• Epidemiology and Trends of Staphylococcus aureus Infections in a Large United States Veteran Population

      Tracy, LaRee; Roghmann, Mary-Claire (2009)
      Background: A public health need exists to describe the epidemiology and trends of all Staphylococcus aureus (S. aureus) infections given the emergence of USA300 methicillin-resistant S. aureus (MRSA) and changing epidemiology of MRSA infection. Also needed is a validated algorithm to identify S. aureus infections using large healthcare databases. Methods: We conducted a retrospective population-based study in veterans receiving health care in the VAMHCS from fiscal years (FY) 1999-2008. A non-invasive S. aureus infection was defined as a positive clinical culture from a non-sterile site with an ICD-9 code for infection. An invasive S. aureus infection was defined as a positive blood or clinical culture from a sterile site. Infections were classified by hospital-onset (HO: culture > 48 hrs after hospitalization) or community-onset (CO: culture while outpatient or ≤48 hrs after hospitalization), methicillin-susceptibility (MSSA or MRSA) and body site. Positive (PPV) and negative predictive values (NPV) for non-invasive infections were determined by chart review using a reference standard. Incidence was calculated per 100,000 veterans or inpatient days. Time series were analyzed using Quasi-Poisson generalized linear regression models (GLMs). Results: There were 3,674 S. aureus infections of which 77% were non-invasive and 61% due to MRSA. PPV and NPV of a clinical culture and ICD-9 were 79% (95% CI 70-86%) and 82% (95% CI 73-88) respectively. Proportion of CO and HO were 69% and 32% respectively. The averaged annual incidences were 749, 178, and 571 per 100,000 veterans for all, invasive and non-invasive infections respectively. The annual incidence significantly increased (p<0.001) due to increases in non-invasive MRSA infections (271 to 504/100,000 veterans, 1.9 fold increase) and non-invasive CO infections (360 to 546/100,000 veterans, 1.5 fold increase) of which >60% were skin and soft tissue infections (SSTIs). GLMs revealed an increased risk of all infections. Incidence of invasive S. aureus infections decreased 2.3 fold. Conclusion: Clinical culture and ICD-9 is a predictive approach to identify non-invasive S. aureusinfection. From FY1999 to 2008, the incidence of all S. aureus infections significantly increased due to increases in CO non-invasive MRSA SSTIs; however, gradual decreases in invasive S. aureus infections were observed.
    • Rural Veterans: Pathways to Homelessness

      Jorden, Brenda J.; Belcher, John R.; DeForge, Bruce R. (2018)
      Veterans are overrepresented in homeless populations compared to non-veterans (Gamache, Rosenheck, & Tessler, 2001; Perl, 2015). Most homeless individuals live in urban centers and as a result most research studies have focused on urban homelessness leaving the rural homeless less studied and understood (Knopf-Amelung, 2013). The purpose of the current qualitative study was to explore the pathways to homelessness for a sample of rural homeless veterans. Fifteen veterans and 16 staff/administrators were interviewed to determine the causes of homelessness for veterans living in a rural area. A limited grounded theory approach was used to develop themes identified as causing homelessness. The primary pathway according to both groups was chronic substance abuse. Mental health and economic problems, and adverse childhood events were also major factors in veterans experiencing homelessness. Social support appeared to delay the onset of homelessness for some individuals. Not all veterans qualify for VA services, which leaves a segment of the population without access to VA services. Overcoming barriers to substance abuse and mental health services for rural homeless veterans is an area to focus research efforts. Creative ways to provide outreach to the hidden homeless are needed.
    • Sociocultural Mechanisms Associated with Posttraumatic Stress Disorder: An Analysis of Latino Veterans

      LeFevre, Ann L.; Harrington, Donna; Gioia, Deborah (2011)
      Although numerous risk factors are related to the development of PTSD and the severity of PTSD symptoms, ethnicity - especially factors related to Latino ethnicity - has recently been reported as a risk factor in numerous studies. The purpose of this study was to identify and examine social and cultural factors that may contribute to the development of PTSD and increased PTSD symptom severity among Latino veterans through the development of a cultural model of traumatic stress. Grounded in stress and coping theory, the cultural model was broken down into three phases: 1) pre-trauma; 2) peri-trauma; and 3) post-trauma. Mail surveys were used to gather information from a sample of Latino veterans enrolled in the VA Palo Alto Health Care System. Approximately half of the respondents met criteria for PTSD and the other half did not, with a total of 146 completed surveys. Bivariate analyses, hierarchical logistic regression, and hierarchical multiple regression were used to analyze the data. Variables analyzed in this study included demographics, childhood adversity, acculturation, familialism, perceived racial and ethnic discrimination, combat exposure, combat injury, peri-trauma coping (i.e., dissociation), post-trauma coping (i.e., emotion-focused, problem-focused, dysfunctional), post-trauma social support, and fatalism. Although most of the cultural variables were correlated with PTSD in the bivariate analyses, they were no longer significant in the multivariate models when stronger predictors were included. Combat exposure and stress appraisal predicted the development of PTSD and PTSD symptom severity in both multivariate models. Whereas combat injury predicted PTSD development, it was not a strong predictor of PTSD symptom severity. Peri-trauma dissociation and dysfunctional post-trauma coping predicted PTSD symptom severity, but were not strongly correlated with the development of PTSD. Although the cultural factors and many of the social factors did not individually predict PTSD or severity of PTSD symptoms in the full models, the conceptual model as a whole performed well and the individual predictors worked well together as sets to predict PTSD and PTSD symptom severity. This indicates that factors related to ethnicity may be of importance in models predicting PTSD and PTSD symptom severity and should be considered.