Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex

Importance

Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups.

Objective

To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex.

Design, Setting, and Participants

This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022.

Main Outcomes and Measures

The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group.

Results

Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect.

Conclusions and Relevance

In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.

Stearidonic and γ-linolenic acids in echium oil improves glucose disposal in insulin resistant monkeys

Echium oil (EO) contains stearidonic acid (18:4), a n-3 polyunsaturated fatty acids (PUFAs), and gamma-linolenic acids (18:3), a n-6 PUFA that can be converted to long chain (LC)-PUFAs. We aimed to compare a safflower oil (SO)-enriched diet to EO- and fish oil (FO)-enriched diets on circulating and tissue PUFAs levels and glycemic, inflammatory, and cardiovascular health biomarkers in insulin resistant African green monkeys. In a Latin-square cross-over study, eight monkeys consumed matched diets for 6 weeks with 3-week washout periods. Monkeys consuming FO had significantly higher levels of n-3 LC-PUFAs and EO supplementation resulted in higher levels of circulating n-3 LC-PUFAs and a significant increase in dihomo-gamma linolenic acid (DGLA) in red blood cells and muscle. Glucose disposal was improved after EO consumption. These data suggest that PUFAs in EO supplementation have the capacity to alter circulating, RBC and muscle LC-PUFA levels and improve glucose tolerance in insulin-resistant monkeys.

100-GHz transistors from wafer-scale epitaxial graphene

The high carrier mobility of graphene has been exploited in field-effect transistors that operate at high frequencies. Transistors were fabricated on epitaxial graphene synthesized on the silicon face of a silicon carbide wafer, achieving a cutoff frequency of 100 gigahertz for a gate length of 240 nanometers. The high-frequency performance of these epitaxial graphene transistors exceeds that of state-of-the-art silicon transistors of the same gate length.

Avian genomics and the innate immune response to viruses

Viral diseases pose a significant threat to the poultry industry. However, there is currently a lack of antivirals and suitable vaccine adjuvants available to the poultry industry to combat this problem. The innate immune system is now recognised to be essential in the response to viral infection. However, in contrast to mammals, the innate immune response in chickens is relatively uncharacterised. The release of the full chicken genome sequence has accelerated the identification of genes involved in the immune response. The characterisation of these genes, including Toll-like receptors and cytokines has led to the identification of potential alternate antivirals and adjuvants.

Comparison of air-displacement plethysmography, hydrodensitometry, and dual X-ray absorptiometry for assessing body composition of children 10 to 18 years of age

Body density (Db) of 54 boys and girls 10-18 years of age (13.9 +/- 2.4 years) was measured in an air-displacement plethysmograph, the BOD POD, and compared to Db determined by hydrodensitometry (HW). Both Db values were converted to percent body fat (%BF) using a two-component model conversion formula and compared to %BF determined by dual energy X-ray absorptiometry (DXA). Body density estimated from the BOD POD (1.04657 +/- 0.01825 g/cc) was significantly higher than that estimated from HW (1.04032 +/- 0.01872 g/cc). The relative body fat calculated from the BOD POD (23.12 +/- 8.39 %BF) was highly correlated but, on average, 2.9% BF lower than %BF DXA. Average %BF estimates from HW and DXA were not significantly different. Despite consistently underestimating the %BF of children, the strong relationship between DXA and the BOD POD suggests that further investigation may improve the accuracy of the BOD POD for assessing body composition in children.

Paraffin section immunophenotyping of acute leukemias in bone marrow specimens

The immunohistochemical evaluation of acute leukemia specimens has been limited in the past due of the inability to detect many lineage-related antigens in paraffin sections. With the improvement in immunohistochemical methods as well as the introduction of new antibodies, these limitations are now reduced. To evaluate the diagnostic utility of paraffin section immunohistochemistry in the lineage determination of acute leukemias, 77 previously immunophenotyped acute leukemias were studied with a panel of antibodies that included antibodies directed against CD3, CD20, CD34, CD43, CD68, CD79a, HLA-DR, myeloperoxidase (MPX), and terminal deoxynucleotidyl transferase (TdT). The cases included 48 acute myeloid leukemias, 18 precursor B-cell acute lymphoblastic leukemias, 6 T-cell acute lymphoblastic leukemias, and 5 mixed precursor B/myeloid leukemias. This immunohistochemical panel correctly identified the lineage of 96% of both acute myeloid leukemias and acute lymphoblastic leukemias and identified evidence of mixed lineage in 60% of mixed lineage leukemias. Antibodies directed against CD3, CD79a, MPX, and TdT were found to be the most useful, although the latter three alone were not entirely lineage specific. These findings suggest a role for paraffin section immunohistochemistry in the lineage determination of some cases of acute leukemia.

CD79 alpha expression in acute myeloid leukemia. High frequency of expression in acute promyelocytic leukemia

CD79 alpha is a subunit of an intracytoplasmic protein reported to be specific for B lymphocytes, including immature B lineage cells. To evaluate expression of the CD79 alpha antigen in acute myeloid leukemia (AML), we studied forty-eight cases of AML by paraffin section immunohistochemistry. The cases included four MO, nine M1, nine M2, ten M3, ten M4, and six M5 AMLs using criteria of the French-American-British cooperative group. Eleven cases demonstrated cytoplasmic staining for the CD79 alpha antigen, including one M1, nine M3, and one M5 AML. These CD79 alpha-positive cases represented 5% of all non-promyelocytic AMLs and 90% of all acute promyelocytic leukemias studied. All acute promyelocytic leukemias had the characteristic t(15;17)(q24;q21), including two cases of the microgranular variant (M3v). No other B-lineage-associated antigens were found in the CD79 alpha-positive cases, with the exception of a subpopulation of CD19-positive leukemic cells in one patient. The two non-promyelocytic leukemias that expressed CD79 alpha had no evidence of t(15;17) and did not express any additional B-lineage-associated antigens that might suggest a mixed lineage proliferation. This study demonstrates that CD79 alpha expression in acute leukemia is not restricted to B-lineage acute lymphoblastic leukemias and that CD79 alpha expression is frequently associated with t(15;17) acute myeloid leukemia.

Immunohistochemical analysis of T cell phenotypes in patients with graft-versus-host disease following allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation has become the therapy of choice in many cases of hematologic malignancy. In both matched related donor transplants--and, to a greater degree, in unrelated donor transplant situations--a major complication of the procedure is GVHD. This problem is caused by mature T cells in the graft, which also facilitate engraftment, and mediate an antitumor effect to reduce relapse. In order to further characterize the T cells that are present at the GVHD site of injury, we have studied 134 fresh tissue biopsies using immunohistochemical methods from 50 consecutive ABMT recipients clinically suspected of having acute GVHD. Antibodies specific for T cells, T cell receptor subsets, B cells, and NK cells were used to characterize the lymphocytic infiltrate in the biopsy tissue from GVHD patients. The data showed that the majority of lymphocytes that had infiltrated the epithelium or epidermis were CD3+ T cells. Using antibodies that distinguished the alpha/beta (beta F1) from the gamma/delta TCR (TCR delta 1)-expressing T cells, we observed that the lymphocytic infiltrates from involved tissues of the gastrointestinal tract, skin, and liver are almost exclusively derived from the alpha/beta expressing T cell subset, and are of the memory cell subset of T cells (CD45RO). This is in contrast to some examples from other disease states, in which a significant proportion of the lymphocytes that infiltrate the epidermal layers are of the gamma/delta type.

Predictive accuracy of three field methods for estimating relative body fatness of nonobese and obese women

Three methods of body composition assessment were used to estimate percent body fat (%BF) in nonobese (n = 77) and obese (n = 71) women, 20-72 yrs of age. Skinfolds (SKF), bioelectrical impedance (BIA), and near-infrared interactance (NIR) methods were compared to criterion-derived %BF from hydrostatic weighing (%BFHW). Nonobese subjects had < 30% BFHW and obese subjects had > or = 30% BFHW. The Jackson, Pollock, and Ward SKF equation and the manufacturer's equations for BIA (Valhalla) and NIR (Futrex-5000) were used. For nonobese women there were no significant differences between mean %BFHW and %BFSKF, %BFBIA, and %BFNIR. The rs and SEEs were 0.65 and 3.4% BF for SKF, 0.61 and 3.6% BF for BIA, and 0.58 and 3.7% BF for NIR for nonobese subjects. For obese women, mean %BFHW was significantly underestimated by the SKF, BIA, and NIR methods. The rs and SEEs for the obese group were 0.59 and 3.4% BF for SKF, 0.56 and 3.5% BF for BIA, and 0.36 and 3.9% BF for NIR. The total errors of the equations ranged from 5.6 to 8.0% BF in the obese group. It is concluded that all three field methods accurately estimate %BF for nonobese women; however, none of the methods is suitable for estimating %BF for obese women.

Toxoplasma gondii infection of the central nervous system. Use of the peroxidase-antiperoxidase method to demonstrate toxoplasma in formalin fixed, paraffin embedded tissue sections

The peroxidase-antiperoxidase immunohistochemical technique was employed to stain formalin fixed, paraffin embedded tissue sections from three cases of encephalitis caused by Toxoplasma gondii. We studied two cases of congenital infection and one case of acquired toxoplasmosis occurring in an immunocompromised host. The peroxidase-antiperoxidase method was exquisitely sensitive and highly specific and stained both the encysted and tachyzoite forms of the organism, as well as allowing for easy identification of infected cells. In two cases of necrotizing encephalitis--one congenital, the other acquired--widespread dissemination of the Toxoplasma organism throughout the neural parenchyma was visualized using the peroxidase-antiperoxidase stain. Brain biopsy material that had been obtained eight days prior to death in the case of adult acquired toxoplasmosis did not contain any of the characteristic tissue cysts and was not diagnostic for toxoplasmosis by conventional staining techniques. However, peroxidase-antiperoxidase staining of tissue sections from this biopsy unequivocally demonstrated both free tachyzoites and multiple infected cells. Further application of the peroxidase-antiperoxidase method should increase our understanding of the pathology and pathogenesis of toxoplasmic encephalitis as well as allowing timely diagnosis in cases presenting with neurologic symptomatology.

Immunohistological study of the anatomic relationship of toxoplasma antigens to the inflammatory response in the brains of mice chronically infected with Toxoplasma gondii

The relationship of toxoplasma antigen(s) to the origin and long-term persistence of the mononuclear cell inflammatory infiltrate that is present in the brains of mice chronically infected with Toxoplasma gondii was studied by using the peroxidase-antiperoxidase immunohistochemical staining technique. C3H/Km mice were infected with the avirulent C37 strain of T. gondii and sequentially sacrificed over the ensuing 107 days. Comparable sections of each brain were prepared for routine light microscopy. Antisera to toxoplasma made in rabbits were used for immunohistological staining, and adjacent slides were also stained with conventional histological stains. The peroxidase-antiperoxidase stain demonstrated toxoplasma tissue cysts, tachyzoites, and intra- and extracellular antigen-antibody reaction products. Early infection was characterized by small tight clusters of free tachyzoites gaining access to brain substance in the absence of an inflammatory response. Once there was disruption of neural parenchyma, a mononuclear cellular infiltrate rapidly ensued. After the first days of infection, mononuclear cells were always present in all infected brains and were anatomically associated with some component of toxoplasma antigen(s). The histological picture of late infection suggested that recurrent episodes of hematogenous dissemination of tachyzoites occurred in infected mice and that such episodes were at least partially responsible for persistence of an antigenic stimulus.