U.S. Department of Veterans Affairs

Prior research finds that individuals with greater exposure to homelessness express more favorable attitudes toward people experiencing homelessness. However, it is unclear whether exposure to more broader forms of housing insecurity (e.g. lack of affordability, poor housing quality, being doubled-up) is linked to perceptions of and attitudes toward homelessness. We thus examined the association between both exposure to homelessness and several broader measures of housing insecurity and perceptions and attitudes toward homelessness. We also assessed whether rurality modified these associations. We used Qualtrics Panels to conduct an online survey of 1270 low- and moderate-income adults, equally split between urban and rural areas nationwide in 2018. The survey included questions assessing experiences and opinions about homelessness and housing insecurity. In multiple regression models, we found that exposure to both homelessness and other forms of housing insecurity were associated with an increased degree of perception of homelessness as beyond individual control and an increased propensity for sympathetic interactions with people experiencing homelessness. Rurality did not modify these relationships. As both homelessness and other forms of housing insecurity are on the rise, these findings may portend a shift toward more favorable attitudes and perceptions of homelessness.

Posttraumatic stress disorder (PTSD) significantly impacts many veterans. Although PTSD has been linked to alterations in the fear brain network, the disorder likely involves alterations in both the fear and anxiety networks. Fear involves responses to imminent, predictable threat and is driven by the amygdala, whereas anxiety involves responses to potential, unpredictable threat and engages the bed nucleus of the stria terminalis (BNST). The BNST has been implicated in PTSD, but the role of the BNST in combat veterans with PTSD has yet to be examined. Identifying alterations in BNST responses to unpredictable threat could provide important new targets for treatment. The current study examined whether veterans with PTSD have altered BNST or amygdala responses (function and connectivity) to unpredictable and predictable threat. The fMRI task involved viewing predictable threat cues followed by threat images, predictable neutral cues followed by neutral images, and unpredictable threat cues followed by either a threat or neutral image. Participants included 32 combat-exposed veterans with PTSD and 13 combat-exposed controls without PTSD. Across all conditions, veterans with PTSD had heightened BNST activation and displayed stronger BNST and amygdala connectivity with multiple fear and anxiety regions (hypothalamus, hippocampus, insula, ventromedial prefrontal cortex) relative to controls. In contrast, combat controls showed a pattern of stronger connectivity during neutral conditions (e.g., BNST-vmPFC), which may suggest a neural signature of resilience to developing PTSD, ηp 2 = .087-.527, ps < .001. These findings have implications for understanding fear and anxiety networks that may contribute to the development and maintenance of PTSD.

Objective Surveillance of non–ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses. Methods We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans’ Affairs (VA) hospitals from January 1, 2015, to November 30, 2020. We randomly selected 250 hospitalizations meeting NV-HAP surveillance criteria for independent review by 2 clinicians and calculated the percent of hospitalizations with (1) clinical deterioration, (2) CDC National Healthcare Safety Network (CDC-NHSN) criteria, (3) NV-HAP according to a reviewer, (4) NV-HAP according to a treating clinician, (5) pneumonia diagnosis in discharge summary; and (6) discharge diagnosis codes for HAP. We assessed interrater reliability by calculating simple agreement and the Cohen κ (kappa). Results Among 3.1 million hospitalizations, 14,023 met NV-HAP electronic surveillance criteria. Among reviewed cases, 98% had a confirmed clinical deterioration; 67% met CDC-NHSN criteria; 71% had NV-HAP according to a reviewer; 60% had NV-HAP according to a treating clinician; 49% had a discharge summary diagnosis of pneumonia; and 82% had NV-HAP according to any definition according to at least 1 reviewer. Only 8% had diagnosis codes for HAP. Interrater agreement was 75% (κ = 0.50) for CDC-NHSN criteria and 78% (κ = 0.55) for reviewer diagnosis of NV-HAP. Conclusions Electronic NV-HAP surveillance criteria correlated moderately with existing manual surveillance criteria. Reviewer variability for all manual assessments was high. Electronic surveillance using clinical data may therefore allow for more consistent and efficient surveillance with similar accuracy compared to manual assessments or diagnosis codes.

Abdominopelvic varicosities are a rare occurrence after traumatic venous injuries. Several disorders exist that present with abdominopelvic varicosities such as May-Thurner syndrome, pelvic congestion syndrome, and nutcracker syndrome; however, it has rarely been described after trauma.1 We present a case in 70-year-old male, who in 1974 sustained a penetrating injury from fragments secondary to mortar explosion, requiring exploratory laparotomy. He presented to the hospital with abdominopelvic varicosities that began 20 years after the incident and was asymptomatic at initial presentation. While there is a known case report of congenital absence of a common iliac vein in a young, healthy, athletic man who developed abdominopelvic varicosities, this is the first case report, to our knowledge, of evolution of a traumatic injury of this nature over a lifetime. Pathophysiology, diagnostics, risks of ligation, and management of chronic abdominopelvic varicosities in this patient are discussed.

Background In the Veterans Health Administration (VA), Primary Care-Mental Health Integration (PC-MHI) clinics offer mental health services embedded in primary care, a strategy shown to reduce overall specialty mental health clinic burden while facilitating prompt referrals when indicated. Among newly initiated patients, same-day access to PC-MHI from primary care increases subsequent specialty mental health engagement. However, the impact of virtual care on the association between same-day access to PC-MHI and subsequent mental health engagement remains unclear. Objective To examine the effects of same-day access to PC-MHI and virtual care use on specialty mental health engagement. Methods We used administrative data from 3066 veterans who initiated mental health care at a large, California VA PC-MHI clinic during 3/1/2018 to 2/28/2022 and had no previous mental health visits for at least 2 years prior to the index appointment. We conducted Poisson regression analyses to examine the effects of same-day access to PC-MHI, virtual access to PC-MHI and their combined effect on subsequent specialty mental health engagement. Results Same-day access to PC-MHI from primary care was positively associated with specialty mental health engagement (IRR = 1.19; 95% CI 1.14-1.24). Virtual access to PC-MHI was negatively associated with specialty mental health engagement (IRR = 0.83; 95% CI 0.79-0.87). The positive effect of same-day access on specialty mental health engagement was smaller among patients who initiated PC-MHI in a virtual visit (IRR = 1.07) compared to in-person visits (IRR = 1.29; 95% CI 1.22-1.36). Conclusions Although same-day access to PC-MHI increased overall specialty mental health engagement, the magnitude of this effect varied between in-person and virtual modalities. More research is needed to understand mechanisms of the association between virtual care use, same-day access to PC-MHI, and specialty mental health engagement.

Introduction: This study investigated demographic differences in interpersonal theory of suicide factors and their associations with suicide attempts among sexual minority young adults. Methods: 784 sexual minority young adults ages 18-29 (42.7% cisgender men, 42.2% cisgender women, 15.1% transgender/gender diverse; 62.2% non-Hispanic White; 50.5% gay/lesbian, 49.5% bisexual+) completed an online survey assessing lifetime suicide attempts and interpersonal theory of suicide factors. Results: Demographic differences included (1) greater perceived burdensomeness among transgender/gender diverse participants compared to other gender groups; (2) greater acquired capability for suicide and suicide attempts among cisgender men compared to cisgender women; (3) greater acquired capability for suicide among bisexual+ compared to gay/lesbian participants; and (4) a lower number of suicide attempts among Asian/Asian American sexual minority participants compared to most other sexual minority participants. All interpersonal theory of suicide factors were significantly associated with a higher number of suicide attempts, though only perceived burdensomeness and acquired capability for suicide remained significant when examining all three simultaneously. No two- or three-way interactions between interpersonal theory of suicide factors were significant. Conclusion: The interpersonal theory of suicide may be useful for understanding suicide attempts in this population, with perceived burdensomeness and acquired capability being particularly relevant to consider.

The objective of this exploratory mixed methods study is to assess the use of hotels/motels among Veterans experiencing housing instability during the COVID-19 pandemic to inform policy and programmatic responses to homelessness during such emergencies. We analyzed qualitative interviews conducted with national-level homeless services leadership and Supportive Services for Veteran Families (SSVF) program providers during October 2020–May 2021 and quantitative data for Veterans who enrolled in SSVF during March–August 2020. A multivariable two-part regression model identified factors associated with receiving hotel/motel-specific financial assistance and associated costs. Qualitative interviews indicated that the use of hotels/motels during COVID-19 offered protection from a contagious disease and a novel mechanism to accommodate high-need Veterans who may have previously been unsheltered or resistant to services. Quantitative analyses found that Veteran households’ stays in hotels/motels increased sharply following the onset of the COVID-19 pandemic; this assistance tended to flow to a more vulnerable group (i.e. older, no income, and extensive histories of homelessness). COVID-19 and homelessness are ongoing public health concerns; strategies such as the use of hotels/motels to reduce homelessness and ensure safe options for isolation and quarantine are needed to prevent poor health outcomes for a vulnerable population.

Background Our understanding of the molecular underpinnings of chronic traumatic encephalopathy (CTE) and its associated pathology in post-mortem brain is incomplete. Factors including years of play and genetic risk variants influence the extent of tau pathology associated with disease expression, but how these factors affect gene expression, and whether those effects are consistent across the development of disease, is unknown. Methods To address these questions, we conducted an analysis of the largest post-mortem brain CTE mRNASeq whole-transcriptome dataset available to date. We examined the genes and biological processes associated with disease by comparing individuals with CTE with control individuals with a history of repetitive head impacts that lack CTE pathology. We then identified genes and biological processes associated with total years of play as a measure of exposure, amount of tau pathology present at time of death, and the presence of APOE and TMEM106B risk variants. Samples were stratified into low and high pathology groups based on McKee CTE staging criteria to model early versus late changes in response to exposure, and the relative effects associated with these factors were compared between these groups. Results Substantial gene expression changes were associated with severe disease for most of these factors, primarily implicating diverse, strongly involved neuroinflammatory and neuroimmune processes. In contrast, low pathology groups had many fewer genes and processes implicated and show striking differences for some factors when compared with severe disease. Specifically, gene expression associated with amount of tau pathology showed a nearly perfect inverse relationship when compared between these two groups. Conclusions Together, these results suggest the early CTE disease process may be mechanistically different than what occurs in late stages, that total years of play and tau pathology influence disease expression differently, and that related pathology-modifying risk variants may do so via distinct biological pathways.

Importance: Prior studies have demonstrated an association between cutaneous chronic graft-vs-host disease (cGVHD) and mortality. Assessment of the prognostic value of different measures of disease severity would assist in risk stratification. Objective: To compare the prognostic value of body surface area (BSA) and National Institutes of Health (NIH) Skin Score on survival outcomes stratified by erythema and sclerosis subtypes of cGVHD. Design, setting, and participants: Multicenter prospective cohort study from the Chronic Graft-vs-Host Disease Consortium including 9 medical centers in the US, enrolled from 2007 through 2012 and followed until 2018. Participants were adults and children with a diagnosis of cGVHD requiring systemic immunosuppression and with skin involvement during the study period, who had longitudinal follow-up. Data analysis was performed from April 2019 to April 2022. Exposures: Patients underwent continuous BSA estimation and categorical NIH Skin Score grading of cutaneous cGVHD at enrollment and every 3 to 6 months thereafter. Main outcomes and measures: Nonrelapse mortality (NRM) and overall survival (OS), compared between BSA and NIH Skin Score longitudinal prognostic models, adjusted for age, race, conditioning intensity, patient sex, and donor sex. Results: Of 469 patients with cGVHD, 267 (57%) (105 female [39%]; mean [SD] age, 51 [12] years) had cutaneous cGVHD at enrollment, and 89 (19%) developed skin involvement subsequently. Erythema-type disease had earlier onset and was more responsive to treatment compared with sclerosis-type disease. Most cases (77 of 112 [69%]) of sclerotic disease occurred without prior erythema. Erythema-type cGVHD at first follow-up visit was associated with NRM (hazard ratio, 1.33 per 10% BSA increase; 95% CI, 1.19-1.48; P < .001) and OS (hazard ratio, 1.28 per 10% BSA increase; 95% CI, 1.14-1.44; P < .001), while sclerosis-type cGVHD had no significant association with mortality. The model with erythema BSA collected at baseline and first follow-up visits retained 75% of the total prognostic information (from all covariates including BSA and NIH Skin Score) for NRM and 73% for OS, with no statistical difference between prognostic models (likelihood ratio test χ2, 5.9; P = .05). Conversely, NIH Skin Score collected at the same intervals lost significant prognostic information (likelihood ratio test χ2, 14.7; P < .001). The model incorporating NIH Skin Score instead of erythema BSA accounted for only 38% of the total information for NRM and 58% for OS. Conclusions and relevance: In this prospective cohort study, erythema-type cutaneous cGVHD was associated with increased risk of mortality. Erythema BSA collected at baseline and follow-up predicted survival more accurately than the NIH Skin Score in patients requiring immunosuppression. Accurate assessment of erythema BSA may assist in identifying patients with cutaneous cGVHD at high risk for mortality.

Background Vaccine hesitancy has been an ongoing challenge in campaigns, especially the rapid development and approval of the COVID-19 vaccines. The goal of this study was to understand the characteristics, perceptions and beliefs of COVID-19 vaccination prior to its widespread rollout among middle-income and low-income US adults. Methods Using a national sample of 2101 adults who completed an online assessment in 2021, this study examines the association of demographics, attitudes and behaviours related to COVID-19 vaccination intentions. Adaptive least absolute shrinkage and selection operator models were used to select these specific covariate and participant responses. Poststratification weights were generated using raking procedures and applied to improve generalisability. Results and conclusion Vaccine acceptance was high at 76% with 66.9% reporting intent to receive the COVID-19 vaccine when available. Only 8.8% of vaccine supporters screened positive for COVID-19-related stress compared with 9.3% among the vaccine hesitant. However, there were more people with vaccine hesitancy who screened positive for poor mental health and alcohol and substance misuse. The three main vaccine concerns were side effects (50.4%), safety (29.7%) and mistrust of vaccine distribution (14.8%). Factors influencing vaccine acceptance included age, education, children, region, mental health and social support, threat perception, opinion of governmental response, risk exposure and prevention activities and rejecting COVID-19 vaccine concerns. The results indicated acceptance was more strongly associated with beliefs and attitudes about the vaccine than sociodemographics, which are noteworthy and may lead to targeted interventions to increase COVID-19 vaccine acceptance among subgroups who are vaccine hesitant.

Justice-involved veterans (JIVs) are a high-priority subgroup within the U.S. judicial system. In recent years, empirical research into the characteristics, needs, and outcomes of this veteran subgroup has developed rapidly. To allow research to better inform efforts to support JIVs, a systematic review was completed to organize existing literature on criminogenic risk within this population through the lens of the Risk-Need-Responsivity Model. Of the eight risk factors theorized by the Risk-Need-Responsivity Model, history of antisocial behavior and substance use had the most robust evidence as criminogenic risk factors for veteran justice involvement. Modest evidence was identified for antisocial personality, educational and occupational difficulties, and disruptions to family and marital relationships as risk factors. However, only limited evidence was identified for antisocial thinking, affiliation with antisocial peers, and lack of prosocial activities as risk factors due to these factors being relatively underassessed in research. Such patterns provide insight into potential interventions and supports for JIVs while also highlighting areas for continued research.

Background Osteoarthritis (OA) is a debilitating disease involving cartilage degradation. A need remains for the discovery of new molecular targets in cartilage for pharmaceutical intervention of OA. One potential target is integrin α1β1 that protects against OA when it is upregulated by chondrocytes early in the disease process. Integrin α1β1 offers this protection by dampening epidermal growth factor receptor (EGFR) signaling, and its effects are more robust in females compared to males. The aim of this study, therefore, was to measure the impact of itga1 on chondrocyte EGFR activity and downstream reactive oxygen species (ROS) production in male and female mice. Furthermore, chondrocyte expression of estrogen receptor (ER) α and ERβ was measured to investigate the mechanism for sexual dimorphism in the EGFR/integrin α1β1 signaling axis. We hypothesized that integrin α1β1 would decrease ROS production and pEGFR and 3-nitrotyrosine expression, with this effect being greater in females. We further hypothesized that chondrocyte expression of ERα and ERβ would be greater in females compared to males, with a greater effect seen in itga1-null compared to wild-type mice. Materials and methods Femoral and tibial cartilage of male and female, wild-type and itga1-null mice were processed for ex vivo confocal imaging of ROS, immunohistochemical analysis of 3-nitrotyrosine, or immunofluorescence of pEGFR and ERα and ERβ. Results We show that ROS-producing chondrocytes are more abundant in female itga1-null compared to wild-type mice ex vivo; however, itga1 had limited influence on the percent of chondrocytes stained positively for 3-nitrotyrosine or pEGFR in situ. In addition, we found that itga1 influenced ERα and ERβ expression in femoral cartilage from female mice, and that ERα and ERβ were coexpressed as well as colocalized in chondrocytes. Finally, we show sexual dimorphism in ROS and 3-nitrotyrosine production, but surprisingly not in pEGFR expression. Conclusions Together these data highlight sexual dimorphism in the EGFR/integrin α1β1 signaling axis and underline the need for further investigation into the role of ERs in this biological paradigm. Understanding the molecular mechanisms underlying the development of OA is essential for the development of individualized, sex-specific treatments in this age of personalized medicine.

Meniscus tears represent a common orthopedic injury that often requires surgery to restore pain-free function. The need for surgical intervention is due, in part, to the inflammatory and catabolic environment that inhibits meniscus healing after injury. In other organ systems, healing is dependent on the migration of cells to the site of injury; however, in the meniscus it is currently unknown how the microenvironment dictates cell migration in the post-injury inflamed setting. Here, we investigated how inflammatory cytokines alter meniscal fibrochondrocyte (MFC) migration and sensation of microenvironmental stiffness. We further tested whether an FDA approved interleukin-1 receptor antagonist (IL-1Ra; Anakinra) could rescue migratory deficits caused by inflammatory challenge. When cultured in the presence of inflammatory cytokines (TNFα or IL1β) for one day, MFC migration was inhibited for 3 days before returning to control levels at day 7. This migratory deficit was clear in 3D as well, where fewer MFCs exposed to inflammatory cytokines migrated from a living meniscal explant compared to control. Notably, addition of IL-1Ra to MFCs previously exposed to IL1β restored migration to baseline levels. This study demonstrates that joint inflammation can have negative impacts on meniscus cell migration and mechanosensation, affecting their potential for repair, and that resolution of this inflammation with concurrent anti-inflammatories can reverse these deficits. Future work will apply these findings to mitigate the negative consequences of joint inflammation and promote repair in a clinically relevant meniscus injury model. This article is protected by copyright. All rights reserved.

Study objectives: Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia disorder. The goal of this study was to evaluate clinical benefits of CBT-I to veterans with insomnia disorder during the early months of the COVID-19 pandemic using an uncontrolled observational design. Methods: A cohort of 63 VA mental health providers delivered CBT-I to 180 veterans as part of an evidence-based psychotherapy training program and captured de-identified treatment outcome data through a data portal. The main patient outcomes were: change in the insomnia severity index (ISI) total score from the initial clinical assessment session to the last treatment session, response rate (% with ISI change >7 from assessment to last session) and remission rate (% with ISI <8 at the last session). We tested the non-inferiority of telehealth only compared to at least 1 in-person session. Results: Fifty-six percent of veterans seen for an evaluation completed CBT-I treatment during the structured training program phase and completed an initial and final ISI. Among these veterans, ISI scores decreased by an average of 9.9 points from before to after treatment (p<.001), 66% experienced a clinically meaningful treatment response, and 43% experienced insomnia symptom remission. Benefits were similar whether the veteran received some in-person care or received CBT-I entirely via telehealth. Conclusions: Findings suggest, regardless of treatment modality, CBT-I remained highly effective during the early months of the pandemic, which was a challenging time for both clinical providers and veterans in need of insomnia treatment.

Importance: Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH's effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined. Objective: To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system. Design, setting, and participants: This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion. Intervention: Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships. Main outcomes and measures: Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test. Results: The study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, -0.17 [95% CI, -0.21 to -0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, -0.23 [95% CI, -0.27 to -0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, -0.18 [95% CI, -0.22 to -0.14), PTSD symptoms (mean change, -4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24). Conclusions and relevance: In this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

Importance: Social determinants of health (SDOHs) are known to be associated with increased risk of suicidal behaviors, but few studies use SDOHs from unstructured electronic health record notes. Objective: To investigate associations between veterans' death by suicide and recent SDOHs, identified using structured and unstructured data. Design, setting, and participants: This nested case-control study included veterans who received care under the US Veterans Health Administration from October 1, 2010, to September 30, 2015. A natural language processing (NLP) system was developed to extract SDOHs from unstructured clinical notes. Structured data yielded 6 SDOHs (ie, social or familial problems, employment or financial problems, housing instability, legal problems, violence, and nonspecific psychosocial needs), NLP on unstructured data yielded 8 SDOHs (social isolation, job or financial insecurity, housing instability, legal problems, barriers to care, violence, transition of care, and food insecurity), and combining them yielded 9 SDOHs. Data were analyzed in May 2022. Exposures: Occurrence of SDOHs over a maximum span of 2 years compared with no occurrence of SDOH. Main outcomes and measures: Cases of suicide death were matched with 4 controls on birth year, cohort entry date, sex, and duration of follow-up. Suicide was ascertained by National Death Index, and patients were followed up for up to 2 years after cohort entry with a study end date of September 30, 2015. Adjusted odds ratios (aORs) and 95% CIs were estimated using conditional logistic regression. Results: Of 6 122 785 veterans, 8821 committed suicide during 23 725 382 person-years of follow-up (incidence rate 37.18 per 100 000 person-years). These 8821 veterans were matched with 35 284 control participants. The cohort was mostly male (42 540 [96.45%]) and White (34 930 [79.20%]), with 6227 (14.12%) Black veterans. The mean (SD) age was 58.64 (17.41) years. Across the 5 common SDOHs, NLP-extracted SDOH, on average, retained 49.92% of structured SDOHs and covered 80.03% of all SDOH occurrences. SDOHs, obtained by structured data and/or NLP, were significantly associated with increased risk of suicide. The 3 SDOHs with the largest effect sizes were legal problems (aOR, 2.66; 95% CI, 2.46-2.89), violence (aOR, 2.12; 95% CI, 1.98-2.27), and nonspecific psychosocial needs (aOR, 2.07; 95% CI, 1.92-2.23), when obtained by combining structured data and NLP. Conclusions and relevance: In this study, NLP-extracted SDOHs, with and without structured SDOHs, were associated with increased risk of suicide among veterans, suggesting the potential utility of NLP in public health studies.

PURPOSE Neurotrophic tyrosine receptor kinase 1-3 ( NTRK1-3) gene fusions are found in a broad range of tumor types. Clinical trials demonstrated high response rates to tropomyosin receptor kinase (TRK) inhibitors in NTRK fusion–positive cancers, but few reports have described real-world experience with these targeted agents. We evaluated the prevalence of NTRK fusions and the outcomes with TRK inhibitor therapy in a real-world population of patients in the Veterans Health Administration. METHODS Patients with NTRK fusions or rearrangements were identified from the Veterans Affairs (VA) National Precision Oncology Program (NPOP), and patients who were prescribed TRK inhibitors were identified from the Corporate Data Warehouse. Baseline data and clinical outcomes were obtained by retrospective review of medical records. RESULTS A total of 33 patients with NTRK fusions or rearrangements were identified, including 25 patients comprising 0.12% of all patients with solid tumors sequenced through VA NPOP. Twelve patients with NTRK fusions or rearrangements were treated with TRK inhibitors, none of whom had objective responses. Eight patients experienced toxicities leading to drug interruption, dose reduction, or discontinuation. CONCLUSION In this retrospective study of VA patients, NTRK fusions and rearrangements were less common than in previous studies, and objective responses to TRK inhibitors were not observed. Real-world experience with TRK inhibitors differs markedly from clinical trial findings, possibly due to differences in patient demographics, tumor types, and sequencing methods. Our findings highlight the need to study TRK inhibitors in the real-world setting and in populations underrepresented in clinical trials.

Clinical documentation in electronic health records contains crucial narratives and details about patients and their care. Natural language processing (NLP) can unlock the information conveyed in clinical notes and reports, and thus plays a critical role in real-world studies. The NLP Working Group at the Observational Health Data Sciences and Informatics (OHDSI) consortium was established to develop methods and tools to promote the use of textual data and NLP in real-world observational studies. In this paper, we describe a framework for representing and utilizing textual data in real-world evidence generation, including representations of information from clinical text in the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM), the workflow and tools that were developed to extract, transform and load (ETL) data from clinical notes into tables in OMOP CDM, as well as current applications and specific use cases of the proposed OHDSI NLP solution at large consortia and individual institutions with English textual data. Challenges faced and lessons learned during the process are also discussed to provide valuable insights for researchers who are planning to implement NLP solutions in real-world studies.

"Why should I care about doing Measurement-Based Care (MBC)?" This is a phrase that the editor often hears, either explicitly or implied, when working to champion and implement MBC within integrated primary care (IPC) settings. As an implementation and education specialist within the Veterans Health Administration (VHA) healthcare system, the editor has attended many MBC presentations and meetings where this question is uttered by frontline IPC clinicians, often frustrated with the growing demands on their practice. Many of these sentiments are usually framed around the assumption that MBC is not very important or useful, clinically speaking. This sets up a familiar debate of research versus practice: While many clinicians have heard MBC is "good for us," what accounts for the failure to implement MBC clinically? One of the major aims of this guest editorial is to invite the reader to consider the evidence base we have so far, rethink perceived barriers to MBC, and to ultimately decide for oneself that "the juice is worth the squeeze" for routine clinical practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).