Veterans Administration Hospital Research Articles

Abstract 7382: Artificial intelligence derived features of collagen architecture identify high risk HPV associated oropharyngeal squamous cell carcinoma patients

Abstract Introduction: Human papilloma virus (HPV) induced oropharyngeal squamous cell carcinoma (OPSCC) is a common subtype of head and neck carcinoma. Dysregulation of the extracellular matrix (ECM), an important part of the tumor microenvironment (TME), is shown in HPV related cancers. We studied collagen fibers (CF), the amplest component of the ECM, and evaluated whether their characteristics within the TME can offer a prognostic value in OPSCC. Methods: Whole slide images (WSIs) of OPSCC patients were obtained from Washington University (WU, n=107), Houston Veterans Administration Hospital (HV, n=94), Cleveland Clinic (CC, n=336), John Hopkins University (JH, n=121) and Vanderbilt Medical Centre (VM, n=158). For the identified CF in tumor-stroma regions of WSIs, the extracted CF features included: CF fragmentation measure, CF bundling percentage, CF rigidity measure, CF anisotropy index, and CF density index. For survival analysis using overall survival (OS) and Disease-Free Survival (DFS) as endpoints, the median risk score in the training set (WU) was applied for risk stratification in the validation sets (HV, CC, JH, VM) by means of a Least Absolute Shrinkage and Selection Operator-Cox regression model. Multivariable Cox Proportional Hazards Regression was done for both OS and DFS. Results: The patients defined as “high risk” had worse OS than those identified as “low risk” (HV(p=0.03), CC(p=0.03), JH(p=0.02), VM(p=0.04)). Multivariable analysis showed that CF features were prognostic independent of T/N stages, age, sex, and smoking status with HR=1.99 (95% CI=1.46-2.72, p=0.00001) for OS and HR=1.73 (95% CI=1.21-247, p=0.002) for DFS (Table 1). Table 1: Multivariable Survival Analysis for OS and DFS, HR=Hazard Ratio, CI=Confidence Interval Variable Overall Survival Disease Free Survival HR (95% CI) P value HR (95% CI) P value Age (<65 years vs. >=65 years) 0.99 (0.93-1.06) 0.78444 0.96 (0.82-1.12) 0.62864 Sex (Female vs. Male) 0.56 (0.29-1.10) 0.09042 0.50 (0.22-1.13) 0.09385 Smoking status (Yes vs. No) 1.85 (1.31-2.62) 0.00051 1.03 (0.72-1.47) 0.86871 T-stage (T3/4 vs T1/2) 1.86 (1.38-2.50) 0.00004 1.91 (1.36-2.69) 0.00018 N-stage (N+ vs N0) 1.76 (1.31-2.37) 0.00016 2.04 (1.46-2.86) 0.00003 Collagen fiber features (High risk vs low risk) 1.99 (1.46-2.72) 0.00001 1.73 (1.21-2.47) 0.00286 Conclusion: Artificial intelligence derived features of CF architecture can help identify high vs low risk patients in HPV related OPSCC. These findings deserve further confirmation in larger prospectively collected OPSCC data sets and could impact future treatment paradigms. Citation Format: Reetoja Nag, Haojia Li, Germán Corredor, Pingfu Fu, Nabil F. Saba, Mehmet A. Bilen, Tilak Pathak, Paula Toro, Mojgan Mokhtari, Krunal Pandav, Michael Gilkey, Shlomo Koyfman, Deborah Chute, Wade L. Thorstad, Mitra Mehrad, Patricia D. Castro, Andrew G. Sikora, Rebecca D. Chernock, Jingqin Luo, Mitchell Frederick, Vlad Sandulache, David J. Adelstein, James Lewis Jr., Anant Madabhushi. Artificial intelligence derived features of collagen architecture identify high risk HPV associated oropharyngeal squamous cell carcinoma patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7382.

Abstract 80: Predictors of Door-to-Needle Time in the Veterans Health Administration National Telestroke Program

Introduction: The Veterans Administration (VA) National Telestroke Program (NTSP) increases access to stroke specialists across the VA enterprise. Unlike most telestroke networks, VA hospitals are not integrated into a hub-and-spoke model and most Veterans present to VA emergency departments by personal vehicle, rather than emergency medical services (EMS). Predictors of Door-To-Needle (DTN) time in Veterans receiving tPA via telestroke may differ from community telestroke systems. Methods: A logistic regression model was applied using operations data to identify patient and hospital characteristics predictive of DTN times < 60 minutes. Predictors variables included patient demographics, National Institute of Health Stroke Scale score, Last Known Well time on arrival, rurality, integration with EMS routing systems, local neurology service, VA-designated facility complexity status, time from arrival to CT and time from CT to treatment. Results: Among (N=448) Veterans treated via Telestroke from 2017 to 2022, 32% (n=142) received tPA < 60 minutes. No significant differences were observed between groups in terms of patient characteristics (Table). Significant differences were seen in hospital characteristics of complexity status (p=0.013), time from arrival to CT (p<0.001), and time from CT to treatment (p<0.001). The odds of receiving tPA < 60 minutes were 12.4 times greater for patients with a door to CT time of < 10 minutes (95% CI 6.7, 23.2) and 28.5 times greater for patients with a CT to treatment time < 40 minutes (95% CI 14.5, 56.5). Conclusions: Our data clearly demonstrate that achieving target times of < 10 minutes for arrival to CT and < 40 minutes for CT to treatment increases the odds of receiving tPA in < 60 minutes. This finding underscores the importance of improving stroke systems within VA hospitals to facilitate these key target times.

The Farver–Campos Labor Coping Scale as a Replacement for the 10-Point Pain Scale for Labor

The 10-point pain scale was developed to avoid undertreated pain in the hospital setting. Developed in a Veterans Administration hospital for medical–surgical patients in 2003, the 10-point pain scale was adopted in health care as part of the “pain as the fifth vital sign” initiative. The pain scale was implemented in maternity care as part of a general hospital initiative. Assessing coping is more appropriate to the labor process than focusing on pain or its avoidance. The Farver–Campos Labor Coping Scale is evidence-based and promotes vaginal birth and personal labor care by guiding nurses and laboring women through a number of coping options. The scale is an appropriate tool to replace the 10-point pain scale in the maternity care setting.

India ink to 3D imaging: The legacy of Dr. Deepak "Dee" N. Pandya and his influence on generations of neuroanatomists.

Dr. Deepak "Dee" Pandya spent his career as an internal medicine physician as well as in his respective laboratories at the Bedford, Massachusetts Veterans Administration Hospital and at Boston University School of Medicine. His achievements mapping out the cytoarchitecture and connectivity of areas all over the nonhuman primate brain and small mammals are unparalleled. Dee made numerous discoveries and created painstakingly detailed reports, which impacted the field of neuroanatomy and expanded our perceptions of the many diverse inputs and suggestive functions of specific brain regions. The "old school" methods employed from microscopic work to detailed analyses yielded a product that was accurate and exciting all at the same time. We will all miss Dee's smile and tender manner, but more so, we will miss his wonderful and patient mentorship during the precious time we all spent with him. His mentorship resulted in all of his trainees becoming better scientists and left us with the understanding that people like Dee only come by once in a lifetime. In this tribute article for this special issue in the Journal of Comparative Neurology (JCN), the authors describe some of the tedious methods that were used to present our work as a way to provide insight into the extraordinary time and effort it took to produce and publish our articles with Dee in JCN. Dee's work with his colleagues set the stage for more modern methods of counting and mapping neuronal populations presented here, paving the way for such technologies as artificial intelligence and light sheet imaging to advance the field forward to reach new and exciting discoveries.

Diagnosis of mental illness does not affect postoperative outcomes in patients undergoing endovascular aortic aneurysm repair in the VA healthcare system

ObjectiveMental illness can be a debilitating chronic disease associated with a higher likelihood of preexisting medical comorbidities and postoperative morbidity and mortality. Given the relative prevalence of mental health disorders among the veteran population, we sought to examine postoperative outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR). MethodsRetrospective review of a single institution Veterans Administration Hospital operative database was used to identify patients who underwent EVAR from January 2010 to December 2021. Patients’ demographics, comorbidities, medications, and intraoperative variables were collected. In addition, mental illness status was evaluated to stratify patients based on preexisting anxiety, depression, posttraumatic stress disorder, substance abuse disorder, or major psychiatric illness. The study’s primary outcomes were postoperative complications, mortality, and follow-up rates. Secondary outcomes included hospital length of stay, readmission rates, and intervention rates. ResultsA total of 241 patients underwent infrarenal EVARs at our institution. One hundred forty patients (58.1%) were diagnosed with mental illness, whereas 101 (41.9%) had no prior diagnosis of mental illness. Of the 241 patients, 65.7% had a history of substance abuse disorder, 38.6% depression, 29.3% post-traumatic stress disorder, 19.3% anxiety, and 3.6% major psychiatric illness. There was no statistical difference in the number of medical comorbidities, race, smoking status, or medications compared with patients without mental illness. We found no statistical difference in access type, wound infection rates, hypogastric coiling, estimated blood loss, and operating time. χ2 analysis demonstrated a statistically significant lower overall postoperative complication rate (28.6% vs 32.7%; P = .05) and decreased loss to follow-up (8.6% vs 15.8%; P = .05) among patients with a preexisting mental illness diagnosis. There were no statistically significant differences in readmission rate, length of stay, or 30-day mortality. When stratified by type of mental illness, binary logistic regression demonstrated no statistically significant differences in primary outcomes of postoperative complications, readmission rates, loss to follow-up, and 1-year mortality. Cox proportional hazards modeling demonstrated no significant difference in cumulative survival in patients diagnosed with a mental illness (0.56; 95% confidence interval, 0.29-0.107; P = .08). ConclusionsThere was no association between the presence of a prior mental health diagnosis and adverse outcomes following EVAR. Preceding mental illness did not correlate with an increased rate of complications, readmission, length of stay, or 30-day mortality in a veteran population. Lower loss to follow-up rates in patients with mental illness may reflect overall Veterans Health Administration expansion in resources and surveillance of these at-risk individuals. Further research is needed to assess the association between postoperative outcomes and mental illness.

Characterizing the digital divide in a diverse cohort of African American (AA) patients (pts) with prostate cancer (PCa).

e18571 Background: We assessed pts’ self-reported access and ability to use a computer (C) and/or smart phone as part of a larger study exploring treatment decisions in a diverse group of AA PCa pts. Methods: Face-to-face interviews were conducted in a prospective cohort of 152 newly diagnosed early-stage AA PCa pts at Grady Memorial Hospital and the Atlanta Veterans Administration Hospital. Pts were asked whether they had access to a C, whether they had a C in their home, and whether they knew how to use a C. The questions were also asked about smart phones with Internet access. Demographics were collected including income, education (ed), and health literacy (lit) measured with the Rapid Estimate of Adult Literacy in Medicine (categorized as ≤ Grade (Gr) 3; Gr 4-6; Gr 7-8; and high school (HS)). Fisher’s exact test and logistic regression were employed to identify variables associated with the ability to use a C or smart phone. Due to the hypothesis generating, exploratory nature of the current analysis, no adjustments were made for multiple comparisons. Results: Age ranged 44-81. Annual income categories ranged from <$10,000 to >$76,000. Ed ranged from 4 years to 20. Most pts, 62%, had low health lit (< Gr 7-8) but 38% had adequate health lit (HS). In the lowest categories of each variable, more pts had access to a smart phone or C than had a smart phone or C at home, which in turn was greater than the number of pts who knew how to use a smart phone or C. In the lowest categories of each variable, more men knew how to use a smart phone than a C. Of 72 men with some college ed or higher, 90% or more had a smart phone or C and knew how to use them compared with 67% (39/58) with HS ed and 50% (11/22) with < HS ed who knew how to use a smart phone (p < 0.001), and 55% (32/58) with HS ed and 27% (6/22) with < HS ed who knew how to use a C (p < 0.001). Although ~ 90% of pts with income <$25,000 annually had access to smart phones or Cs, 72% (46/64) knew how to use a smart phone (p = 0.016) and just 56% (36/64) knew how to use a C (p = 0.004). Among pts reading at < Gr 4-6, 62% (23/37) knew how to use a smart phone (p = 0.006) and only 43% (16/37) knew how to use a C (p < 0.001). In multivariate logistic models predicting knowledge of how to use Cs or smart phones including the covariates education, income, health lit, and age, education remained a significant predictor of knowledge. Compared to men with < HS ed, men with some college ed or higher were more likely to know how to use a C (OR 77.1, 95% CI 13.8-689, p < 0.001) and were also more likely to know how to use a smart phone (OR 23.0, 95% CI 4.7-176, p < 0.001). Conclusions: Between 28-50% of pts with < HS ed, annual income < $25,000, and < Gr 4-6 health lit do not know how to use a smart phone. Between 44-73% of pts with < HS ed, annual income < $25,000, and < Gr 4-6 health lit do not know how to use a C. Presuming that pts can use the Internet through a C or smart phone to participate in cancer care and research may exacerbate health disparities for the most vulnerable pts. Clinical trial information: NCT03322891 .

They Live in a Desert but Are They Deserted? Analysis of Veteran Patients Undergoing Endovascular Aortic Aneurysm Repair Who Live in Food Deserts

Previous studies have shown that food deserts (FDs) are associated with worse postoperative outcomes, low medication adherence, and decreased screening. We hypothesized that similar to previous studies, FDs would be associated with increased postoperative complications and increased loss to follow-up in a population undergoing endovascular aortic aneurysm repair (EVAR). We retrospectively analyzed a single Veterans Administration Hospital for all patients who underwent an EVAR from January 2010 to December 2021. Patients’ factors collected included age, albumin, body mass index, past medical history, smoking status, medications, anesthesia type, access type, postoperative complications, endoleak history, limb stenosis, readmission rates, and FD status. FD assignment was defined using US Department of Agriculture’s Food Access Research Atlas. The Student t-test** and Fisher exact test* were used. A total of 241 EVARs occurred over the 11-year period. Most patients were male (99.2%), with an average age of 71.7 ± 7.02 years. A total of 57 (23.7%) lived in an FD. Of those living in an FD, there was no statistically significant difference in comorbidities nor ethnicities between the 2 groups. The mean preoperative albumin (3.8 ± 0.37 vs 3.7 ± 0.36; P = .41**) or the mean body mass index (27.4 ± 4.8 vs 28.2 ± 5.0; P = .92**) differed between FD vs non-FD, respectively. There was no statistical difference in postoperative complications including return to the operating room, hemodynamic instability, respiratory failure, acute kidney injury, readmission rates, wound infections, or urinary tract infections. In addition, there was no statistical difference in endoleak rates, limb stenosis, or loss to follow-up rates between the groups. Contrary to previous studies, our data indicate that in a veteran population living in an FD was not associated with increased rate of infection, worse postoperative outcomes, or increased loss to follow-up. Further studies are needed to assess food access impact on EVAR outcomes.

Elder veteran program: A description of a nurse practitioner-led inpatient geriatric consult model.

This article describes the Elder Veteran Program (EVP), a nurse practitioner (NP)-led inpatient consult service at one Midwestern Veterans Administration (VA) hospital. The EVP was designed to address the needs of older hospitalized veterans and serves as a model that uses geriatric expert clinicians as mentors to grow geriatric expertise. Unique to EVP, nurses are coached to identify high-risk older veterans, initiate the consult process to drive geriatric medical and nursing review, and implement best geriatric nursing practice. As a result of EVP implementation, there was a 13-fold increase in the number of older hospitalized veterans receiving geriatric evaluation. The EVP highlights how NPs lead implementation of an evidence-based program that creates a path for engaging, educating, and growing geriatric nursing knowledge and skill while improving veteran access to geriatric sensitive care.

Characterizing the Influence of Exposure to Military Sexual Trauma and Intimate Partner Violence on Mental Health Outcomes among Female Veterans.

Military sexual trauma (MST) has deleterious long-term psychological consequences. Among female U.S. military members, MST is associated with increased risk for future interpersonal victimization, such as experiencing intimate partner violence (IPV). Few studies have investigated the implications of the cumulative effects of IPV and MST on psychological functioning. This study examined rates of co-exposure to MST, IPV, and their cumulative impact on psychological symptoms. Data were collected from 308 female Veterans (FVets; age: M = 42, SD = 10.4) enrolled in an inpatient trauma-focused treatment program in a Veterans Administration (VA) hospital. Data were collected at program admission on symptoms of posttraumatic stress disorder (PTSD), depression, and current suicidal ideation. Lifetime trauma exposure was assessed using semi-structured interviews that identified adverse childhood events (ACEs) and combat theater deployment as well as MST and IPV. Group differences on psychological symptoms were examined among those exposed to MST, IPV, MST + IPV, and compared to FVets with ACEs or combat exposure, but no other adulthood interpersonal trauma (NAIT). Half of the sample (51%) reported experiencing both MST and IPV, approximately 29% reported MST, 10% reported IPV, and 10% reported NAIT. FVets in the MST + IPV group had worse PTSD and depression symptoms than either the MST or IPV groups. The NAIT group had the lowest scores on these measures. There were no group differences in current suicidal ideation; however, 53.5% reported at least one previous suicide attempt. FVets in this sample reported significant lifetime exposure to MST and IPV, with the majority having experienced MST + IPV. Exposure to MST + IPV was associated with greater PTSD and depression symptom severity, yet an overwhelming proportion reported current and past suicidal ideation regardless of trauma exposure history. These results demonstrate the importance of assessing for lifetime interpersonal trauma history when developing and providing mental and medical health interventions for FVets.

Reducing Nighttime Interruptions and Improving Sleep for Hospitalized Patients by Restructuring Nighttime Clinical Workflow.

Nighttime sleep disruptions negatively impact the experience of hospitalized patients. To determine the impact of adopting a sleep-promoting nighttime clinical workflow for hospitalized patients on nocturnal disruptions and sleep. Survey-based pre- and post-intervention cross-sectional study using convenience samples. Hospitalized veterans on a 23-bed general medical ward at a tertiary Veterans Administration Hospital. Baseline sleep surveys (N=149) identified two major sources of interruptions: blood pressure checks at 4 am for telemetry patients and subcutaneous (SQ) heparin injections between 4:30 and 6 am for venous thromboembolism prophylaxis. Clinical workflow was restructured to eliminate these disruptions: moving 4 am blood pressure checks to 6 am and providing daily SQ enoxaparin at 9 am as an alternative to Q 8-h SQ heparin, which had prompted an injection between 4:30 and 6 am. The impact of these changes was assessed in a second round of surveys (N=99). Frequency and sources for nighttime sleep disruptions; percentage of patients reporting longer time to fall asleep, more interruptions, and worse sleep quality (vs. home) before and after restructuring nighttime clinical workflow. After restructuring nighttime clinical workflow, medication administration as a source of nighttime disruption decreased from 40% (59/149) to 4% (4/99) (p<0.001). Blood pressure checks as a source of disruption decreased from 56% (84/149) to 42% (42/99) (p=0.033). Fewer patients reported taking longer to fall asleep in the hospital vs. home (39% pre-intervention vs. 25% post-intervention, p=0.021). Similarly, fewer patients experienced waking up more frequently in the hospital vs. home (46% pre-intervention vs. 32% post-intervention, p=0.036). Fewer patients reported sleeping worse in the hospital (44% pre-intervention vs. 39% post-intervention), though this trend was not statistically significant (p=0.54). Nighttime disruptions in hospitalized patients frequently interfere with sleep. Restructuring of the clinical workflow significantly reduced disruptions and improved sleep.

The total amount of fluid administered is associated with postoperative complications in head and neck cancer surgery.

Patients with head and neck cancer often undergo extensive ablative and reconstructive surgery. Many risk factors are unalterable, but some operative variables are possible to adjust. The goal of this study was to estimate the association between operative variables and the incidence of perioperative complications in a contemporary tertiary care university-based head and neck patient population and a Veteran Administration hospital head and neck patient population from an earlier time period. We retrospectively reviewed all patients whounderwent major head and neck surgery. Two-hundred-two university patients and 122 veteran patients were reviewed. On multivariable analysis, the total amount of intravenous (IV) fluid received during the procedure was associated with postoperative complications as were patients' weight, American Societyof Anesthesiologists(ASA) score, and adult comorbidity evaluation-27 (ACE-27) score. These associations did not depend on whether the patient was treated at the university or veteran hospital. Our study suggests that the odds of a postoperative complication increase as the total amount of IV fluid increases.

Hunter H McGuire– Ignominious Legacy of a Confederate Surgeon

Objectives National protests in the wake of the murder of George Floyddemanded that Confederate statues be removed from public view as symbols of slavery and racism. A statue still stands in Richmond, Virginia, dedicated to a Confederate surgeon, Hunter Holmes McGuire (1835-1900). The Richmond, Virginia Veterans Administration (VA) Hospital bears his name. Dr. McGuire became a contemproary influential figure in American medicine, and served as the President of the American Medical Association; he was also a racist. A biogaphy of McGuire is hereby compiled to better understand his rise to prominence in the Confederate South. Methods Medical articles, commentaries and speeches authored by Dr. McGuire, bibliographies and contemporary newspaper columns. Results Dr. McGuire served as a surgeon in the Confederacy from 1861-1865 and in that rolewas credited for saving many lives. After the war, he became nationally and internationally known as a compassionate physician, gifted surgeon, teacher and educator. A third of his medical publications were devoted to advancing urologic care. He founded Richmond’sUniversity College of Medicine (which merged with the Medical College of Virginia in 1913) and later became president of the American Medical Association. Dr. McGuire was also a pro-slavery advocate his entire life, was a white supremacist, whose statue still sits behind the Virginia state capital building. Conclusions HunterMcGuire made significant contributions to American medicine, but his unrepentent racism and pro-slavery views and actions have tarnished his legacy.

1922. Outbreak and Management of COVID-19 and Infection Prevention Control Practices at a Community Living Center in Veterans Administration Hospital, North Texas

Abstract Background The increase in SARS-CoV-2 cases due to the omicron wave led to significant utilization of healthcare resources and reduced acute care hospital beds at the Veterans Administration Hospital, North Texas Health Care System (VANTHCS). As a result, veterans with non-severe disease were managed at a VANTHCS community living center (CLC) during a COVID-19 outbreak. Methods Veterans residing at the CLC with laboratory-confirmed cases of SARS-CoV-2 (the virus that causes COVID-19) by polymerase chain reaction diagnosed from January 1 to February 15, 2022, were included in the descriptive analysis. We described resident characteristics and outcomes and infection control practices (IPC) implemented to control the outbreak. Resident data was ascertained from the COVID-19 facility dashboard and medical record system. Results From January 1–February 15, 2022, 33 adults residing at the CLC were diagnosed COVID-19. Most infections (93.9%) occurred between January 12–24 (figure 1). The median age was 76 years [interquartile range, 71–80 years] and 30 (90.9%) were men and 25 (75.8%) were white and 5 (15.2%) African American (table 1). Among the total cases, 9 (27.3%) resided in the dementia unit. Nineteen of 33 (57.6%) were asymptomatic. Overall, 28 (84.8%) were documented to be fully vaccinated against SARS-CoV-2 and 24 (72.7%) were boosted. Obesity, ischemic heart disease, chronic obstructive pulmonary disease, and stroke were the most common comorbidities. Residents were cohorted based on COVID-19 results. A multidisciplinary team was convened, and staff were fit tested for appropriate personal protective equipment (PPE) and received refresher training on hand hygiene, donning and doffing of PPE. Most residents were determined to have mild or moderate COVID-19 and managed at the CLC while 7 (21.2%) were hospitalized in the acute care hospital. For management of COVID-19, 11 (33.3%) received dexamethasone and 25 (75.8%) received remdesivir. Overall, 32 (97%) residents survived while one hospice resident was transferred to acute care and died; only 1 resident required ICU admission. Epidemic curve of laboratory-confirmed coronavirus disease 2019 (COVID-19) disease at a Community Living Center, Veterans Administration Hospital, North Texas Health Care System, January–February 2022. Table 1Epidemiological Characteristics, and Outcomes of Laboratory-confirmed COVID-19 cases (N=33)Abbreviation: BMI, body mass index; COPD, Chronic Obstructive Pulmonary Disease; ESRD, end stage renal disease1Other comorbidity (asthma n=1 and chronic liver disease n=2) Conclusion It is feasible to administer COVID-19 therapies to high-risk residents with mild-moderate disease in a CLC with a multidisciplinary team and IPC strategies. Disclosures All Authors: No reported disclosures.

Longitudinal changes in fibrosis markers are associated with risk of cirrhosis and hepatocellular carcinoma in non-alcoholic fatty liver disease

Currently, there is no consistent information on the course of fibrosis-4 (FIB-4) score changes in non-alcoholic fatty liver disease (NAFLD) or their association with subsequent risk of cirrhosis and/or hepatocellular carcinoma (HCC). Thus, we aimed to evaluate the association between longitudinal changes in FIB-4 and subsequent risk of HCC and a composite endpoint of cirrhosis and HCC in patients with NAFLD. We conducted a retrospective cohort study of patients with NAFLD seen in 130 Veterans Administration hospitals between 1/1/2004-12/31/2008, with follow-up through to 12/31/2018. We calculated FIB-4 longitudinally and categorized patients based on risk of advanced fibrosis (low-risk FIB-4 <1.45, indeterminate-risk FIB-4 1.45-2.67, and high-risk FIB-4 >2.67). We used landmark Fine-Gray competing risks models to determine the effects of change in FIB-4 between NAFLD diagnosis date and 3-year landmark time on the subsequent risk of HCC and a composite endpoint. Among the 202,319 patients with NAFLD in the 3-year landmark analysis, 473 progressed to HCC at an incidence rate of 0.28 per 1,000 person years (PY) (95% CI 0.26-0.30). The incidence rate of the composite endpoint was 1.31 per 1,000 PY (95% CI 1.25-1.37). At baseline, 74.7%, 21.4%, and 3.8% of patients had a low, indeterminate, and high FIB-4, respectively. Compared to patients who were at stable low FIB-4 at both time points, the risk of HCC and that of the composite endpoint was higher for all other subgroups with the highest risk in patients with persistently high FIB-4 (HCC adjusted sub-distribution hazard ratio 57.7, 95% CI 40.5-82.2 and composite endpoint hazard ratio 28.6, 95% CI 24.6-33.2). Longitudinal changes in FIB-4 were strongly associated with progression to cirrhosis and HCC. Tools to stratify the risk of HCC development in patients with NAFLD are currently lacking. The fibrosis-4 (FIB-4) score is a widely available non-invasive test for liver fibrosis, a primary determinant of the development of cirrhosis and HCC. In a large retrospective cohort of patients with NAFLD, we found that serial changes in FIB-4 over time were strongly associated with progression to cirrhosis and HCC. Integrating serial measurements of non-invasive tests for fibrosis into the care pathway for patients with NAFLD could help tailor HCC risk prevention.

Social Change: A Gestalt Approach

ABSTRACT This article addresses some of the dilemmas generated by social change initiatives faced by Gestalt practitioners and by anyone involved in such efforts (the word practitioner is being used to include therapist, intervener, coach, and consultant). First, a few assumptions are noted, then the term social change is defined, and next the focus is on psychotherapy, which includes a case study of my experience working in a Veterans Administration Hospital. This is followed by an examination of conflict which, if not the cause of social friction, is often an outcome difficult to address. Finally, a set of process-oriented principles that can help guide social change practitioners are offered.

Preamble

I wish to share with you my excitement about editing a special issue of Gestalt Review that focuses on social justice and social change. Both of these concepts are deeply embedded in the theory of Gestalt therapy, as well as exemplified in the lives of Gestalt practitioners. The issue opens with my own contribution, in which I share some thoughts and reflections regarding social change and include a case study of work with psychiatric patients within a locked ward at a Veterans Administration Hospital during the end of the Vietnam War. The remainder of this issue consists of two more articles, two interviews, a book review, ten reflections, and an Afterword, all of which I hope will stir your emotions and stimulate your thinking. Some fit comfortably within our traditional Gestalt frame, and others should stretch our understandings.The articles by Jochen Lohmeier and Thomas Gross strive to expand the Gestalt approach by incorporating other theoretical perspectives and working with nontraditional populations. Both authors have spent much of their professional lives as social change agents. They were introduced to the Gestalt approach after having already established themselves in their careers. Their articles bring fresh insights and applications. Lohmeier integrates the Gestalt approach with the theory of the German sociologist Niklas Luhman. I particularly found exciting his description of Luhman’s way of conceptualizing organization dynamics. Gross applies Gestalt teachings to a traditional organization, while integrating it with his own theory, developed before his introduction to the Gestalt approach.The issue contains Gloria N. Melnick’s two interviews with Carolyn J. Lukensmeyer. Lukensmeyer is unique in having been a student at the Gestalt Institute of Cleveland while she simultaneously pursued and received a doctorate in Organizational Psychology from Case Western Reserve University. As a result, she is theoretically bilingual. In fact, she is not only a native speaker of both Gestalt therapy and organizational consultation, but she is also able to integrate both modalities into social change work, both in theory and in practice, as her impressive body of work bears out.The issue also includes my own review of Supporting Human Dignity in a Collapsing Field, edited by Joanna Kato, Guus Klaren, and Nurith Levi (2019). The volume contains a wide range of chapters primarily by Gestalt practitioners working as psychotherapists with migrants and immigrants, and utilizing Gestalt interventions with these at-risk populations. These chapters present robust evidence of the efficacy of the Gestalt approach with nontraditional patient populations. This validation is important, yet not surprising: a theory that looks at the functioning of people, both as individuals and as collectives, develops by constantly expanding to new populations and incorporating fresh theoretical insights.I am particularly pleased to present the responses of ten Gestalt practitioners from nine countries who have spent a significant part of their lives engaged in social change initiatives. They respond to the question: “How has the Gestalt approach contributed personally and professionally to your understanding and work with social change?” I believe that you will be touched by their lived-out idealism, and personal and professional commitment, to making this a better world.We end with a brief Afterword by Erving Polster, who has spent much of his distinguished career applying the Gestalt approach to social change.My belief in the power of the Gestalt approach to deal with social change remains strong. It was created to deal with situations in which habits and ways of living are no longer effective, and when the future is minimally predictable. We appreciate that there are no bystanders, that we are all connected in a multitude of ways, and have some responsibility to take action to make a better world. Social change and justice are in our blood, in our DNA.

Aaron T. Beck (1921-2021).

Memorializes Aaron T. Beck (1921-2021). Beck was the founder of cognitive therapy (CT), the father figure of the cognitive-behavior therapy (CBT) movement, creator of the Beck Depression Inventory, champion of the manualized treatment protocol that kept psychotherapy in the game in the era of drugs and randomized clinical trials, and inspiration behind the U.K.'s National Health Service Improving Access to Psychological Therapies program. Beck trained in psychiatry at the height of the influence of psychoanalysis. Beck's psychiatric training was exclusively of the liberal-analytic bent. At Cushing Veterans Administration Hospital (Boston), he trained under Felix Deutsch and Jacob Finesinger, both of whom advocated brief psychoanalytically informed therapies. In 1994, he and his daughter Judith Beck founded the Beck Institute, a CBT training center. In his later years, he studied hatred (Prisoners of Hate) and schizophrenia. Beck garnered many honors including a public meeting with the Dalai Lama (2005) and the Lasker Award for Clinical Medical Research (2006). (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Longitudinal Associations of Risk Factors and Hepatocellular Carcinoma in Patients With Cured Hepatitis C Virus Infection.

There are limited data on the effect and evolution of risk factors for hepatocellular carcinoma (HCC) in patients with virologically cured hepatitis C virus (HCV) infection. We conducted a retrospective cohort study of patients with HCV who achieved sustained virological response with direct-acting antivirals from 130 Veterans Administration hospitals during 2014-2018, followed through 2021. Cox proportional hazards models were constructed at 3 landmark times (baseline and 12 and 24 months after sustained virological response) to examine associations between demographic, clinical, and behavioral factors and HCC risk, stratified by cirrhosis status. Among 92,567 patients (32% cirrhosis), 3,247 cases of HCC were diagnosed during a mean follow-up of 2.5 years. In patients with cirrhosis, male sex (hazard ratios [HR]: 1.89, 1.93, and 1.99), cirrhosis duration ≥5 years (HR: 1.71, 1.79, and 1.34), varices (HR: 1.73, 1.60, and 1.56), baseline albumin (HR: 0.48, 0.47, and 0.49), and change in albumin (HR: 0.82 and 0.90) predicted HCC risk at each landmark time. HCV genotype 3, previous treatment, bilirubin, smoking, and race influenced HCC risk at baseline, but their effects attenuated over time. In patients without cirrhosis, diabetes (HR: 1.54, 1.42, and 1.47) and hypertension (HR: 1.59, 1.65, and 1.74) were associated with HCC risk at all landmark times. Changes in fibrosis-4 scores over time were associated with HCC risk both in patients with and without cirrhosis. Risk factors for HCC were different in patients with and without cirrhosis and some also evolved during follow-up. These factors can help with risk stratification and HCC surveillance decisions in patients with cured HCV.

Influence of Cancer on COVID-19 Incidence, Outcomes, and Vaccine Effectiveness: A Prospective Cohort Study of U.S. Veterans

PurposeCoronavirus disease 2019 (COVID-19) has been a constant health threat since its emergence. Amongst risk factors proposed, a diagnosis of cancer has been worrisome. We report the impact of cancer and other risk factors in US Veterans receiving care at Veterans Administration (VA) Hospitals, their adjusted odds ratio (aOR) for infection and death, and report on the impact of vaccines on the incidence and severity of COVID-19 infections in Veterans without/with cancer. MethodsWe conducted a cohort study of US Veterans without/with cancer by mining VA COVID-19 Shared Data Resource (CSDR) data using the VA Informatics and Computing Infrastructure (VINCI). Our observation period includes index dates from 14DEC2020 to 25JAN2022, encompassing both the delta and omicron waves in the US. ResultsWe identified 915,928 Veterans, 24% of whom were African Americans who had undergone COVID testing–688,541 were and 227,387 were not vaccinated. 157,072 had a cancer diagnosis in the preceding two years. Age emerged as the major risk factor, with gender, BMI, and (Elixhauser) comorbidity contributing less. Among veterans with solid tumors other than lung cancer, risks of infection and death within 60 days were comparable to Veterans without cancer. However, those with hematologic malignancies fared worse. Vaccination was highly effective across all cancer cohorts; the respective rates of infection and death after infection were 8% and 5% among the vaccinated compared to 47% and 10% in the unvaccinated. Amongst vaccinated, increased risk of infection was noted in both, Veterans with hematologic malignancy treated with chemotherapy (HR, 2.993, P < 0.0001) or targeted therapies (HR, 1.781, P < 0.0001), and in solid tumors treated with either chemotherapy (HR 2.328, 95%CI 2.075–2.611, P < 0.0001) or targeted therapies (HR 1.328, P < 0.0001) when compared to those not on treatment. ConclusionsRisk for COVID-19 infection and death from infection vary based on cancer type and therapies administered. Importantly and encouragingly, the duration of protection from infection following vaccination in Veterans with a diagnosis of cancer was remarkably like those without a cancer diagnosis. Veterans with hematologic malignancies are especially vulnerable, with lower vaccine effectiveness (VE).

Feasibility of a Combined Neuromodulation and Yoga Intervention for Mild Traumatic Brain Injury and Chronic Pain: Protocol for an Open-label Pilot Trial.

BackgroundMild traumatic brain injury (mTBI) and chronic pain often co-occur and worsen rehabilitation outcomes. There is a need for improved multimodal nonpharmacologic treatments that could improve outcomes for both conditions. Yoga is a promising activity-based intervention for mTBI and chronic pain, and neuromodulation through transcranial magnetic stimulation is a promising noninvasive, nonpharmacological treatment for mTBI and chronic pain. Intermittent theta burst stimulation (iTBS) is a type of patterned, excitatory transcranial magnetic stimulation. iTBS can induce a window of neuroplasticity, making it ideally suited to boost the effects of treatments provided after it. Thus, iTBS may magnify the impacts of subsequently delivered interventions as compared to delivering those interventions alone and accordingly boost their impact on outcomes.ObjectiveThe aim of this study is to (1) develop a combined iTBS+yoga intervention for mTBI and chronic pain, (2) assess the intervention’s feasibility and acceptability, and (3) gather preliminary clinical outcome data on quality of life, function, and pain that will guide future studies.MethodsThis is a mixed methods, pilot, open-labeled, within-subject intervention study. We will enroll 20 US military veteran participants. The combined iTBS+yoga intervention will be provided in small group settings once a week for 6 weeks. The yoga intervention will follow the LoveYourBrain yoga protocol—specifically developed for individuals with TBI. iTBS will be administered immediately prior to the LoveYourBrain yoga session. We will collect preliminary quantitative outcome data before and after the intervention related to quality of life (TBI-quality of life), function (Mayo-Portland Adaptability Index), and pain (Brief Pain Inventory) to inform larger studies. We will collect qualitative data via semistructured interviews focused on intervention acceptability after completion of the intervention.ResultsThis study protocol was approved by Edward Hines Jr Veterans Administration Hospital Institutional Review Board (Hines IRB 1573116-4) and was prospectively registered on ClinicalTrials.gov (NCT04517604). This study includes a Food and Drug Administration Investigational Device Exemption (IDE: G200195). A 2-year research plan timeline was developed. As of March 2022, a total of 6 veterans have enrolled in the study. Data collection is ongoing and will be completed by November 2022. We expect the results of this study to be available by October 2024.ConclusionsWe will be able to provide preliminary evidence of safety, feasibility, and acceptability of a novel combined iTBS and yoga intervention for mTBI and chronic pain—conditions with unmet treatment needs.Trial RegistrationClinicalTrials.gov NCT04517604; https://www.clinicaltrials.gov/ct2/show/NCT04517604International Registered Report Identifier (IRRID)DERR1-10.2196/37836