OBJECTIVE:We examined the association of self-reported substance use with quality of life (QOL), and pain severity and interference among Veterans who are survivors of head and neck cancer (HNC). METHODS:We administered a cross-sectional survey to Veterans with chronic pain who were at least 2 years post-HNC diagnosis. We examined associations between self-reported nicotine, alcohol, and cannabis use with measures of HNC related QOL, pain interference, pain severity, and pain management self-efficacy. We hypothesized current substance use would be positively associated with pain interference and severity and inversely associated with QOL. RESULTS:The final sample included 191 Veterans, the majority were aged 66 years or older (58.7%), male (97.4%) and White identifying (82.7%). One-third of participants endorsed moderate (29.8%) or high (4.7%) current nicotine use, and one-quarter had moderate (21.5%) or high (2.7%) alcohol use. Compared to those who did not endorse alcohol use, high alcohol use was significantly associated with a 25-point lower score on eating quality of life (on a 0-100 scale) (p = 0.03). In interaction models, no/low nicotine use and low self-efficacy had significantly higher pain interference compared to those with high self-efficacy (5.8 (95% CI: 5.1, 6.6); 2.4 (95% CI: 1.6, 3.2). CONCLUSION:Among HNC survivors, current alcohol and nicotine use is associated with lower quality of life and higher pain interference. Pain and substance use psychosocial services with focus on chronic pain, alcohol, and nicotine use, may improve QOL for patients post-HNC treatment.

BACKGROUND:Gulf War illness is a chronic multisymptom illness impacting Veterans of the 1990-1991 Persian Gulf War. Toxic exposures are believed to be associated with the condition, but little is known about how multiple types of exposures can impact the disease. The aim of this study is to determine if a positive association exists between the multiplicity of exposure types and symptom severity score. METHODS:A cross-sectional survey design was used in which Persian Gulf Veterans completed a questionnaire with items related to symptom severity and types of self-reported toxic exposures. Linear regression models were used to examine the association between the number of types of toxic exposures and symptom severity scores. We also examined the association between each type of reported exposure and symptom severity score. RESULTS:Veterans with a greater number of self-reported toxic exposures reported higher scores on symptom severity. While no individual exposure type reached a statistically significant association with symptom score, radiation and biological agent exposures showed the strongest association. DISCUSSION:We found a positive association between the number of toxic exposure types and total symptom severity. Veterans who self-reported having Gulf War Illness also reported more types of toxic exposures compared with Veterans who did not report having Gulf War Illness. Radiation and biological agent exposure showed the strongest positive association with symptom scores, yet very few Veterans reported isolated exposure of these types. Our findings suggest that cumulative exposure to multiple types of toxins could be associated with the development and severity of Gulf War Illness symptoms.

INTRODUCTION:Women Veterans of the Persian Gulf War (GW) expanded the military roles they had filled in previous military eras, with some women engaging in direct combat for the first time. Many GW service members, including women, had unique combat exposures to hazardous agents during deployment, which might have contributed to the development of chronic health problems. This study aims to understand the experiences of women GW Veterans (GWVs) as it is related to their military service and subsequent health in order to better inform and improve their clinical care.MATERIALS AND METHODS:We conducted in-depth interviews with 10 women GWVs to understand their experiences and perspectives about how their military service in the Gulf has impacted their lives and health. We used an integrated approach of content analysis and inductive thematic analysis to interpret interview data.RESULTS:Besides having many of the same war-related exposures as men, women faced additional challenges in a military that was inadequately prepared to accommodate them, and they felt disadvantaged as women within the military and local culture. After service, participants had emergent physical and mental health concerns, which they described as developing into chronic and complex conditions, affecting their relationships and careers. While seeking care and service connection at Veterans Health Administration (VA), women voiced frustration over claim denials and feeling dismissed. They provided suggestions of how VA services could be improved for women and GWVs. Participants found some nonpharmacological approaches for symptom management and coping strategies to be helpful.CONCLUSIONS:Women in the GW encountered challenges in military and healthcare systems that were inadequately prepared to address their needs. Women faced chronic health conditions common to GWV and voiced the desire to be understood as a cohort with unique needs. There is an ongoing need to expand services within the VA for women GWVs, particularly involving psychosocial support and management of chronic illness. While the small sample size can limit generalizability, the nature of these in-depth, minimally guided interviews provides a rich narrative of the women GWVs in this geographically diverse sample.

BACKGROUND:We characterized prescription opioid medication use up to 2 years following the head and neck cancer (HNC) diagnosis and examined associations with moderate or high daily opioid prescription dose.METHODS:Using administrative data from Veterans Health Administration, we conducted a retrospective cohort analysis of 5522 Veterans treated for cancers of the upper aerodigestive tract between 2012 and 2019. Data included cancer diagnosis and treatments, pain severity, prescription opioid characteristics, demographics, and other clinical factors.RESULTS:Two years post-HNC, 7.8% (n = 428) were receiving moderate or high-dose opioid therapy. Patients with at least moderate pain (18%, n = 996) had 2.48 times higher odds (95% CI = 1.94-3.09, p < 0.001) to be prescribed a moderate opioid dose or higher at 2 years post diagnosis.CONCLUSIONS:Survivors of HNC with at least moderate pain were at elevated risk of continued use of moderate and high dose opioids.

Importance:There is increasing recognition of the long-term health effects of SARS-CoV-2 infection (sometimes called long COVID). However, little is yet known about the clinical diagnosis and management of long COVID within health systems. Objective:To describe dominant themes pertaining to the clinical diagnosis and management of long COVID in the electronic health records (EHRs) of patients with a diagnostic code for this condition (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] code U09.9). Design, Setting, and Participants:This qualitative analysis used data from EHRs of a national random sample of 200 patients receiving care in the Department of Veterans Affairs (VA) with documentation of a positive result on a polymerase chain reaction (PCR) test for SARS-CoV-2 between February 27, 2020, and December 31, 2021, and an ICD-10 diagnostic code for long COVID between October 1, 2021, when the code was implemented, and March 1, 2022. Data were analyzed from February 5 to May 31, 2022. Main Outcomes and Measures:A text word search and qualitative analysis of patients' VA-wide EHRs was performed to identify dominant themes pertaining to the clinical diagnosis and management of long COVID. Results:In this qualitative analysis of documentation in the VA-wide EHR, the mean (SD) age of the 200 sampled patients at the time of their first positive PCR test result for SARS-CoV-2 in VA records was 60 (14.5) years. The sample included 173 (86.5%) men; 45 individuals (22.5%) were identified as Black and 136 individuals (68.0%) were identified as White. In qualitative analysis of documentation pertaining to long COVID in patients' EHRs 2 dominant themes were identified: (1) clinical uncertainty, in that it was often unclear whether particular symptoms could be attributed to long COVID, given the medical complexity and functional limitations of many patients and absence of specific markers for this condition, which could lead to ongoing monitoring, diagnostic testing, and specialist referral; and (2) care fragmentation, describing how post-COVID-19 care processes were often siloed from and poorly coordinated with other aspects of care and could be burdensome to patients. Conclusions and Relevance:This qualitative study of documentation in the VA EHR highlights the complexity of diagnosing long COVID in clinical settings and the challenges of caring for patients who have or are suspected of having this condition.

Patients and clinicians want to know who is protected from SARS-CoV-2 infection. This update is part of a living systematic review to understand the potential value of antibody testing as a correlate of protection against infection. Because the previous review found that seroconversion was a near-universal consequence of recent infection in immunocompetent patients, this review examines the risk for reinfection in adults after SARS-CoV-2 infection, whether diagnosed by polymerase chain reaction test, antibody test, or a combination of both.

Purpose The healthcare field is struggling with urgent questions about how to respond to the current COVID-19 pandemic. Health systems, clinicians, policymakers, and the general public want evidence to inform critical decisions.

AimsGulf War Illness (GWI) is a chronic multisymptom illness with debated etiology and pathophysiology. This systematic review catalogues studies of validated biological tests for diagnosing GWI and of associations between biological measures and GWI for their promise as biomarkers.Main methodsWe searched multiple sources through February 2020 for studies of diagnostic tests of GWI and of associations between biological measures and GWI. We abstracted data on study design, demographics, and outcomes. We assessed the risk of bias of included studies.Key findingsWe did not identify any studies validating tests of biomarkers that distinguish cases of GWI from non-cases. We included the best-fitting studies, 32 completed and 24 ongoing or unpublished studies, of associations between GWI and biological measures. The less well-fitting studies (n = 77) were included in a Supplementary Table. Most studies were of the central nervous and immune systems and indicated a significant association of the biological measure with GWI case status. Biological measures were heterogeneous across studies.SignificanceOur review indicates that there are no existing validated biological tests to determine GWI case status. Many studies have assessed the potential association between a variety of biological measures and GWI, the majority of which pertain to the immune and central nervous systems. More importantly, while most studies indicated a significant association between biological measures and GWI case status, the biological measures across studies were extremely heterogeneous. Due to the heterogeneity, the focus of the review is to map out what has been examined, rather than synthesize information.

Aim We conducted a systematic review of therapeutic interventions for Gulf War Illness (GWI) to evaluate effectiveness and harms and identify potentially promising treatments. Methods We searched electronic databases, trial registries, and reference lists through September 2019 for randomized and non-randomized controlled trials and cohort studies directly comparing interventions for Veterans with GWI to each other, placebo, or usual care. We abstracted data on study design, demographics, interventions, and outcomes. Two reviewers independently assessed studies for inclusion, quality, and strength of evidence using pre-specified criteria. We resolved discordant ratings by discussion and consensus. Results We identified 12 RCTs, each of which examined a different intervention for GWI. We found moderate-strength evidence that cognitive behavioral therapy (CBT) and exercise, separately and in combination, were associated with improvements in several GWI symptom domains. There was low-strength evidence of benefit from 2 mindfulness-based interventions and Continuous Positive Airway Pressure (CPAP). Mindfulness-based stress reduction improved pain, cognitive functioning, fatigue, depression, and posttraumatic stress disorder (PTSD), while mind-body bridging improved fatigue, depression, PTSD, and sleep, although pain and other outcomes did not improve. CPAP improved overall physical health, pain, cognitive functioning, fatigue, mental health, and sleep quality in a small study of Veterans with sleep-disordered breathing and GWI. We found moderate-strength evidence that doxycycline is ineffective for GWI in mycoplasma DNA-positive Veterans and increases the risk of adverse effects compared with placebo. We also found 33 ongoing, single-arm pilot, or unpublished studies examining a variety of interventions. Conclusion There is moderate-strength evidence of benefit from CBT and exercise, and low-strength evidence of benefit from 2 distinct mindfulness-based interventions as well as CPAP. Doxycycline was ineffective and associated with harms (moderate-strength evidence). Emerging evidence examines a wide array of treatments. Larger, more rigorous studies are needed to reproduce and characterize positive findings.

INTRODUCTION:After the 1990 to 1991 conflict in the Persian Gulf, many Gulf War Veterans began reporting numerous unexplained symptoms including, but not limited to, systemic pain, fatigue, flu-like symptoms, and difficulty with memory/concentration. These symptom clusters are now referred to as Gulf War Illness (GWI). Although the etiology of GWI is still debated, as many as 250,000 former service members have been continually suffering from GWI since 1991, making the need for treatment urgent. A broad variety of treatments have been considered for GWI, but there has not been a broad and comprehensive assessment of what is known and not known about GWI treatment. We conducted a systematic review to catalogue the types of treatments that have been examined for GWI, to evaluate the effectiveness and harms of these interventions, and to identify promising and ongoing areas of future GWI treatment research.MATERIALS AND METHODS:We searched electronic databases, trial registries, and reference lists through September 2019 for randomized controlled trial and nonrandomized controlled trial and cohort studies directly comparing interventions for Veterans with GWI to each other, placebo, or usual care. We abstracted data on study design, demographics, interventions, and outcomes. Two reviewers independently assessed studies for inclusion, quality, and strength of evidence (SOE) using prespecified criteria. We resolved discordant ratings by discussion and consensus.RESULTS:We identified 12 randomized controlled trials, each of which examined a different intervention for GWI. We found moderate SOE that cognitive behavioral therapy and exercise, separately and in combination, were associated with improvements in several GWI symptom domains. There was low SOE of benefit from two mindfulness-based interventions and continuous positive airway pressure (CPAP). Mindfulness-based stress reduction improved pain, cognitive functioning, fatigue, depression, and posttraumatic stress disorder (PTSD), whereas mind-body bridging improved fatigue, depression, posttraumatic stress disorder, and sleep, although pain and other outcomes did not improve. Continuous positive airway pressure improved overall physical health, pain, cognitive functioning, fatigue, mental health, and sleep quality in a small study of Veterans with sleep-disordered breathing and GWI. We found moderate SOE that doxycycline is ineffective for GWI in mycoplasma DNA-positive Veterans and increases the risk of adverse events compared with placebo. We also found 33 ongoing, single-arm pilot, or unpublished studies examining a variety of interventions.CONCLUSION:Cognitive behavioral therapy (moderate SOE), exercise (moderate SOE), and mindfulness-based interventions (low SOE) may be effective in improving several symptom domains in patients with GWI. Doxycycline was ineffective and associated with harms (moderate SOE). Larger, more rigorous studies are needed to confirm the benefits found in completed trials. A wide array of treatments are being assessed in ongoing trials. A sufficient evidence base will need to be developed to guide clinicians about which treatments are most likely to be effective in clinical practice and which treatments should be avoided.

Background Social isolation and loneliness in older adults are substantial public health problems. Interventions have been examined for their effect on reducing social isolation and loneliness; however, it is unclear which are effective at improving health outcomes and avoiding unnecessary health care utilization. Purpose To review recent literature evaluating the effectiveness of interventions that target social isolation and loneliness to improve health and/or health care utilization. Methods We used rapid review methods to evaluate recent research. We systematically searched Ovid/Medline®, PsycInfo®, and CINAHL® from 2013 to 2018 for systematic reviews and from 2016 to 2018 for primary studies. We used predetermined criteria to select primary studies from systematic reviews published in 2018, in addition to the primary study search. We extracted study-level data, conducted quality assessments, and synthesized results. Findings Sixteen studies were included: one good-quality randomized controlled trial [RCT], seven fair-quality studies (6 RCTs and 1 pre-post), and eight poor-quality studies (7 pre-post and 1 cross-sectional with post-test survey). Of the eight good- or fair-quality studies, five examined physical activity, two examined social interventions, and one examined an arts and recreation intervention. Two were associated with a positive effect on health outcomes: a resistance training, nutrition, and psychosocial support intervention improved functionality, depression, diet, and social capital, and a physical/leisure activity intervention improved quality of life but not social support. Two interventions (group tai chi and facilitated group discussion) improved loneliness but not health outcomes (e.g. quality of life or depression). Of the four fair- or good-quality studies reporting a positive impact on social isolation or health outcomes, three involved a health care professional in delivery, and three met more than once/week. Most poor-quality studies showed improvement in health but not social isolation; however, study design issues limited the reliability of these results. Five of 16 studies reported on harms and none were clinically significant. Three reported on health care utilization, with conflicting results. Implications Of interventions to reduce social isolation, physical activity interventions show the most promise at improving the health of older adults; however, effects were inconsistent and studies short term. Information on the effect of interventions on health care utilization is sparse and inconsistent. Health systems should target interventions to the needs of their population while keeping in mind that the documented impact of such interventions specific to social isolation, health, and health care utilization outcomes is limited. Health systems should rigorously evaluate their efforts to increase the evidence base and share results with other health care systems.

Patients with diabetes lack information on which commercially available applications (apps) improve diabetes-related outcomes. We conducted a rapid evidence review to examine features, clinical efficacy, and usability of apps for self-management of type 1 and type 2 diabetes in adults.

Background While hundreds of mobile applications (apps) for diabetes self-management are commercially available, patients lack information on which apps are effective in improving diabetes-related outcomes. Purpose Examine the evidence, usability, and features of commercially available mobile apps for self-management of type 1 and type 2 diabetes. Methods We searched Ovid/Medline and the Cochrane Database of Systematic Reviews for systematic reviews and technology assessments, and selected five recent, high-quality systematic reviews of highest relevance. We also conducted searches online and through Ovid/Medline, CINAHL, Embase, and ClinicalTrials.gov to identify additional, recently published primary studies. We used predetermined criteria to identify eligible studies, then extracted study-level data. We conducted quality assessments, extracted technical specifications and costs, and evaluated the usability of each app. Findings We identified 15 studies/analyses evaluating 11 unique apps: six apps for type 1 diabetes and five for type 2 diabetes. Two apps had multiple tiers of access (free and paid), which resulted in the evaluation of features of 13 apps. Common features of apps include the ability to track blood glucose, HbA1c, medications, physical activity, and weight. Studies were 2–12 months long. For type 1 diabetes, patients had clinically significant improvement in HbA1c if they used either of two apps and statistically significant improvement using one additional app. For type 2 diabetes, patients using any of three apps experienced clinical and statistical improvement in HbA1c. Patients using two apps for type 1 diabetes experienced improvements in hypoglycemic episodes. Patients did not experience improvements in quality of life, blood pressure, weight, or body mass index outcomes, regardless of the app or type of diabetes. The quality of studies was variable. Study design and presentation made it difficult to distinguish the effect of the app and the effect of additional interactions with study personnel or health care providers. Of the eight apps available for usability testing, three apps (two for type 1 and one for type 2 diabetes) were scored by researchers as “acceptable,” two apps (type 1 diabetes) as “marginal,” and three apps (one for type 1 and two for type 2 diabetes) as “not acceptable.” Implications Some apps for diabetes self-management may improve outcomes in the short-term, but the effect cannot be distinguished from the concomitant effect of additional support from a health care provider. More rigorous and longer-term evaluations are needed to determine how these apps affect weight, blood pressure, quality of life, and complications of diabetes.

Background Multiple patient navigation programs have been developed to address barriers to care (e.g., financial, logistical, and communication) across the cancer care continuum, but health systems are unsure which components of patient navigation are important and how to implement them. In addition the effectiveness of patient navigation programs to improve lung cancer outcomes is uncertain. Purpose To review recent literature on components of patient navigation programs addressing all types of cancer, the effectiveness of patient navigation programs on lung cancer outcomes, and the variable effectiveness of patient navigation programs on lung cancer outcomes based on patient characteristics. This report was developed to address the diverse research needs of a stakeholder group interested in the needs of people with lung cancer. Methods We searched for systematic reviews from 2015 to 2018 in PubMed®, CINAHL®, Cochrane Database of Systematic Reviews, Veterans Affairs Evidence-based Synthesis Program, Agency for Healthcare Research and Quality Effective Health Care Program, PubMed Health, and PROSPERO. We also searched for primary studies from 2013 to 2018 in PubMed and CINAHL. We extracted data from systematic reviews and primary studies, and synthesized results. Findings We identified four systematic reviews and six primary studies that focused primarily on breast, cervical, prostate, and colorectal cancer. Navigators’ backgrounds varied from lay people to health care professionals, and training ranged from a few to several hundred hours. Navigation programs were both individual and team based, were delivered in diverse health care settings, and had more clearly defined entry criteria than exit criteria. Navigators performed multiple diverse services, including assisting patients to overcome health care system barriers, maintaining resource networks, and promotion of patient engagement. Only two completed studies evaluated the effectiveness of lung cancer patient navigation programs. One randomized clinical trial found that navigated patients were more likely to receive a screening chest computed tomography, and one observational study found that navigation was associated with increased satisfaction with care. No completed studies analyzed the effectiveness of lung cancer patient navigation programs based on patient characteristics. Implications Patient navigation programs for all cancer types are quite diverse with regard to navigators’ characteristics and program structure. Future research studies should describe components in sufficient detail to facilitate implementation and determine which program is most effective for which health system. Lung cancer patients face unique challenges in managing their care, so additional studies on which components are important for lung cancer may be warranted.