Health-related quality of life and social determinants of health following COVID-19 infection in a predominantly Latino population.

BACKGROUND: As the COVID-19 pandemic evolves, more information is needed on its long-term impacts on health-related quality of life (HRQoL) and social determinants of health (SDoH). The aim of the study was to assess HRQoL and SDoH among a predominantly Latino population of COVID-19 survivors and to compare effects in Latinos versus non-Latinos. METHODS: This cross-sectional study consisted of a survey (in English and Spanish) of COVID-19 survivors from December 2020 to July 2021. The study assessed sociodemographic data, clinical characteristics, and SDoH, consisting of 10 COVID-19-related concerns. The PROMIS-29 + 2 (PROPr) measure, which captures 8 HRQoL domains and a preference-based health utility, was used to assess HRQoL. Bivariate analyses included chi-square tests and t-tests. Generalized linear models were conducted for multivariable analyses. RESULTS: Of 230 respondents (6.3% response rate), the mean [SD] age was 43.1 [14.3] years; 83.0% were Latino; the mean [SD] time since diagnosis was 8.1 [3.2] months; and 12.6% had a history of hospitalization with COVID-19. HRQoL scores were slightly worse than population norms on all domains, especially anxiety; the mean [SD] PROPr health utility was 0.36 [0.25]. Domain scores were similar by ethnicity except for cognitive function-abilities, where scores were lower in Latinos. Multivariable analyses revealed that: (1) financial concerns were associated with worse health utility, as well as worse scores on all 8 PROMIS domains; (2) interpersonal conflict was associated with worse health utility and worse scores on 6 of the 8 PROMIS domains (anxiety, depression, fatigue, sleep disturbance, social function, and pain interference); and (3) Latino ethnicity was only associated with 1 PROMIS domain (cognitive function-abilities) after controlling for covariates. CONCLUSION: COVID-19 infection is associated with HRQoL decrements long after the acute infection, and financial concerns and interpersonal conflict are particularly associated with worse HRQoL.

Persistent Pain, Physical Dysfunction, and Decreased Quality of Life After Combat Extremity Vascular Trauma.

BACKGROUND: Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. METHODS: Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. RESULTS: Eighty-one patients responded with an average time since injury of 129 months (SD: 31; range 67-180 months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P = 0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. CONCLUSIONS: EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.

Patency of arterial repairs from wartime extremity vascular injuries.

BACKGROUND: Extremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied on successful limb salvage as a surrogate for vascular repair. We used imaging studies as a specific measure of arterial repair durability. METHODS: Service members with EVI were identified using the Department of Defense Trauma Registry and validated by chart abstraction. Inclusion criteria for the arterial patency subgroup included an initial repair attempt with subsequent imaging reports (duplex ultrasound, CT angiography, and angiogram) documenting initial patency. RESULTS: The cohort of 527 included 140 Veterans with available imaging studies for 143 arterial repairs; median follow-up from injury time to last available imaging study was 19 months (Q1-Q3: 3-58; range: 1-175). Injury mechanism was predominantly explosions (52%) and gunshot wounds (42%). Of the 143 arterial repairs, 81% were vein grafts. Eight repairs were occluded, replaced or included in extremity amputations. One upper extremity and three transtibial late amputations were performed for chronic pain and poor function averaging 27 months (SD: 4; range: 24-32). Kaplan-Meier analysis estimated patency rates of 99%, 97%, 95%, 91% and 91% at 3, 6, 12, 24, and 36 months, respectively, with similar results for upper and lower extremity repairs. Explosive and gunshot wound injury mechanisms had similar patency rates and upper extremity injuries repaired with vein grafts had increased patency. CONCLUSIONS: Arterial repair mid-term patency in combat-related extremity injuries is excellent based on imaging studies for 143 repairs. Assertive attempts at acute limb salvage and vascular repair are justified with decisions for amputation versus limb salvage based on the overall condition of the patient and degree of concomitant nerve, orthopedic and soft tissue injuries rather than the presence of arterial injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Association of parental status and diagnosis of posttraumatic stress disorder among veterans of Operations Iraqi and Enduring Freedom.

Research indicates that concerns about disruption of family relationships during military service may be associated with greater posttraumatic stress symptomatology. The current study sought to extend previous findings by examining the relative odds of a posttraumatic stress disorder (PTSD) diagnosis among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with dependent children versus veterans without dependent children. Administrative databases were queried to identify 36,334 OEF/OIF veterans with dependent children seeking care in the Veterans Health Administration (VA) during fiscal years 2006-2009. These veterans were matched 1:1 on age, gender, and demobilization date to veterans without dependent children (N = 72,668). In unconditional analyses, OEF/OIF veterans with dependent children versus those without were significantly more likely to incur a PTSD diagnosis (44% vs. 28%). After controlling for demographic variables, mental health utilization, and other serious mental illness, OEF/OIF veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. The association was stronger for men than for women. It may be of value for clinicians to consider parental status when assessing and treating veterans with PTSD. In-depth study of OEF/OIF veterans is needed to determine whether disruption of family relationships leads to increased psychological stress or parents are more likely than nonparents to seek VA mental health services for PTSD symptoms.

Use of Health Care System-Supplied Aspirin by Veterans With Postoperative Heart Attack or Unstable Angina.

Evidence-based guidelines for the use of aspirin in secondary prevention of cardiovascular disease events are well established. Despite this, the prevalence of aspirin use for secondary prevention is suboptimal. The study aimed to determine the prevalence of aspirin use for secondary prevention of cardiovascular disease events when it is dispensed as a prescription, as is performed in the Veterans Affairs (VA) managed care system. VA patients who had undergone major surgery and experienced a postoperative myocardial infarction (MI) or unstable angina between the years 2005 and 2009 were identified from administrative databases. VA pharmacy records were used to determine whether a prescription for aspirin was filled after the postoperative MI or unstable angina. Multivariable logistic regression models estimated odd ratios of filling aspirin prescriptions for the predictors of interest. Of the 321,131 men and women veterans who underwent major surgery, 7,700 experienced a postoperative MI or unstable angina. Among those 7,700, 47% filled an aspirin prescription. Only 59% of veterans with no co-pay filled an aspirin prescription. Aspirin fills were more common in younger veterans, Blacks, Hispanics, males, hypertensive veterans, mentally ill patients, those with no co-pay and those prescribed antiplatelets/anticoagulants in addition to aspirin postoperatively. These findings suggest that the impact of dispensing aspirin as a prescription may not be significant in increasing the appropriate use of aspirin for secondary prevention.

Posttransplantation Outcomes in Veterans With Serious Mental Illness.

BACKGROUND: Anticipating poor recovery due to impaired self-management and appointment-keeping, clinicians may consider serious mental illness (SMI) a significant concern in organ transplantation. However, little empirical evidence exists regarding posttransplantation outcomes for patients with SMI. METHODS: This study analyzed health services data to evaluate posttransplantation 3-year survival by SMI status in a nationwide cohort of patients in the Veterans Health Administration (VHA). RESULTS: A total of 960 recipients of solid organ or bone marrow transplants were identified from Veterans Health Administration administrative data extracts for fiscal years 2006 to 2009. Of these, 164 (17%) had an SMI diagnosis before transplantation (schizophrenia, posttraumatic stress, major depressive, and bipolar disorders); 301 (31%) had some other mental illness diagnosis (such as anxiety, adjustment reactions, or substance abuse); and 495 (52%) had no mental health diagnosis. Twenty-two patients (2%) required retransplantation and 208 patients (22%) died during follow-up. Data on whether these were primary or repeat transplantations were unavailable. Rates of attendance at postoperative outpatient visits and number of months for which immunosuppressive drugs fills were recorded were similar among mental illness groups, as were rates of diagnosed immunological rejection. Three-year mortality was equivalent among mental health groups: no mental health (19%) versus other mental illness (23%) versus SMI (27%; χ(2) = 5.11; df = 2; P = .08). In adjusted survival models, no effect of mental health status was observed. CONCLUSIONS: Serious mental illness diagnosis does not appear to be associated with adverse transplantation outcomes over the first 3 years; however, a potentially diverging survival curve may portend higher mortality at 5 years.

Prevalence of suicidality among Hispanic and African American veterans following surgery.

OBJECTIVES: We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89,995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006. METHODS: We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes. RESULTS: African Americans (18% of sample; 16,252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI] = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI. CONCLUSIONS: The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity.