VA Heart of Texas Health Care Network

Abstract Disclosure: V. Vimalananda: None. S. Qian: None. K.A. Arao: None. A. Leibowitz: None. M. Zupa: None. J. Benzer: None. M. Zocchi: None. G. Fincke: None. M. Meterko: None. D. Berlowitz: None. K. Sitter: None. J. Wormwood: None. Background: Use of telehealth (telephone or video) for outpatient care peaked early in the COVID-19 pandemic. Use has decreased since that time but remains well above pre-pandemic levels. We described the observed levels of variation in telehealth use under this “new normal” and examined the predictors of its utilization for endocrinology outpatient care. These data can be used to develop strategies to ensure equitable access for endocrine patients to clinically appropriate modes of care. Methods: Cross-sectional study of national data from the Veterans Health Administration (VA), the largest integrated health system in the U.S. Multivariable mixed effects logistic regression models were used to identify patient-, clinician-, facility-, and Veterans Integrated Service Network (VISN)-level characteristics associated with telehealth use among patients seen for outpatient endocrinology from 3/9/21 – 3/8/22. We examined two outcomes: telehealth (telephone or video) v. in-person visits, and within the subsample of telehealth visits, telephone v. video visits. Results: The dataset included 167,017 patients, 618 clinicians, 99 facilities, and 18 VISNs for visits that were in person (58%), telephone (29%), and video (13%). Intraclass correlation coefficients revealed unique variability in telehealth use accounted for by each level of the analysis (56% patient/visit, 24% clinician, 18% facility, and 2% VISN). Visits were more likely to be telehealth (v. in person) if the visit was a follow-up (v. an initial consultation: OR 1.99, 95%CI [1.93, 2.06]); the clinician was an APN (v. physician: OR 2.11, 95%CI [1.06, 2.76]); the clinician was full-time (OR 1.46, 95%CI [1.15, 1.87]); and the facility was of higher complexity (OR 3.40, 95%CI [1.51, 7.68]). Among telehealth visits, unique variability in telephone (vs. video) usage was accounted for by each level of the analysis (44% patient/visit, 24% clinician, 26% facility, and 6% VISN). Telehealth visits were significantly more likely to be telephone (v. video) for follow-up visits (vs. initial consultation: OR 2.22, 95%CI [2.09, 2.35], for moderately disabled patients with partial copays (v. patients with poverty, no copayments: OR 1.36, 95%CI [1.28,1.47]), for diabetes visits (vs. bone/mineral disorder: OR 1.30, 95%CI [1.20, 1.41], and for facilities serving a more rural population (OR 16.6, 95%CI [2.2, 123.4]). Conclusion: This study found wide variation in use of telehealth for endocrinology under the “new normal”. A significant amount of this variation may reflect uneven use among clinicians or differences in facility use of telehealth. More work is needed to investigate the range of reasons for variation at the clinician and facility level, particularly as many of those drivers may be amenable to influence by clinical leaders and could be leveraged to enhance availability of all clinically appropriate modes of care for endocrine patients. Presentation: Saturday, June 17, 2023

Abstract IntroductionCortical thickness (CT) and surface area (SA) are established biomarkers of brain pathology in posttraumatic stress disorder (PTSD). Structural covariance networks (SCN) constructed from CT and SA may represent developmental associations, or unique interactions between brain regions, possibly influenced by a common causal antecedent. The ENIGMA-PGC PTSD Working Group aggregated PTSD and control subjects’ data from 29 cohorts in five countries (n=3439).MethodsUsing Destrieux Atlas, we built SCNs and compared centrality measures between PTSD subjects and controls. Centrality is a graph theory measure derived using SCN.ResultsNotable nodes with higher CT-based centrality in PTSD compared to controls were left fusiform gyrus, left superior temporal gyrus, and right inferior temporal gyrus. We found sex-based centrality differences in bilateral frontal lobe regions, left anterior cingulate, left superior occipital cortex and right ventromedial prefrontal cortex (vmPFC). Comorbid PTSD and MDD showed higher CT-based centrality in the right anterior cingulate gyrus, right parahippocampal gyrus and lower SA-based centrality in left insular gyrus.ConclusionUnlike previous studies with smaller sample sizes (≤318), our study found differences in centrality measures using a sample size of 3439 subjects. This is the first cross-sectional study to examine SCN interactions with age, sex, and comorbid MDD. Although limited to group level inferences, centrality measures offer insights into a node’s relationship to the entire functional connectome unlike approaches like seed-based connectivity or independent component analysis. Nodes having higher centrality have greater structural or functional connections, lending them invaluable for translational treatments like neuromodulation.

We aimed to assess rates and predictors of hepatocellular carcinoma (HCC) screening among patients with cirrhosis. We reviewed electronic health records of 11,361 patients with cirrhosis from 11 U.S. Veterans Health Administration facilities for receipt of HCC screening in the 6 months preceding October 1, 2019. Nearly half of the cohort (46%) received HCC screening over a 6-month period. Screening rates and modalities (ultrasound, computed tomography, magnetic resonance imaging, serum alpha fetoprotein) varied by facility. Screening was associated with race/ethnicity, body mass index ≥ 25, cirrhosis etiology, thrombocytopenia, Fibrosis-4 ≥ 3.25, and lower Model for End-Stage Liver Disease-Sodium. HCC screening rates varied by facility. Higher risk patients were more likely to receive screening.

Gratitude has been consistently linked to well-being, but its influence on health-related functioning is not well understood. Furthermore, research suggests the need to differentiate between-person and within-person effects of personality characteristics, and research on gratitude and health has not typically done so. This prospective study aimed to (1) differentiate the unique effects of trait and state gratitude on health-related quality of life (HRQoL) and (2) test state gratitude as a mediator between baseline trait gratitude and subsequent HRQoL. Undergraduate participants (N = 141) completed a trait gratitude measure at baseline and then repeated measures of weekly state gratitude and HRQoL over eight weeks. Multilevel models examined baseline trait gratitude, state gratitude averaged across the study (person aggregate) as between-person individual differences, and within-person variability in state gratitude (person-centered) as predictors of HRQoL, as well as the indirect effect of trait gratitude on HRQoL via state gratitude. Greater aggregate and person-centered state gratitude each predicted higher HRQoL. Baseline trait gratitude did not have a significant direct effect but prospectively predicted higher HRQoL via higher weekly state gratitude. Results suggest that understanding effects of gratitude on health-related perceptions requires accounting for both between-person individual differences and within-person fluctuation in state gratitude.

Abstract A growing number of studies have examined alterations in white matter organization in people with posttraumatic stress disorder (PTSD) using diffusion MRI (dMRI), but the results have been mixed, which may be partially due to relatively small sample sizes among studies. Altered structural connectivity may be both a neurobiological vulnerability for, and a result of, PTSD. In an effort to find reliable effects, we present a multi-cohort analysis of dMRI metrics across 3,049 individuals from 28 cohorts currently participating in the PGC-ENIGMA PTSD working group (a joint partnership between the Psychiatric Genomics Consortium and the Enhancing NeuroImaging Genetics through Meta-Analysis consortium). Comparing regional white matter metrics across the full brain in 1,446 individuals with PTSD and 1,603 controls (2152 males/897 females) between ages 18-83, 92% of whom were trauma-exposed, we report associations between PTSD and disrupted white matter organization measured by lower fractional anisotropy (FA) in the tapetum region of the corpus callosum (Cohen’sd=−0.12,p=0.0021). The tapetum connects the left and right hippocampus, structures for which structure and function have been consistently implicated in PTSD. Results remained significant/similar after accounting for the effects of multiple potentially confounding variables: childhood trauma exposure, comorbid depression, history of traumatic brain injury, current alcohol abuse or dependence, and current use of psychotropic medications. Our results show that PTSD may be associated with alterations in the broader hippocampal network.

BackgroundThe U.S. Department of Veterans Affairs (VA) has recently implemented a comprehensive national program to help veterans who use or experience intimate partner violence (IPV). One important component of this plan is to implement Strength at Home (SAH), a 12-week cognitive-behavioral and trauma-informed group treatment designed to reduce and end IPV use among military and veteran populations.MethodThe present study describes initial patient and clinician findings from the first year of a training program tasked with implementing SAH at 10 VA medical centers.ResultsResults from 51 veterans who completed both pre- and post-treatment assessments indicate SAH was associated with significant pre- to post-treatment reductions in the proportion of veterans who reported using physical and psychological IPV toward a partner, the types of IPV used, and posttraumatic stress disorder symptoms. Overall, veterans reported high satisfaction with the quality and nature of services received, and with the program materials. In addition, 70% of sites and 34% of the 79 clinicians trained were successful in launching the program in the first year. The mean number of days between site training and initiation of the first group session was 135.86 (SD = 63.16, range 72–252).ConclusionsResults suggest that the training and implementation program was successful overall. However, average length of time between in-person training and initiation of group services was longer than desired and there were three sites that did not successfully implement the program within the first year, suggesting a need to reduce implementation barriers and enhance institutional support.

Childhood sexual abuse (CSA) has been a topic of interest in sexual health research for decades, yet literature on the sexual health correlates of CSA has been hindered by methodologic inconsistencies that have resulted in discrepant samples and mixed results. To review the major methodologic inconsistencies in the field, explore the scientific and clinical impact of these inconsistencies, and propose methodologic approaches to increase consistency and generalizability to the general population of women with CSA histories. A comprehensive literature review was conducted to assess the methodologic practices used in examining CSA and sexual health outcomes. Methodologic decisions of researchers examining sexual health outcomes of CSA. There are a number of inconsistencies in the methods used to examine CSA in sexual health research across the domains of CSA operationalization, recruitment language, and measurement approaches to CSA experiences. The examination of CSA and sexual health correlates is an important research endeavor that needs rigorous methodologic approaches. We propose recommendations to increase the utility of CSA research in sexual health. We recommend the use of a developmentally informed operationalization of childhood and adolescence, rather than age cutoffs. Researchers are encouraged to use a broad operationalization of sexual abuse such that different abuse characteristics can be measured, reported, and examined in the role of sexual health outcomes. We recommend inclusive recruitment approaches to capture the full range of CSA experiences and transparency in reporting these methods. The field also could benefit from the validation of existing self-report instruments for assessing CSA and detailed reporting of the instruments used in research studies. The use of more consistent research practices could improve the state of knowledge on the relation between CSA and sexual health. Kilimnik CD, Pulverman CS, Meston CM. Methodologic Considerations for the Study of Childhood Sexual Abuse in Sexual Health Outcome Research: A Comprehensive Review. Sex Med Rev 2018;6:176-187.

A central goal in systems neuroscience is the parcellation of the cerebral cortex into discrete neurobiological "atoms". Resting-state functional magnetic resonance imaging (rs-fMRI) offers the possibility of in vivo human cortical parcellation. Almost all previous parcellations relied on 1 of 2 approaches. The local gradient approach detects abrupt transitions in functional connectivity patterns. These transitions potentially reflect cortical areal boundaries defined by histology or visuotopic fMRI. By contrast, the global similarity approach clusters similar functional connectivity patterns regardless of spatial proximity, resulting in parcels with homogeneous (similar) rs-fMRI signals. Here, we propose a gradient-weighted Markov Random Field (gwMRF) model integrating local gradient and global similarity approaches. Using task-fMRI and rs-fMRI across diverse acquisition protocols, we found gwMRF parcellations to be more homogeneous than 4 previously published parcellations. Furthermore, gwMRF parcellations agreed with the boundaries of certain cortical areas defined using histology and visuotopic fMRI. Some parcels captured subareal (somatotopic and visuotopic) features that likely reflect distinct computational units within known cortical areas. These results suggest that gwMRF parcellations reveal neurobiologically meaningful features of brain organization and are potentially useful for future applications requiring dimensionality reduction of voxel-wise fMRI data. Multiresolution parcellations generated from 1489 participants are publicly available (https://github.com/ThomasYeoLab/CBIG/tree/master/stable_projects/brain_parcellation/Schaefer2018_LocalGlobal).