The United States has more than 1,000 free medical clinics. Because these clinics do not bill Medicare or Medicaid, they are not eligible for federal reimbursement for electronic health record (EHR) adoption. As a result, most do not have EHRs or electronic disease registries. A web-based diabetes registry was created with all open-source components for use in an urban free clinic to manage patients with type 2 diabetes and comorbidities. The registry was modeled after the Chronic Disease Electronic Management System and recommendations of the American Diabetes Association. The software was enhanced to include multiple other features, such as progress notes, so that it can function as a simple EHR. The configuration permits other free clinics to join securely, and the software can be shared.

Diminished vitamin D is common among older individuals. Sunlight contributes more to vitamin D synthesis than diet or supplementation. This study examined associations between objectively measured light exposure, vitamin D serum levels, and bone biomarkers in 100 men aged over 60 years. Light exposure was measured in lux via Actigraph monitors for 1 week. Significantly, greater levels of vitamin D were observed in participants with higher light exposure. Seasonal differences in lux were also noted. Significant differences in bone markers were not found. Objective measurement of light exposure is an inexpensive, simple, and effective way to address vitamin D deficiency.

Following the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, electronic health records were widely adopted by eligible physicians and hospitals in the United States. Stage 2 meaningful use menu objectives include a digital family history but no stipulation as to how that information should be used. A variety of data mining techniques now exist for these data, which include artificial neural networks (ANNs) for supervised or unsupervised machine learning. In this pilot study, we applied an ANN-based simulation to a previously reported digital family history to mine the database for trends. A graphical user interface was created to display the input of multiple conditions in the parents and output as the likelihood of diabetes, hypertension, and coronary artery disease in male and female offspring. The results of this pilot study show promise in using ANNs to data mine digital family histories for clinical and research purposes.

This study explored whether physical activity and sleep, combined with the biomarker C-reactive protein, indexed positive health in older men. Many were former prisoners of war, with most remaining psychologically resilient and free of any psychiatric diagnoses. Activity and sleep were recorded through actigraphy in 120 veterans (86 resilient and 34 nonresilient) for 7 days. Resilient men had higher physical activity, significantly lower C-reactive protein levels, and 53 percent had lower cardiac-disease risk compared to nonresilient men. Sleep was adequate and not associated with C-reactive protein. Results suggest continued study is needed in actigraphy and C-reactive protein as means to index positive health.

"Positive health," defined as a state beyond the mere absence of disease, was used as a model to examine factors for enhancing health despite extreme trauma. The study examined the United States' longest detained American prisoners of war, those held in Vietnam in the 1960s through early 1970s. Positive health was measured using a physical and a psychological composite score for each individual, based on 9 physical and 9 psychological variables. Physical and psychological health was correlated with optimism obtained postrepatriation (circa 1973). Linear regressions were employed to determine which variables contributed most to health ratings. Optimism was the strongest predictor of physical health (β = -.33, t = -2.73, p = .008), followed by fewer sleep complaints (β = -.29, t = -2.52, p = .01). This model accounted for 25% of the variance. Optimism was also the strongest predictor of psychological health (β = -.41, t = -2.87, p = .006), followed by Minnesota Multiphasic Personality Inventory-Psychopathic Deviate (MMPI-PD; McKinley & Hathaway, 1944) scores (β = -.23, t = -1.88, p = .07). This model strongly suggests that optimism is a significant predictor of positive physical and psychological health, and optimism also provides long-term protective benefits. These findings and the utility of this model suggest a promising area for future research and intervention.

: Our previous report, NMOTC-REMC-002, described how we designed an online family history questionnaire to collect computable data which can be used in clinical decision support for Vietnam-era repatriated prisoners of war medical history. This paper provides the summarized family history data. The top categories of diseases identified by 150 or more surveyed included high blood pressure, high cholesterol, diabetes, coronary artery disease, heart attacks, and cancer (unspecified).

: As we move closer to ubiquitous electronic health records (EHRs) there will be a need to incorporate genetic, familial and clinical information as structured data that can be used for clinical decision support. While the Human Genome Project has produced new and exciting genomic data, the cost to sequence the human personal genome is high and significant controversies of how to interpret genomic data exist. Many experts feel that the family history is a surrogate marker for actual genetic studies and should be part of any paper-based or electronic health record (EHR). A digital family history is now part of meaningful use stage 2 requirements. It is likely that family history information will be used for clinical decision support in EHRs in the not too distant future. We designed an online family history questionnaire (FHQ) to collect computable data to determine whether resiliency (defined as no psychiatric illnesses post-trauma) in Vietnam-era repatriated prisoners of war (RPWs) is associated with any component of the family history. This paper describes our approach to create a digital FHQ in order to answer a research question.

As we move closer to ubiquitous electronic health records (EHRs), genetic, familial, and clinical information will need to be incorporated into EHRs as structured data that can be used for data mining and clinical decision support. While the Human Genome Project has produced new and exciting genomic data, the cost to sequence the human personal genome is high, and significant controversies regarding how to interpret genomic data exist. Many experts feel that the family history is a surrogate marker for genetic information and should be part of any paper-based or electronic health record. A digital family history is now part of the Meaningful Use Stage 2 menu objectives for EHR reimbursement, projected for 2014. In this study, a secure online family history questionnaire was designed to collect data on a unique cohort of Vietnam-era repatriated male veterans and a comparison group in order to compare participant and family disease rates on common medical disorders with a genetic component. This article describes our approach to create the digital questionnaire and the results of analyzing family history data on 319 male participants.

This study examined sleep histories associated with resilience after trauma defined as a continuous lack of psychiatric illness across 37 years. Data were drawn from a 37-year follow-up examination of the effects of the Vietnam prisoner of war (POW) experience. The Robert E. Mitchell Center for POW Studies is a unique institution holding the only longitudinal study of the effects of the American POW experience in existence. The study used a sample of 440 Vietnam repatriated prisoners of war (RPWs). Psychiatric disorders were assessed at repatriation (1973) and were continued annually by a psychiatrist or clinical psychologist. Sleep issues before, during, and after captivity were assessed upon repatriation during medical examinations. Odds ratios examining presence of sleep symptoms show resilient RPWs reporting fewer symptoms compared to nonresilient RPWS before, during, and after captivity. Logistic regression comparing before, during, and after indicates fewer reported sleep disturbance symptoms after captivity was the strongest predictor of resilience (b = -0.82, Wald chi2 (1) = 16.70, p < 0.000). Reporting fewer sleep complaints, but not necessarily an absence of them before, during, and after the trauma predicts resilience across time.

: Background: In an earlier study, the Robert E. Mitchell Center for POW Studies identified in the 1973 medical/psychiatric database those former, Vietnam-era, repatriated prisoners of war who at the time of captivity viewed their experience as one to survive and overcome, to not ruin their entire life once freed (known as dispositional optimism), these repatriates did not suffer from any psychiatric illnesses 37 years after their POW experience. This follow-up study added new mental, physical, biological data collected in 2011 to 2012 to determine whether dispositional optimism was still linked to their overall state of health today. Results: Dispositional optimism identified in the 1973 time-frame was linked to physical and mental state of health Conclusions: Optimistic repatriates who bounced back from their captivity experience by reporting fewer sleep, post-traumatic stress, and captivity-related medical problems after repatriation have maintained good physical and psychological health 38 years after their prolonged captivity/torture experiences.

Resilience, exhibiting intact psychological functioning despite exposure to trauma, is one perspective as to why some people who are exposed to trauma do not develop symptoms. This study examines the prisoner of war experience to expand our understanding of this phenomenon in extreme cases of trauma such as prolonged captivity, malnourishment, and physical and psychological torture. The study examined the United States' longest detained American prisoners of war, those held in Vietnam in the 1960s through early 1970s. A logistic regression analysis using resilience, defined as never receiving any psychiatric diagnosis over a 37-year follow-up period, as the outcome was performed (n = 224 with complete data). Six variables showing at least small effects emerged: officer/enlisted status, age at time of capture, length of solitary confinement, low antisocial/psychopathic personality traits, low posttraumatic stress symptoms following repatriation, and optimism. Odds ratios (ORs) and confidence intervals (CIs) confirmed the significance and relative strength of these variables, with a range from OR = 0.54, 95% CI [0.13, 2.29] to OR = 1.11, 95% CI [1.04, 1.17]. When all variables were examined continuously and categorically, dispositional optimism was the strongest variable, accounting for 17%, continuously, and 14%, categorically. We discuss optimism as a protective factor for confronting trauma and the possibility of training to increase it.

OBJECTIVE:We conducted a retrospective study of metabolic data for Vietnam-era repatriated prisoners of war (RPWs) and a comparison group to determine if metabolic syndrome (MbS) was more common in those individuals with clinically diagnosed, current or lifetime posttraumatic stress disorder (PTSD) as suggested in a recent report.METHODS:The metabolic data of our patients nearest the time of psychiatric evaluation (1998-2004) for PTSD were analyzed using both an analysis of variance and logistic regression.RESULTS:Although we found elevated triglyceride levels (40 mg/dl higher) in RPWs with PTSD who met MbS criteria, overall the prevalence of MbS was the same in RPWs with and without PTSD and comparison group. Moreover, current PTSD symptom severity did not increase the likelihood of MbS.CONCLUSIONS:Our results from these repatriates who actively participate in a 37-year medical follow up program do not support the conclusion that MbS occurs more commonly in individuals with current PTSD.

OBJECTIVEWe conducted a retrospective evaluation of bone mineral density data collected during routine medical follow-up evaluations of 241 Vietnam-era male repatriated prisoners of war, with and without the lifetime diagnosis of posttraumatic stress disorder (PTSD), and 79 subjects in a comparison group.METHODSDual-energy X-ray absorptiometry scans evaluated total hip and lumbar spine T-scores. A multivariate analysis of covariance was performed on the data using age, body mass index, ethnicity, and reported alcohol consumption as covariates.RESULTSThere was a significant effect of group on total hip, but not lumbar spine, T-scores. Pairwise comparisons revealed statistically lower total hip T-scores in repatriates with a lifetime history of PTSD in comparison to both the comparison group and repatriates without a lifetime history of PTSD.CONCLUSIONIn this study of elderly repatriated prisoners of war, we noted an association between a lifelong history of PTSD and decreased bone mineral density at the hip.

This study evaluated the implementation of voice recognition (VR) for documenting outpatient encounters in the electronic health record (EHR) system at a military hospital and its 12 outlying clinics. Seventy-five clinicians volunteered to use VR, and 64 (85 percent) responded to an online questionnaire post implementation to identify variables related to VR continuance or discontinuance. The variables investigated were user characteristics, training experience, logistics, and VR utility. Forty-four respondents (69 percent) continued to use VR and overall felt that the software was accurate, was faster than typing, improved note quality, and permitted closing a patient encounter the same day. The discontinuation rate of 31 percent was related to location at an outlying clinic and perceptions of inadequacy of training, decreased productivity due to VR inaccuracies, and no improvement in note quality. Lessons learned can impact future deployment of VR in other military and civilian healthcare facilities.