Canandaigua VA Medical Center

Article AbstractObjective: The potential association of various sleep disturbances to suicidal thoughts and behaviors is the subject of several reviews. The current meta-analysis was conducted to estimate the size of the association generally as well as between more specific relationships.Data Sources: Electronic databases for years 1966-2011 were searched to identify candidate studies using PubMed search terms suicide and sleep or sleep initiation/maintenance disorders or dreams or nightmares or sleep disorders/psychology or sleep disorders/epidemiology as well as Ovid search terms suicide and sleep or insomnia or nightmares. The search was supplemented by cross-referencing from identified articles and reviews.Study Selection: Original studies reporting both sleep disturbance and suicide outcomes were identified with 39 of 98 studies (40%) comprising 147,753 subjects selected for inclusion.Data Extraction: Data were extracted by multiple independent observers and verified by a study author. The meta-analysis was performed using random-effects models. The size of associations was calculated for all types of sleep disturbances and suicide outcomes combined and for more specific categories including nightmares, insomnia, and insomnia subtypes and suicidal ideation, suicide attempts, and suicide. Moderator effects were evaluated.Results: Overall, sleep disturbance was significantly associated with an increased relative risk for suicidal ideation, suicide attempt, and suicide ranging from 1.95 (95% CI, 1.41-2.69) to a relative risk of 2.95 (95% CI, 2.48-3.50) in unadjusted studies. Associations were smaller, but remained highly significant among adjusted studies. Depression did not moderate the association between sleep and suicide variables.Conclusions: This meta-analysis supports an association between sleep disturbance and suicidal thoughts and behaviors. Sleep disturbances in general, as well as insomnia and nightmares individually, appear to represent a risk factor for suicidal thoughts and behavior. This proposition is further bolstered by the result that depression did not show risk moderation.J Clin Psychiatry 2012;73(9):e1160-e1167© Copyright 2012 Physicians Postgraduate Press, Inc.Submitted: December 7, 2011; accepted April 30, 2012 (doi:10.4088/JCP.11r07586).Corresponding author: Wilfred R. Pigeon, PhD, Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, 400 Fort Hill Ave, Canandaigua, NY 14424 (Wilfred.pigeon2@va.gov).

BACKGROUND: Strength loss is strongly associated with functional decline and is reversible with exercise. The effect of increased strength on function has not been clearly established. The purpose of this study was to determine whether strength gain is associated with improvement in physical performance and disability. METHODS: One hundred functionally impaired community-dwelling men and women (77.6 +/- 7.6 yrs) were tested at baseline and outcome for lower extremity strength, physical performance, and disability. After random group assignment, exercise participants received strengthening exercises in their homes three times a week for 10 weeks while control subjects continued their normal activities. Using multiple regression techniques, the relationship between strength gain and improvement in physical performance and disability was assessed, controlling for age, depression, and baseline strength. RESULTS: A significant impact of strength gain on mobility skills (p = .0009) was found. The impact of strength gain on chair rise performance was significant in participants who were more impaired (p = .04). Strength gain was associated with gain in gait speed (p = .02) and in falls efficacy (p = .05), but not with other balance, endurance, or disability measures. CONCLUSIONS: Lower extremity strength gain is associated with gains in chair rise performance, gait speed, and in mobility tasks such as gait, transfers, stooping, and stair climbing, but not with improved endurance, balance, or disability. Strength gain is also associated with improvement in confidence in mobility. Factors that may influence the ability of strength gain to affect function are initial level of frailty and specificity of exercise. These results support the idea that strength training is an intervention that can potentially improve physical health status in many frail elders.

BACKGROUND: Adverse childhood experiences (e.g., physical, sexual and emotional abuse, neglect, exposure to domestic violence, parental discord, familial mental illness, incarceration and substance abuse) constitute a major public health problem in the United States. The Adverse Childhood Experiences (ACE) scale is a standardized measure that captures multiple developmental risk factors beyond sexual, physical and emotional abuse. Lesbian, gay, and bisexual (i.e., sexual minority) individuals may experience disproportionately higher prevalence of adverse childhood experiences. PURPOSE: To examine, using the ACE scale, prevalence of childhood physical, emotional, and sexual abuse and childhood household dysfunction among sexual minority and heterosexual adults. METHODS: Analyses were conducted using a probability-based sample of data pooled from three U.S. states' Behavioral Risk Factor Surveillance System (BRFSS) surveys (Maine, Washington, Wisconsin) that administered the ACE scale and collected information on sexual identity (n = 22,071). RESULTS: Compared with heterosexual respondents, gay/lesbian and bisexual individuals experienced increased odds of six of eight and seven of eight adverse childhood experiences, respectively. Sexual minority persons had higher rates of adverse childhood experiences (IRR = 1.66 gay/lesbian; 1.58 bisexual) compared to their heterosexual peers. CONCLUSIONS: Sexual minority individuals have increased exposure to multiple developmental risk factors beyond physical, sexual and emotional abuse. We recommend the use of the Adverse Childhood Experiences scale in future research examining health disparities among this minority population.

IMPORTANCE: Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data. OBJECTIVE: To compare the prevalence of ACEs among individuals with and without a history of military service. DESIGN, SETTING, AND PARTICIPANTS: Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973. MAIN OUTCOMES AND MEASURES: History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex. RESULTS: Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras. CONCLUSIONS AND RELEVANCE: Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.

IMPORTANCE: Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT. OBJECTIVE: To systematically review studies of the effectiveness and harms of SMT for acute (≤6 weeks) low back pain. DATA SOURCES: Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms. DATA EXTRACTION AND SYNTHESIS: Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. MAIN OUTCOMES AND MEASURES: Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks. FINDINGS: Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, -9.95 [95% CI, -15.6 to -4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, -0.39 [95% CI, -0.71 to -0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT. CONCLUSIONS AND RELEVANCE: Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

To study the impact of yeast populations on wine flavour and to better understand yeast growth dynamics, wines were produced by the (i) indigenous microflora, (ii) vigorous yeast starter EC1118 and (iii) slowly fermenting yeast Assmannshausen. Sensory analysis revealed that wines differed depending on the fermentation type. However, these yeast-related differences did not exceed the varietal character. Both added starter cultures clearly dominated the Saccharomyces population from the middle of fermentation onwards. The starter cultures differed in their repression of indigenous non-Saccharomyces yeast. EC1118 limited growth of non-Saccharomyces yeasts more strongly than Assmannshausen. Sulphite addition further repressed growth of non-Saccharomyces yeasts. On completion, more than one Saccharomyces strain was present in each fermentation, with the largest variety in the non-inoculated and the smallest in the EC1118-inoculated fermentation. Results from the two genetic assays, karyotyping, and PCR using delta-primers were not fully equivalent, limiting the usefulness of delta-PCR in studies of native Saccharomyces yeasts.

Abstract A 5‐yr cropping system experiment was initiated in 1981 to study transition from a conventional agricultural system using pesticides and fertilizers to a low‐input system. The site was primarily Comly silt loam (fine‐loamy, mixed, mesic, Typic Fragiudalf) with 12% Berks shaly silt loam (loamy‐skeletal, mixed, mesic, Typic Dystrochrept), and a small area of Duffield silt loam (fine‐loamy, mixed, mesic, Ultic Hapludalf), in Berks County, eastern Pennsylvania. Three 5‐yr rotations were compared. A conventional corn ( Zea mays L.)‐soybean [ Glycine max (L.) Merr.] rotation (designated “conventional”) was compared to two low‐input rotations which utilized oat ( Avena sativa L.), red clover ( Trifolium pratense L.) and winter wheat ( Triticum aestivum L.), in addition to corn and soybean. One low‐input rotation used cattle manure as a nutrient source and produced forage crops in addition to cash crops (designated “low‐input/livestock”), while the other used legume crops as a nutrient source, and produced a cash crop every year (designated “low‐input/cash grain”). Corn grain yields in the low‐input systems were 75% of conventional in 1981 to 1984, but yields were not significantly different in 1985. Weed competition and insufficient N limited low‐input corn yields during the first 4 yr. Soybean yields in the low‐input systems were equal to or greater than conventional all 5 yr. It is concluded that a favorable transition from input‐intensive cropping to low‐input systems is feasible, but only if crop rotations are used which include crops that demand less N and are competitive with weeds, such as small grain, soybean, or legume hay. Corn should be avoided for the first 3 to 4 yr.

A double-blind, placebo-controlled crossover study was conducted to examine the effects of long-acting propranolol in the treatment of violent behavior associated with organic brain disease in 10 patients whose symptoms had proved refractory to various conventional medications. Long-acting propranolol treatment was associated with reductions of assaultive behavior without apparent sedative effects. Cautions are noted regarding potential undesirable side effects which may necessitate careful patient monitoring during treatment.

A reverse phase HPLC and electrospray interface with ion trap mass spectrometer method was developed for the characterization of anthocyanins in Concord, Rubired, and Salvador grape juices. Rubired and Salvador grapes are hybrids from Vitis vinifera and Vitis rupestris. Concord grape is a grape from the native American cultivar Vitis labrusca. Individual anthocyanins in these three varieties were identified on the basis of UV-vis and MS spectra and further elucidated by MS/MS spectra. Anthocyanins in Salvador and Concord grapes were 3-O-glucosides, 3-O-(6' '-O-p-coumaroyl)glucosides, 3-O-(6' '-O-p-acetyl)glucosides, 3,5-O-diglucosides, and 3-O-(6' '-O-p-coumaroyl)-5-O-diglucosides of delphinidin, cyanidin, petunidin, peonidin, and malvidin. Vitisin B was detected in Salvador grape juice. Anthocyanins in Rubired grape juice were primarily anthocyanin diglucosides: peonidin 3,5-O-diglucoside, malvidin 3,5-O-diglucoside, peonidin 3-O-(6' '-O-p-coumaroyl)-5-O-diglucoside, and malvidin 3-O-(6' '-O-p-coumaroyl)-5-O-diglucoside are the four major anthocyanins. The presence of pelargonidin 3-O-glucoside, not previously reported, has been established for the first time in all three juices.

This study ascertained whether a proprietary tart cherry juice blend (CherryPharm, Inc., Geneva, NY, USA) associated with anecdotal reports of sleep enhancement improves subjective reports of insomnia compared to a placebo beverage. The pilot study used a randomized, double-blind, crossover design where each participant received both treatment and placebo for 2 weeks with an intervening 2-week washout period. Sleep continuity (sleep onset, wake after sleep onset, total sleep time, and sleep efficiency) was assessed by 2-week mean values from daily sleep diaries and disease severity by the Insomnia Severity Index in a cohort of 15 older adults with chronic insomnia who were otherwise healthy. The tart cherry juice beverage was associated with statistically significant pre- to post-treatment improvements on all sleep variables. When compared to placebo, the study beverage produced significant reductions in insomnia severity (minutes awake after sleep onset); no such improvements were observed for sleep latency, total sleep time, or sleep efficiency compared to placebo. Effect sizes were moderate and in some cases negligible. The results of this pilot study suggest that CherryPharm, a tart cherry juice blend, has modest beneficial effects on sleep in older adults with insomnia with effect sizes equal to or exceeding those observed in studies of valerian and in some, but not all, studies of melatonin, the two most studied natural products for insomnia. These effects, however, were considerably less than those for evidence-based treatments of insomnia: hypnotic agents and cognitive-behavioral therapies for insomnia.

OBJECTIVES: Barriers associated with the decision not to seek treatment for symptoms of combat-related posttraumatic stress disorder (PTSD) were examined. METHODS: Participants were 143 military men and women who served in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) and who screened positive for posttraumatic stress disorder (PTSD), as assessed by the PTSD Checklist-Military Version, and who had not sought treatment for PTSD. During a cognitive-behavioral telephone intervention, participants were asked about their beliefs concerning seeking PTSD treatment. RESULTS: Four categories of beliefs were associated with the decision to seek treatment, including concerns about treatment (40%), emotional readiness for treatment (35%), stigma (16%), and logistical issues (8%). CONCLUSIONS: This work suggests areas for intervention efforts to minimize barriers to treatment for PTSD for OEF/OIF veterans.

OBJECTIVES: We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program. METHODS: We determined the AFSPP's impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program's 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward. RESULTS: Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004. CONCLUSIONS: The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.

In this pilot study we report on proximate outcomes of a 1-hour community gatekeeper training in-service for 76 nonclinical employees in a university hospital workplace setting. Pre-post analyses resulted in positive changes in participants' knowledge about suicide and attitudes (self-efficacy) about intervening with suicidal individuals. A subset of participants engaged in role play practice of gatekeeper skills following training and rated the experience positively. Fifty-five observations were rated using an observational measure developed for this study and approximately half of these demonstrated satisfactory skills post training. Participants in this workplace gatekeeper training reported sharing new knowledge and skills with family, friends, and coworkers.

Suicide prevention must be transformed by integrating injury prevention and mental health perspectives to develop a mosaic of common risk public health interventions that address the diversity of populations and individuals whose mortality and morbidity contribute to the burdens of suicide and attempted suicide. Emphasizing distal preventive interventions, strategies must focus on people and places--and on related interpersonal factors and social contexts--to alter the life trajectories of people before they become suicidal. Attention also must be paid to those in the middle years--the age with the greatest overall burden. We need scientific and social processes that define priorities and assess their potential for reducing what has been a steadily increasing rate of suicide during the past decade.

OBJECTIVES: Although it is well known that people with alcohol dependence are at a markedly elevated risk for suicide, much less is known about the role of acute alcohol use in suicidal behaviours. The primary aims of this epidemiological study were to assess the prevalence and factors associated with acute alcohol intoxication among 57 813 suicide decedents in 16 states. METHODS: Data from the restricted National Violent Death Reporting System 2003-2009 for male and female suicide decedents aged 18 years and older were analysed by multiple logistic regression to compare decedents with and without acute alcohol intoxication (defined as blood alcohol concentration (BAC) ≥0.08 g/dl). RESULTS: Among men, those who were younger, American Indian/Alaska Native, Hispanic, veterans, of lower educational attainment, deceased from a self-inflicted firearm injury or hanging/suffocation and residing in rural areas were more likely to have been intoxicated at the time of death. Among women, the factors associated with a BAC ≥0.08 g/dl were younger age, being American Indian/Alaska Native, and using a firearm, hanging/suffocation or falling as method of death. CONCLUSIONS: In both men and women, alcohol intoxication was associated with violent methods of suicide and declined markedly with age, suggesting that addressing risks associated with acute alcohol use may be of the greatest aid in the prevention of violent suicides among young and middle age adults.

BACKGROUND: Suicide is a significant public health problem worldwide that requires evidence-based prevention efforts. One approach to prevention is gatekeeper training. Gatekeeper training programs for community members have demonstrated positive changes in knowledge and attitudes about suicide. Changes in gatekeeper skills have not been well established. AIMS: To assess and to predict the impact of a brief, gatekeeper training on community members' observed skills. METHODS: Participants in a community gatekeeper training were employees at US universities. 50 participants were randomly selected for skills assessment and videotaped interacting with a standardized actor prior to and following training. Tapes were reliably rated for general and suicide-specific skills. RESULTS: Gatekeeper skills increased from pre- to posttest: 10% of participants met criteria for acceptable gatekeeper skills before training, while 54% met criteria after training. Pretraining variables did not predict increased skills. LIMITATIONS: Results do not provide conclusions about the relationship between observed gatekeeper skills and actual use of those skills in the future. CONCLUSIONS: Gatekeeper training enhances suicide-specific skills for the majority of participants. Other strategies, such as behavioral rehearsal, may be necessary to enhance skills in the remaining participants.

Clinical providers and "front line" nonclinical staff who work with veterans, families, and communities are natural gatekeepers to identify and to refer veterans at risk for suicide. A national cohort (n = 602) of community based counseling center staff from the U.S. Department of Veterans Affairs (VA) participated in an evaluation of a brief standardized gatekeeper training program and a scripted behavioral rehearsal practice session. A significant difference in knowledge and self efficacy was observed from pre to post (p < .0001) with the nonclinicians showing larger effect sizes for knowledge (0.96 vs. 0.42) and self efficacy (0.89 vs. 0.41). Gatekeeper training for suicide prevention shows promise for increasing the capacity of VA staff to work with at risk veterans.

OBJECTIVES: We examined the role of sleep disturbance in time to suicide since the last treatment visit among veterans receiving Veterans Health Administration (VHA) services. METHODS: Among 423 veteran suicide decedents from 2 geographic areas, systematic chart reviews were conducted on the 381 (90.1%) who had a VHA visit in the last year of life. Veteran suicides with a documented sleep disturbance (45.4%) were compared with those without sleep disturbance (54.6%) on time to death since their last VHA visit using an accelerated failure time model. RESULTS: Veterans with sleep disturbance died sooner after their last visit than did those without sleep disturbance, after we adjusted for the presence of mental health or substance use symptoms, age, and region. CONCLUSIONS: Findings indicated that sleep disturbance was associated with time to suicide in this sample of veterans who died by suicide. The findings had implications for using the presence of sleep disturbance to detect near-term risk for suicide and suggested that sleep disturbance might provide an important intervention target for a subgroup of at-risk veterans.

OBJECTIVES: To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end-of-life care transitions and acute care use DESIGN: Propensity score-matched retrospective cohort study. SETTING: Forty-six NHs in two states. PARTICIPANTS: Nursing home residents who died from 2006 to 2010 stratified according to days between initial consultation and death (≤7, 8-30, 31-60, 61-180). Propensity score matching identified three controls (n = 1,174) according to strata for each consultation recipient (n = 477). MEASUREMENTS: Outcomes were hospitalizations in the last 7, 30, and 60 days of life; emergency department (ED) visits in the last 30 and 60 days; and any potentially burdensome care transition, defined as hospitalization or hospice admission within 3 days of death or two or more hospitalizations or ED visits within 30 days. Weighted multivariate logistic regression analyses were used to evaluate outcomes. RESULTS: Residents with consultations had lower rates of hospitalization than controls, with rates lowest when initial consultations were furthest from death. For instance, in residents with initial consultations 8 to 30 days before death, the adjusted hospitalization rate in the last 7 days of life was 11.1% (95% confidence interval (CI) = 9.8-12.4%), vs 22.0% (95% CI = 20.6-23.4%) in controls, although in those with initial consultations 61 to 180 days before death, rates were 6.9% (95% CI = 5.5-8.4%), vs 22.9% (95% CI = 20.5-25.4%). Potentially burdensome transition rates were lower when consultations were 61 to 180 days before death (16.2%, 95% CI = 13.7-18.6%), vs 28.2% (95% CI = 25.8-30.6%) for controls. CONCLUSION: Palliative care consultations improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.

Serum concentration of hepatic enzymes are linked to liver dysfunction, metabolic and cardiovascular diseases. We perform genetic analysis on serum levels of alanine transaminase (ALT), alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) using data on 437,438 UK Biobank participants. Replication in 315,572 individuals from European descent from the Million Veteran Program, Rotterdam Study and Lifeline study confirms 517 liver enzyme SNPs. Genetic risk score analysis using the identified SNPs is strongly associated with serum activity of liver enzymes in two independent European descent studies (The Airwave Health Monitoring study and the Northern Finland Birth Cohort 1966). Gene-set enrichment analysis using the identified SNPs highlights involvement in liver development and function, lipid metabolism, insulin resistance, and vascular formation. Mendelian randomization analysis shows association of liver enzyme variants with coronary heart disease and ischemic stroke. Genetic risk score for elevated serum activity of liver enzymes is associated with higher fat percentage of body, trunk, and liver and body mass index. Our study highlights the role of molecular pathways regulated by the liver in metabolic disorders and cardiovascular disease.