Pleiotropic endophenotypic and phenotype effects of GABAergic neurosteroid synthesis deficiency in posttraumatic stress disorder.

PTSD is associated with deficits in synthesis of progesterone metabolites such as allopregnanolone and pregnanolone that potently facilitate gamma-amino-butyric acid (GABA) effects at GABA receptors. These neurosteroids modulate neuronal firing rate, regional brain connectivity, and activation of amygdala-mediated autonomic nervous system, hypothalamic-pituitary-adrenal axis, and behavioral reactions to unconditioned and conditioned threat. They also play critical roles in learning and memory processes such as extinction and extinction retention and inhibit toll-like receptor activation of intracellular pro-inflammatory pathways.

Requests for Directed Blood Donations.

This Ethics Rounds presents a request for directed blood donation. Two parents feel helpless in the setting of their daughter's new leukemia diagnosis and want to directly help their child by providing their own blood for a transfusion. They express hesitancy about trusting the safety of a stranger's blood.

Understanding veteran barriers to specialty outpatient PTSD clinical care.

Objective: Veterans seeking treatment for posttraumatic stress disorder (PTSD) commonly report general and veteran-specific barriers to treatment such as stigma and challenges with navigating the Veterans Health Affairs (VHA) system. This study aimed to characterize barriers endorsed by a national sample of veterans seeking care in VHA PTSD specialty outpatient clinics, as well as to examine the impact of demographics on endorsed barriers.

Methods: This study included 17,069 veterans referred to PTSD specialty outpatient clinics in the VHA during Fiscal Year 2019.

Nicotine Use and Metabotropic Glutamate Receptor 5 in Individuals With Major Depressive and Posttraumatic Stress Disorders.

Metabotropic glutamate receptor 5 (mGluR5) dysregulation has been implicated in the pathophysiology of many psychiatric disorders, as well as nicotine use and dependence. We used positron emission tomography with [F]FPEB to measure mGluR5 availability in vivo in 6 groups: (1) nicotine users (NUs) without other psychiatric comorbidities (=23); (2) comparison controls (CCs) without nicotine use or psychiatric comorbidities (=38); (3) major depressive disorder subjects with concurrent nicotine use (MDD-NU; =19); (4) MDD subjects without concurrent nicotine use (MDD-CC; =20); (5) posttraumatic stress disorder subjects with concurrent nicotine use (PTSD-NU; =17); and (6) PTSD subjects without concurrent nicotine use (PTSD-CC; =16). The goal of the study was to test the hypothesis that mGluR5 availability in key corticolimbic regions of interest (ROIs) is different in NU with versus without comorbid psychiatric disorders (ROI: dorsolateral prefrontal cortex [dlPFC], orbitofrontal cortex [OFC], ventromedial prefrontal cortex [vmPFC], anterior cingulate cortex [ACC], amygdala, hippocampus).

A Cross Sectional Survey of Recruitment Practices, Supports, and Perceived Roles for Unaffiliated and Non-scientist Members of IRBs.

Background: Institutional Review Boards (IRBs) are federally mandated to include both nonscientific and unaffiliated representatives in their membership. Despite this, there is no guidance or policy on the selection of unaffiliated or non-scientist members and reports indicate a lack of clarity regarding members' roles. In the present study we sought to explore processes of recruitment, training, and the perceived roles for unaffiliated and non-scientist members of IRBs.

Research Letter: Traumatic Brain Injury Among Veterans Accessing VA Justice-Related Services.

Objective: Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (ie, justice-involved Veterans) remains limited. The sequelae of TBI can impact justice-involved Veterans' engagement in Department of Veterans Affairs (VA) justice-related services (ie, Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting psychosocial functioning.

Contralateral inhibition of distortion product otoacoustic emissions in young noise-exposed Veterans.

Although animal models show a clear link between noise exposure and damage to afferent cochlear synapses, the relationship between noise exposure and efferent function appears to be more complex. Animal studies indicate that high intensity noise exposure reduces efferent medial olivocochlear (MOC) reflex strength, whereas chronic moderate noise exposure is associated with a conditioning effect that enhances the MOC reflex. The MOC reflex is predicted to improve speech-in-noise perception and protects against noise-induced auditory damage by reducing cochlear gain.

Developing an operational definition of housing instability and homelessness in Veterans Health Administration's medical records.

The main objective of this study was to examine how homelessness and housing instability is captured across data sources in the Veterans Health Administration (VHA). Data from 2021 were extracted from three data repositories, including the Corporate Data Warehouse (CDW), the Homeless Operations Management System (HOMES), and the Homeless Management Information System (HMIS). Using these three data sources, we identified the number of homeless and unstably housed veterans across a variety of indicators.

Beyond Supported Housing: Correlates of Improvements in Quality of Life Among Homeless Adults with Mental Illness.

Background: The goal of supported housing, aside from exiting homelessness, is to improve overall quality of life. The contribution of factors that enhance quality of life in supported housing programs, beyond housing itself, have not been empirically identified.

Methods: Five-year follow-up data from two arms of a randomized trial comparing case management with and without housing vouchers (n = 278) were examined to identify correlates of improved quality of life, beyond housing resources.

Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making.

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low.

Does Street Outreach Engage Its Intended Target Population? Clinical Experience in the Veteran's Health Administration Homeless Service Programs.

Objective: Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals.

Methods: Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred.

Providers' reflections on infrastructure and improvements to promote access to care for Veterans experiencing housing instability in rural areas of the United States: A qualitative study.

Veterans in rural areas of the United States face barriers to accessing healthcare and other services, which are intensified for those experiencing housing instability. Recent legislative acts have the potential to address obstacles faced by rural patients in the U.S.

Progressive Tinnitus Management Level 3 Skills Education: A 10-Year Clinical Retrospective.

Purpose: The purpose of this study was to examine progressive tinnitus management (PTM) Level 3 skill utilization among Veterans in the Bay Pines Veterans Affairs Healthcare System 6-10 years after completing the PTM workshops.

Method: In fiscal year 2020, the Tinnitus Workshop Follow-Up form was mailed to Veterans who completed the workshops during fiscal years 2010-2014. Veterans were identified as receiving care via the traditional face-to-face method or clinical video telehealth (CVT).

What does the word healing mean to you? Perceptions of patients with life-limiting illness.

Introduction: There is a growing consensus that patient-centered care is more effective in treating patients than a strictly biomedical model, where there are known challenges to involving the patient in assessments, treatment goals, and determining preferred outcomes.

Objectives: The current study seeks to integrate patient values and perspectives by exploring how people diagnosed with a life-limiting disease define healing in their own words.

Methods: As a part of a larger study that included cognitive interviewing, we asked the question "what does the word healing mean to you?" Data were collected during face-to-face interviews with patients from three metropolitan healthcare facilities.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

Background: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.

Seeing the Value of Video: A Qualitative Study on Patient Preference for Using Video in a Veteran Affairs Telemental Health Program Evaluation.

As the use of telemental health-mental health care delivered through video or phone-has increased in the era of COVID, it is important to understand patients' preferences and perspectives regarding the use of video for telehealth visits. A new web-based treatment program for veterans uses video visits with mental health experts to supplement its online cognitive behavioral therapy to treat clinically significant symptoms of depression and/or post-traumatic stress disorder. As part of the program evaluation, Veterans were asked, "How important was it for you to be able to physically see your provider through video telehealth?" to understand whether they thought using video was important and why it may or may not be important.

Delays in Diagnosis, Treatment, and Surgery: Root Causes, Actions Taken, and Recommendations for Healthcare Improvement.

Objectives: Although patient safety continues to be a priority in the U.S. healthcare system, delays in diagnosis, treatment, or surgery still led to adverse events for patients.

Hospice and palliative care clinicians' perceptions of posttraumatic stress disorder at end-of-life in military veterans.

At the end of life, individuals may re-engage with earlier life trauma as they reflect on life experiences and confront their mortality. As such, posttraumatic stress disorder (PTSD) symptoms at the end of life may worsen the quality of death experience. This is a concern for military veterans, who tend to have more trauma exposures and higher rates of PTSD, and particularly for veterans receiving care in rural areas where access to PTSD specialty services is limited.

The VA Life-Sustaining Treatment Decisions Initiative: A qualitative analysis of veterans with advanced kidney disease.

Background: Documentation of patients' goals of care is integral to promoting goal-concordant care. In 2017, the Department of Veterans Affairs (VA) launched a system-wide initiative to standardize documentation of patients' preferences for life-sustaining treatments (LST) and related goals-of-care conversations (GoCC) that included using a note template in its national electronic medical record system. We describe implementation of the LST note based on documentation in the medical records of patients with advanced kidney disease, a group that has traditionally experienced highly intensive patterns of care.