 29.9%: p&amp;lt;0.001), cardiogenic shock (9.1% vs 2.1%; p&amp;lt;0.001) cardiac arrest (5.3% vs 2.3%; p=0.007), less co-morbidities but no difference in cerebrovascular disease, increased acute mortality (4.2% vs 1.1%; p&amp;lt;0.001) severe LVEF (11.8% vs 6.2%; p&amp;lt;0.001) and increased emergency PCI (70.3% vs 14.1%; p&amp;lt;0.001), With latent class analysis, while clusters of similar patients are observed in the dataset, we determined that the variables captured by BCIS do not usefully indicate an acutely occluded MI compared to non-occlusive MI (Figure 1). Conclusion Features between occlusive MI and STEMI are broadly very similar. However, unlike STEMI/NSTEMI, there was no difference in age and risk of cerebrovascular disease in the occlusive MI/non-occlusive MI group. This could indicate occlusion MI occurs in higher numbers in elderly and frail patients and may be frequently missed, possibly from greater collateralisation. There is no reliable characteristic for identifying occlusive between non-occlusive MI. Improved methods are needed for the identification of occlusive MI patients. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): A project supported by the European Union's INTERREG VA Programme, managed by the Special EU Programmes Body (SEUPB). The funders of this project had no input in designing, implementation or writing of this review. Step 1 of latent class analysis

Enhancing Veteran Community Reintegration Research (ENCORE): a Stakeholder-Engaged Research Agenda Setting Approach

<h3>Research Objectives</h3> The goal of the Enhancing Veteran Community Reintegration Research (ENCORE) project is to maximize Veteran and family reintegration by promoting innovative research and knowledge translation that informs and improves equitable VA policies, programs, and services. Two strategic objectives guide ENCORE activities: (1) mobilize Veteran community reintegration (CR) research and (2) promote innovation, relevance and acceleration of Veteran CR research and knowledge translation. <h3>Design</h3> ENCORE used a stakeholder-engaged approach to achieve objectives. In the first 2 years, the team assembled a Multi-Stakeholder Partnership (MSP), reviewed the VA funding portfolio and CR research literature, interviewed stakeholders from VA program offices to identify existing funded CR research and stakeholder needs, and conducted a gap analysis. <h3>Setting</h3> Data collection and stakeholder activities are all conducted remotely due to the COVID-19 pandemic. <h3>Participants</h3> We interviewed 20 participants from 16 VA program offices providing CR-related services. MSP participants represent 10 VA program offices, 5 Veterans and caregivers, 5 established CR researchers, and 5 strategically identified community organizations. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Primary outcome measures include results from feedback surveys. <h3>Results</h3> The MSP has achieved several goals and deliverables: Mission, Vision and Values statements, and consensus-based definition of CR and inclusive research guidelines. ENCORE is completing a scientific gap analysis. Future products include a stakeholder-driven research agenda on Veteran CR, the development of an effective and relevant dissemination plan, and the generation of innovative, relevant dissemination products designed for rapid knowledge translation. <h3>Conclusions</h3> The goal of this program is to improve the impact of CR research on policies and programs. Using a stakeholder-engaged process, we are incorporating insights from key stakeholder groups to set a research agenda more likely to result in a relevant and responsive CR research program. <h3>Author(s) Disclosures</h3> This work was supported by the Award IVI 19-487 from Health Services Research and Development Service of the Office of Research and Development, VHA, US Department of Veterans Affairs. The contents of this presentation do not represent the views of the Department of Veterans Affairs or the US Government.

Factors That Promote Vulnerability Versus Resilience Among Older Disaster Survivors

Catastrophic environmental events, such as floods and hurricanes, are associated with widespread destruction and loss of life. Older adults, who often have health challenges and medical co-morbidities, appear to be at greater risk for adverse post-disaster outcomes, such as depression, worry, and medical uncertainty, than younger adults impacted by the same disaster. Researchers, therefore, are interested in identifying factors that tend to bring about vulnerability and adverse outcomes for older adults during and after a disaster, as well as factors that may generate resilience and psychological well-being for older adults. The purpose of this symposium is to present research based on multiple disaster experiences and to examine factors associated with vulnerability and resilience. The first two speakers introduce empirical findings from research that addresses flooding, the 2016 Baton Rouge flooding and the frequent flooding of coastal Louisiana brought about by coastal erosion. The next two presenters explore successful VA and Non-VA Home-Based programs during and after the 2017 Hurricane Maria in Puerto Rico and during the 2017 Atlantic hurricane season. The final speaker highlights the impact of lifetime trauma on the recovery of older adults following a natural disaster. Collectively, these presenters will provide evidence of how lifetime adversity is a factor promoting vulnerability for older adults after a disaster. Critically, they will also examine how age, disaster preparedness, intense patient tracking, VA support networks, and community resources and programs are protective factors generating resilience post-disaster for older adult populations.

A Peacock That Does Not Show Its Feathers Is Not Much Different From a Turkey: On Being a Physician Executive for 25 Years

Compelling common threads in the fabric of being an academic and clinical geriatrician, VA health care executive and physician champion for VIONE – a national medication deprescribing project that was launched at 59 VA programs across the nation will be presented in a thought provoking, objective, evidence based and legacy oriented format. Highlights include a)success factors b)networking c) effective presentations d) lessons learned e)implementing elements of High Performance Delivery Model (HPDM), f)transforming ideas into actions that help rise and shine g) creating a legacy h)survey readiness h) keeping the main thing the main thing i) understanding others and helping others understand you. Making significant contributions in career is important. How the work is captured, projected, made visible as a viable, actionable solution to a critical and significant mission critical problem, strategic engagement with stakeholders, implementation with measurable outcomes, passionate engagement while being an affirmative, non-controversial leader who is eager, willing, available, capable and knowledgeable etc., are some of the other non-negotiable aspects of getting work recognized. Experiences shared include creating VIONE – a medication deprescribing project that won VA USH Shark Tank competition as a Gold Status Fellow with outcomes such as over 95,000 veterans impacted, over 194,000 non-essential medications deprescribed with accomplished cost savings of over 9.6 million US dollars in 4 years. This profound journey taught me the importance of effectively displaying worthy work with global relevance with dignity, credibility, pride, persuasion, leadership, efficiency, teamwork, art of persuasion, ponder, recharge, rejuvenate and start fresh – time and again.

Associations between adverse childhood experiences and weight, weight control behaviors and quality of life in Veterans seeking weight management services

IntroductionA neglected area of trauma research with Veterans is the study of Adverse Childhood Experiences (ACEs). The present study aimed to examine the prevalence of ACEs, and to explore relationships between ACEs and measures of weight, eating behaviors and quality of life in weight loss seeking Veterans. MethodsParticipants were 191 Veterans [mean age 58.9 (SD = 12.8), mean Body Mass Index (BMI) 35.4 (SD = 6.1), 86.9% male, 33.7% racial/ethnic minority] receiving care at VA Connecticut Healthcare System (VA CT) who attended an orientation session of VA's behavioral weight management program. Participants completed a measure of ACEs and measures related to weight, eating and health. ResultsAmong completers, 68.6% endorsed at least one ACE. The average number of reported ACEs was 2.2 (SD = 2.5), with 48.7% of Veterans reporting more than one type of ACE. Women were more likely to report any ACE (88.0% vs. 65.6%, p = .025) and reported significantly more ACEs compared to males (4.2 vs. 1.9, p < .001). ACEs were associated with lower physical activity (p = .05), lower quality of life (p's < 0.05), and lower weight-related quality of life (p < .01), but not weight, weight control strategies, binge eating, or alcohol use. ConclusionACEs are common among weight loss seeking Veterans, particularly among female Veterans. Findings suggest that there is a high rate of ACEs in Veterans, which are associated with exercise and quality of life outcomes, but not diet and weight outcomes.

Regulatory and social dynamics of voluntary agreement adoption: The case of voluntary energy efficiency and GHG reduction agreement in South Korea

What are the forces that drive increasing adoption of voluntary agreements in the policy field? This paper attempts to answer the question by analyzing the mechanism behind the adoption by 877 entities of the voluntary energy efficiency and GHG reduction agreement (VA) that was in place between 1999 and 2010 in South Korea. We argue that in South Korea's distinct regulatory context, participation in a public voluntary program (PVP), a VA, is a manifestation of participant entities' varied motivations as well as regulatory and social-normative pressures that arise from the institutionalization of the VA program. In addition, aligning the PVP with other policy programs such as eco-labelling program was found to have provided additional incentives for adoption while public ownership, socioeconomic status and environmental management capacity of targeted entities were significant factors. Thus, this study analyzes changes in the motives of participant entities over the course of the program's maturation and demonstrates how government and industries adopt and manage a PVP for policy learning and strategic regulation in the area of energy efficiency management and GHG reduction.

P0917N-ACETYL CYSTEINE FAILS TO IMPACT ON PLASMA ANTIOXIDANT CAPACITY IN BOTH A PLACEBO CONTROLLED CROSSOVER STUDY AND A PARALLEL GROUP TRIAL OF PATIENTS WITH CKD STAGE III: IMPLICATIONS FOR ITS USE AS A PROPHYLACTIC FOR CONTRAST INDUCED NEPHROPATHY

Abstract This project has been funded by the EU’s INTERREG VA programme, managed by the special EU Programmes Body (SEUPB) Background and Aims N-acetyl-L-cysteine (NAC) has been proposed as a prophylactic for the prevention of contrast induced nephropathy (CIN), a serious, adverse complication following administration of contrast media in patients with diabetes and chronic kidney disease (CKD). However, clinical trial results have failed to demonstrate consistently the beneficial qualities of NAC in this setting. The suggested mechanism by which NAC has been proposed to be effective is via antioxidant activity, but NAC itself appears not to be a powerful antioxidant; intracellular conversion of NAC to glutathione (GSH) is essential for antioxidant effects. We tested the hypothesis that oral or intravenous NAC fails to increase antioxidant activity in the plasma of healthy volunteers or CKD stage III patients undergoing elective coronary angiography. Method 16 healthy volunteers (8 receiving contrast media) and 8 patients with chronic renal failure were recruited to 3 separate groups as a part of a crossover design study. 66 patients with CKD stage III undergoing elective coronary angiography were recruited to a parallel group randomized controlled trial. Each volunteer or patient was randomised to receive NAC (i.v.; 50 mg/kg/hr infusion for 2 h, followed by 20 mg/kg/hr infusion for a further 5 h), or NAC (oral; 1200 mg twice daily, commencing the day before the study visit) or placebo. Participants attended the Clinical Research Facility on three occasions for the crossover groups, but only once in the parallel group trial. Patients were infused with para-aminohippurate (PAH) and inulin to enable measurement of renal function parameters. Plasma and paired buffy coat samples were collected at several time points for 2 hours before contrast infusion and for 6 hours after. Samples were used to measure various clinical parameters, along with intracellular and plasma thiol concentrations and the plasma antioxidant capacity (oxygen radical antioxidant capacity; ORAC). Results Plasma NAC concentrations peaked at 222 µM (healthy volunteers), 354 µM (CKD patients), 271 µM (healthy volunteers receiving contrast) and 348 µM (CKD patients undergoing elective coronary angiography) following infusion of NAC. The corresponding peak concentrations were ∼2 µM following oral NAC across all groups. No comparable increase in the plasma compartment ORAC antioxidant capacity was measured in any of the treatment groups. Equally, contrast infusion itself did not significantly reduce antioxidant capacity in plasma, even in the placebo group. Buffy coat measures showed that there was a significant increase of intracellular GSH in some patients. Also, no clear additional benefit was witnessed by increasing plasma NAC ∼100-fold through infusion of NAC over oral administration. Conclusion NAC fails to influence ORAC antioxidant capacity in the plasma compartment of CKD stage III patients receiving contrast media. Our results question the importance of oxidative stress in contrast-induced nephropathy. Furthermore, the findings fail to demonstrate a direct antioxidant impact of NAC in the plasma compartment and question the antioxidant hypothesis related to contrast-induced nephropathy and NAC.