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One Mission, One Goal: Veterans Health
Research News
Dr. Raymond Swanson co-authored two studies that recently published studies exploring cofilactin rod formation and its impact on the brain
NCIRE-supported Principal Investigator Dr. Raymond Swanson along with his research team recently co-authored two studies that explore cofilactin rod formation and its impact on the brain traumatized by instances of stroke and conditions such as multiple sclerosis, traumatic brain injury, and neurodegenerative disorders.
In the study “Cofilactin rod formation mediates inflammation-induced neurite degeneration”, Dr. Swanson and colleagues investigated the formation of cofilactin rods (CARs) and subsequent neurite loss in the brain. The research team discovered that even with mild inflammation, CARs strip away the neurites (the little arms of the neurons) leaving the neurons as isolated entities—such a loss is associated with functional impairment. Thus, a new degenerative pathway was discovered: inflammation caused immune cells to release superoxide, pulling cofilin and actin out of neurites and making CARs. Neurites died, and the disconnected brain malfunctioned.
In the related study “Bioenergetic and excitotoxic determinants of cofilactin rod formation”, Dr. Swanson and his team also looked into how the biochemical pathways driving CAR formation are engaged under ischemic conditions.
With both studies, scientists now have a better understanding of the pathways in which CARs are formed and the impact that has on the brain’s neurological structure. Armed with this information, therapies can be designed to interrupt inflammatory pathway. Stroke patients, for example, could be treated early on with anti-inflammatory agents to shield neurites from damage and preserve cognition.
Raymond Swanson, MD is a clinician-scientist with joint appointments in the University of California San Francisco Department of Neurology and the San Francisco Veterans Affairs Health Care System. His research explores bioenergetics and oxidative signaling in neurological disease. Dr. Swanson’s studies in the area of stroke aim to identify ways to mitigate the dendritic and axonal ischemic injury, and in particular injuries caused by neuronal NADPH oxidase and cofilin-actin rod formation.
Read More:
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“Cofilactin rod formation mediates inflammation-induced neurite degeneration”. Cell Reports, Volume 43, Issue 3.
https://www.cell.com/cell-reports/fulltext/S2211-1247(24)00242-0
2. "Bioenergetic and excitotoxic determinants of cofilactin rod formation”. Journal of Neurochemistry.
Blood Markers show neural consequences of LongCOVID-19
In a co-authored study published in the science journal Cells, NCIRE-supported Principal Investigators Drs. Lynn Pulliam and Judith Ford collaborated with colleagues to investigate the impact of Long-COVID-19 (LongC) on the nervous system.
To search for neurological markers of LongC, the research team investigated the soluble biomolecules present in the plasma and the proteins associated with plasma neuronal-enriched extracellular vesicles (nEVs) in 33 LongC patients with neurological impairment (nLongC), 12 COVID-19 survivors without any LongC symptoms (Cov), and 28 pre-COVID-19 healthy controls (HC). COVID-19 positive participants were infected between 2020 and 2022, not hospitalized, and were vaccinated or unvaccinated before infection. Interleukin-1-beta (IL-1β) was significantly increased in both nLongC and Cov and Interleukin-8 (IL-8) was elevated in only nLongC. Both brain-derived neurotrophic factor and cortisol were significantly elevated in nLongC and Cov compared to HC. Additionally, nEVs from people with nLongC had significantly elevated protein markers of neuronal dysfunction, including amyloid beta 42, pTau181 and transactive response DNA binding protein 43 kDa (TDP-43).
The study showed chronic peripheral inflammation with increased stress after COVID-19 infection. Additionally, differentially expressed nEV neurodegenerative proteins were identified in people recovering from COVID-19 regardless of persistent symptoms: differentially expressed peripheral markers of inflammation and stress after SARS-CoV-2 infection between healthy pre-pandemic controls, people recovered from COVID-19 and neuroLongCOVID-19 subjects.
Judith Ford, PhD is Professor of Psychiatry at the University of California San Francisco (UCSF) Weill Institute for Neurosciences and Senior Career Research Scientist, Mental Health Service at the San Francisco VA Health Care System (SFVAHCS). She co-directs the Brain Imaging and Electroencephalography (EEG) Laboratory at UCSF, where she is using human electrophysiological methods to understand failures of a basic neurophysiological mechanism in patients with schizophrenia.
Lynn Pulliam, MS, PhD is the Chief of Microbiology at the SFVAHCS and Professor of Laboratory Medicine and Medicine at UCSF. Dr. Pulliam’s laboratory was the first to show that blood monocytes (white blood cells) from individuals with HIV release toxins that kill or damage neural cells. Her lab is interested in finding blood monocyte biomarkers to identify chronic activation, which puts subjects at risk for different co-morbid pathologies, as well as determine how the immune system affects cognition.
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Dr. Kristine Yaffe co-authors studies that assess the risk of dementia in older adults with multiple sclerosis and related disorders; the health of the brain and midlife
In the co-authored study “Risk of dementia in older veterans with multiple sclerosis” published in the medical journal Multiple Sclerosis and Related Disorders, NCIRE-supported Investigator and NCIRE Board Member Dr. Kristine Yaffe and her fellow investigators found that among older veterans with multiple sclerosis (MS), risk of dementia diagnosis was higher compared to matched controls even after controlling for comorbidities. The risk difference was highest in northern regions and in younger patients. Clinicians caring for older MS patients should be aware of this risk and offer screening and treatment accordingly.
The study used data from a random sample of U.S. Veterans aged ≥ 55 years followed at Veterans Affairs Health Care Systems nationwide from 1999 to 2019.
In an additional study, “Trajectories in depressive symptoms and midlife brain health”, co-authored and published in the journal Translational Psychiatry, Dr. Yaffe and her colleagues investigated how depressive symptoms may either be a risk factor or prodromal to dementia in middle-aged adults. Investigating such an association in midlife may help clarify the role of depression in cognitive aging. The study aimed to identify trajectories in depressive symptoms in early to mid-life and related cognitive and brain outcomes in midlife.
The study included 3,944 Black and White participants (ages 26−45 years at baseline) from the Coronary Artery Risk Development in Young Adults (CARDIA) study with 20 years of follow-up.
Kristine Yaffe, MD is the Director of NeuroPsychiatry and Director of the Memory Evaluation Clinic at SFVAHCS. She is also the Scola Endowed Chair and Vice Chair, Professor of Psychiatry, Neurology, and Epidemiology, Director of the Center for Population Brain Health at UCSF, and NCIRE Board Member. She is an internationally recognized expert in the epidemiology of dementia and cognitive aging and the foremost leader in identifying modifiable risk factors for dementia. Her research, currently supported by over a dozen NIH, Department of Defense, VA, and foundation grants, bridges the fields of neurology, psychiatry, and epidemiology.
Read more:
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“Risk of dementia in older veterans with multiple sclerosis”. Multiple Sclerosis and Related Disorders, Volume 82 https://doi.org/10.1016/j.msard.2023.105372
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“Trajectories in depressive symptoms and midlife brain health”. Translational Psychiatry, Volume 14 https://doi.org/10.1038/s41398-024-02883-2
Moral Injury Awareness and Prevention in Healthcare Organizations: A Blueprint Informed by the COVID-19 Pandemic
NCIRE-supported investigators Drs. Natalie Purcell, Shira Maguen, and Karen Seal co-authored the recent publication “Moral Injury Awareness and Prevention in Healthcare Organizations: A Blueprint Informed by the COVID-19 Pandemic”.
The publication is a result of the NCIRE CDC project titled “Moral Injury Among Healthcare Workers on the Frontlines of the COVID-19 Crisis.” (1 R21OH012201-01-00); and serves as a public-facing document with guidance for healthcare leaders and managers on preventing moral injury in the workplace.
Moral injury is lasting psychological and spiritual distress that stems from violating one’s values or feeling betrayed by a trusted institution or authority. It is often associated with posttraumatic stress (PTSD), depression, anxiety, substance use, functional impairments, and suicide risk.
Healthcare workers whose jobs put them in high-stakes life-or-death situations, and who may experience intense and prolonged work stress, may be especially vulnerable to moral injury.
The research team surveyed 2,004 healthcare workers at VA inpatient units, emergency rooms, and community living centers during the COVID-19 pandemic with 39% reporting morally distressing experiences that could lead to moral injury.
The most common type of moral injury was betrayal-based moral injury: 30% of surveyed workers felt betrayed by healthcare leaders, coworkers, or others. Among the workers who reported potential moral injury, 79% reported burnout and 60% screened positive for posttraumatic stress (PTSD).
The guidance outlines five protective factors that could help prevent moral injury:
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Community support: Distressing events are not faced alone, and responsibility is meaningfully shared.
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Processing & debriefing: There is time and opportunity to process and discuss distressing events; there are breaks that allow for reflection and recovery.
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Learning & making change: It is possible to make meaningful changes to the situation or environment and to address the factors that caused moral distress.
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Leadership presence & communication: Leaders/managers are present and visible on the frontlines. Frontline workers feel heard and appreciated by leaders.
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Shared risks and burdens: There is an effort to share major risks and burdens, and to meaningfully acknowledge workers who must carry more than their share.
The guide was published by the Healthforce Center at the University of California San Francisco (UCSF).
Natalie Purcell, PhD, MPA is a sociologist who specializes in the study of violence, trauma, and pain across healthcare contexts. Her work uses mixed methods drawn from the social sciences and the humanities, as well as program-evaluation and implementation-science techniques.
Shira Maguen, PhD is the Mental Health Director of the Post-9/11 Integrated Care Clinic and Staff Psychologist on the Posttraumatic Stress Disorder Clinical Team (PCT) at the San Francisco VA Health Care System (SFVAHCS), and Vice Chair of SFVAHCS and Professor in the Department of Psychiatry and Behavioral Sciences, UCSF School of Medicine.
Karen Seal, MD is a primary care internist and Chief of the Integrative Health Service for the SFVAHCS, and a Professor of Medicine and Psychiatry in Residence at UCSF. She directs the Integrated Care Clinic for Iraq and Afghanistan Veterans, the Integrated Pain Team Clinic and the roll-out of Complimentary and Integrative Health (CIH) services for veterans and VA staff.
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Dr. Bruce Ovbiagele recipient of a national award from the American College of Physicians
NCIRE-supported Principal Investigator and Board Member Dr. Bruce Ovbiagele received the W. Lester Henry Award for Diversity, Equity, and Inclusion from the American College of Physicians (ACP) at its annual scientific conference, Internal Medicine Meeting 2024, on April 18th in Boston.
The W. Lester Henry Award for Diversity, Equity and Inclusion is given to an ACP member with outstanding accomplishments in advancing diversity, equity, and inclusion in the health care workforce, and/or improving health equity for people with historically marginalized group identities. The award was established in 2008.
Dr. Ovbiagele is the is Professor of Neurology and Associate Dean at the University of California, San Francisco, as well as Chief of Staff at the San Francisco Veterans Affairs Health Care System. In his Chief of Staff role, Dr. Ovbiagele serves as a statutory member of the NCIRE Board of Directors. Before his current position, he was Chair of the Department of Neurology at the Medical University of South Carolina for six years before moving to San Francisco. In his career thus far, he has led several National Institutes of Health–sponsored programs, which have helped to narrow local and global stroke disparities, as well as facilitated a strong pipeline of capable underrepresented-in-medicine researchers (>110), many of whom have become award-winning independently funded researchers. Dr. Ovbiagele has submitted content about his discoveries from his research activities to over 620 peer-reviewed publications and has edited five books.
His research work has been recognized with the highest scientific research awards of the American Academy of Neurology, American Brain Foundation, American Stroke Association, and American Heart Association. His health equity and community service efforts have been recognized with prominent awards from the American Neurological Association and World Stroke Organization. He served as Chair of the International Stroke Conference (the preeminent global stroke science meeting) for two years and is currently editor-in-chief of the Journal of the American Heart Association. Dr. Ovbiagele is an elected member of the National Academy of Medicine, Association of American Physicians, and the American Clinical and Climatological Association.
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HIV, HIV-specific Factors and Myocardial Disease in Women
In an effort to close the gap in research between men and women with HIV, NCIRE-supported Principal Investigators Drs. Phyllis Tien and Jorge Kizer recently co-authored the study “HIV, HIV-specific Factors and Myocardial Disease in Women”.
People with HIV (PWH) have an increased risk of cardiovascular disease. Cardiac magnetic resonance (CMR) has documented higher myocardial fibrosis, inflammation, and steatosis in PWH. However, studies have mostly relied on healthy volunteers as comparators and focused on men.
In their study, Drs. Tien and Kizer and their colleagues investigated the associations of HIV and HIV-specific factors with CMR phenotypes in female participants enrolled in the Women's Interagency HIV Study's New York and San Francisco sites. Primary phenotypes included myocardial native (n) T1 (fibro-inflammation), extracellular volume fraction (ECV, fibrosis) and triglyceride content (steatosis). Associations were evaluated with multivariable linear regression, and results pooled or meta-analyzed across centers.
Phyllis Tien, MD is a clinical translational researcher who investigates chronic viral infections, specifically HIV and HCV, and their metabolic and inflammatory consequences on long term organ injury (e.g. liver, bone and vascular injury). As part of this work, she also studies novel non-invasive techniques to estimate steatosis and fibrosis using magnetic resonance (MR) imaging and ultrasound-based transient elastography as well as novel CT and MR imaging methods to measure bone and vascular injury.
Jorge Kizer, MD, MSc is the Chief of the Division of Cardiology for the San Francisco VA Health Care System. His research program seeks to advance the understanding of risk factors for heart disease and stroke in order to improve prevention, risk stratification, and treatment of these disorders. These investigations leverage molecular epidemiology and cardiovascular imaging to identify biochemical markers and endophenotypes involved in the initiation, development, and progression of cardiovascular diseases.
Read more: https://pubmed.ncbi.nlm.nih.gov/38356158/
Addressing disparities in the global epidemiology of stroke
Stroke, the second leading cause of death and the third leading cause of disability worldwide, has seen numbers of those impacted by the disease decrease significantly; yet not everyone can revel in this medical achievement.
Co-authoring a recent article in Nature Reviews Neurology titled “Addressing disparities in the global epidemiology of stroke”, NCIRE-supported Principal Investigator and Board Member Dr. Bruce Ovbiagele highlights the rapid uptick in the burden of stroke in low- and middle-income countries (LMICs). The article sites that epidemiological, socioeconomic, and demographic shifts are the culprit for this desperate disparity, with increases to the incidence of stroke and other non-communicable diseases.
While high-income countries (HICs) have boasted lower incidents of stroke than their LMIC counterparts, there is still disparities in stroke epidemiology along racial, ethnic, socioeconomic, and geographical lines.
Bruce Ovbiagele, MD, MSc, MAS, MBA, MLS, is a vascular neurologist, clinical epidemiologist, and health equity scholar, with a focus on reducing the burden of stroke. He is Professor of Neurology and Associate Dean at UCSF, as well as Chief of Staff at SFVAHCS, and serves a Statuary Director on the NCIRE Board.
Learn more: https://www.nature.com/articles/s41582-023-00921-z
NCIRE is proud to announce the following exciting new developments for research conducted by NCIRE-supported Principal Investigators Drs. Michael Shlipak and Michelle Estrella:
UCSF/SFVAHCS research collaboration reveals lack of albuminuria testing and describes treatment approaches in the real-world setting for patients with type 2 diabetes and chronic kidney disease
University of California, San Francisco (UCSF), Kidney Health Research Collaborative (KHRC), and San Francisco VA Health Care System (SFVAHCS) has released 2 real-world evidence studies that are focused on helping appropriate patients with chronic kidney disease (CKD) access more timely treatment.
More than 1 in 7 American adults (14%) are estimated to have CKD, with diabetes and high blood pressure being the most common causes of CKD in American adults.(1) Many of these patients are unaware of their disease because there are typically no or few symptoms in the early stages of the disease and, historically, there is under-detection of CKD due to lack of testing. Treatment for CKD depends on the stage of disease and, while there is no cure, treatment can help slow its progression and lower the burden of associated heart disease complications.
We are pleased to report the findings from the first 2 collaborative studies with UCSF and SFVAHCS.
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Prescription Patterns of Cardiovascular- and Kidney-Protective Therapies Among Patients with Type 2 Diabetes and Chronic Kidney Disease was undertaken to assess the prevalence and correlations of prescriptions for 2 drugs that protect against CKD progression and heart disease events, sodium-glucose cotransporter 2 inhibitors (SGLT2is) and/or glucagon-like peptide 1 receptor agonists (GLP1-RAs) in individuals with T2D with and without CKD. This was a cross-sectional analysis of SGLT2i and GLP1-RA prescriptions from 1 January 2019 to 31 December 2020 in the Veterans Health Administration (VHA) System. This study, which was published in Diabetes Care, demonstrated that patients with the greatest risk of cardiovascular disease (CVD) and kidney failure (ie, with severe albuminuria, elevated 10-year risk of atherosclerotic CVD, and 5-year risk of end-stage kidney disease >5%) were less likely to receive SGLT2is or GLP1-RAs.(3)
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Estimated Prevalence and Testing for Albuminuria in US Adults at Risk for Chronic Kidney Disease aimed to estimate the extent of albuminuria under-detection from lack of testing and evaluate its association with provision of common CKD treatments in patients with hypertension or diabetes. Using data from the 2007 to 2018 National Health and Nutrition Examination Surveys (NHANES), a model was created to predict abnormal albuminuria levels based on multiple predictor variables; this model was then applied to a 5% random sample of the Optum de-identified electronic health record dataset from 1 January 2017 to 31 December 2018 to predict the likelihood of abnormal albuminuria in untested patients in the clinical dataset. The results of these analyses, recently published in JAMA Network Open, estimate that two-thirds of patients with albuminuria were undetected due to lack of testing and that albuminuria testing was associated with greater likelihood of receiving CKD treatments.4 With improved identification of albuminuria, there would be a substantial opportunity to optimize care delivery for reducing kidney disease progression and cardiovascular complications.(4)
Drs. Estrella and Shlipak commitment to these research efforts, “We’re excited to continue these collaborative partnerships as it strongly aligns with the KHRC’s longstanding research dedication to optimize the prevention, early detection, and treatment of kidney disease and its associated cardiovascular complications. We believe that such academic-industry partnerships have the potential to close the gap between scientific discoveries and clinical care delivery, and additionally to accelerate research focused on early stages of kidney disease, which traditionally has lagged behind research into advanced stages of CKD.”
For more information, please contact Michelle.Estrella@ucsf.edu or Michael.Shlipak@ucsf.edu.
About UCSF and SFVAHCS’s Commitment in Kidney Disease
The University of California, San Francisco (UCSF) is one of the top hospitals in Northern California and the nation for kidney care.(5) The Kidney Health Research Collaborative (KHRC), based at UCSF and the San Francisco Veterans Affairs Health Care System (SFVAHCS), encompasses a group of leading scientists from multiple disciplines working to improve kidney health worldwide.(6) A non-profit research institute, the Northern California Institute for Research and Education (NCIRE) is a critical partner for the KHRC, as NCIRE provides outstanding administrative support for these awards from Bayer to KHRC. NCIRE promotes and supports the research of investigators who have joint faculty appointments at both UCSF and SFVAHCS, such as Drs. Estrella and Shlipak. San Francisco VA Health Care System (SFVAHCS) is a comprehensive network that provides health services to Veterans through the San Francisco VA Medical Center (SFVAMC) and nine community-based outpatient clinics in Santa Rosa, Oakland, Eureka, Ukiah, Clearlake, San Bruno and downtown San Francisco.
Funding for this research was provided by Bayer Healthcare Pharmaceuticals.
References
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Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2023. May 30, 2023. Accessed July 24, 2023. https://www.cdc.gov/kidneydisease/publications-resources/CKD-national-facts.html
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National Health Service. Chronic kidney disease – treatment. March 23, 2023. Accessed July 24, 2023. https://www.nhs.uk/conditions/kidney-disease/treatment/
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Lamprea-Montealegre JA, Madden E, Tummalapalli SL, et al. Prescription patterns of cardiovascular- and kidney-protective therapies among patients with type 2 diabetes and chronic kidney disease. Diabetes Care. 2022;45:2900-2906.
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Chu CD, Xia F, Yuxian D, et al. Estimated prevalence and testing for albuminuria in US adults at risk for chronic kidney disease. JAMA Network Open. 2023;6(7):e2326230. doi:10.1001/jamanetworkopen.2023.26230
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UCSF. Kidney disease (nephrology). Accessed July 31, 2023. https://www.ucsfhealth.org/list-of-clinics/kidney-disease-nephrology
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UCSF. Kidney Health Research Collaborative. Accessed July 31, 2023. https://khrc.ucsf.edu/
Geriatrics Team Publications Explore Aging Research Challenges, and Nursing Home Needs for Older Dementia patients
Lead by University of California San Francisco (UCSF) Principal Investigator Dr. James Deardorff, several NCIRE-supported Investigators recently co-published two articles exploring research challenges in the geriatrics field and predicting the level of nursing home care needs for older adults with dementia.
Published in the Journal of the American Geriatrics Society, the article “Around the EQUATOR with Clin-STAR: Prediction modeling opportunities and challenges in aging research” highlights methodologic challenges that aging-focused researchers will encounter when designing and reporting studies involving prediction models for older adults and provides guidance for addressing these challenges.
NCIRE-supported Investigators Drs. Alexander Smith, John Boscardin, and Sei Lee joined Dr. Deardorff in suggesting that clinical prediction models are becoming increasingly popular and are often applied to populations involving older adults. Proper design and reporting of these studies are critical to ensure that they are developed and validated in a manner that does not misinform individuals or worsen healthcare inequities.
Read the article here: https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18704
In another article co-published by Dr. Deardorff and NCIRE-supported Investigators Drs. Deborah Barnes, John Boscardin, Kenneth Covinsky, Sei Lee, and Alexander Smith, the research team addressed the question: can need for nursing home level of care (NHLOC) in community-dwelling older adults with dementia be accurately predicted?
Titled “Development and External Validation of Models to Predict Need for Nursing Home Level of Care in Community-Dwelling Older Adults With Dementia”, the prognostic study showed that relatively simple models using self-reported or proxy responses can predict need for NHLOC among older adults with probable dementia with moderate discrimination and excellent calibration. Given that most individuals with dementia ultimately need NHLOC, model estimates may help frame conversations between patients and families/caregivers regarding care planning.
The study was published by the Journal of the American Medical Association (JAMA) Network-JAMA Internal Medicine, and may be read here:
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2812543
The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions
NCIRE-supported Researchers Drs. Shira Maguen and Sabra Inslicht co-published a paper with University of California, San Francisco and San Francisco VA Health Care System Principal Investigator Dr. Shane Adams that posits the importance of implementing the Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions.
Published in the International Society for Traumatic Stress Studies’ Journal of Traumatic Stress by Shane Adams et al., the paper introduces the Middle-Out Approach as a new integrative methodological framework for advancing the study and treatment of traumatic stress reactions to be increasingly representative of more individuals and contexts. This approach is differentiated from other practices by the assessments and data used as well as their application and analysis.
The Middle-Out Approach aims to uncover unique theory- and data-driven phenotypes characterizing traumatic stress reactions that may have been previously obstructed by historical practices and restrictions of bottom-up, top-down, and variable centered-only designs and statistical approaches. This approach can help identify and explicate intra- and interindividual differences in traumatic stress reactions that can lead to increased empirical and diagnostic representations of unique experiences within diverse communities that meaningfully impact treatments.
Within the article, the research team provides a conceptual roadmap for integrating existing methods into new or existing studies to facilitate clear clinical applications and increased patient-centered care to address persisting research and clinical issues.
Sabra Inslicht, PhD, is a Staff Psychologist with the Mental Health Service with the San Francisco VA Health Care System (SFVAHCS), and Adjunct Professor of Psychiatry at the University of California, San Francisco (UCSF). Dr. Inslicht’s research focuses on identifying neurobiological mechanisms that underlie post-traumatic stress disorder (PTSD), fear conditioning models of PTSD, putative biomarkers that may explain sex differences in PTSD, and pharmacological and psychological interventions to ameliorate stress responding and insomnia.
Shira Maguen, PhD is the Mental Health Director of the Post-9/11 Integrated Care Clinic and Staff Psychologist on the Posttraumatic Stress Disorder Clinical Team (PCT) at the SFVAHCS, and Vice Chair of SFVAHCS and Professor in the Department of Psychiatry and Behavioral Sciences, UCSF School of Medicine. Dr. Maguen was appointed to and served on the Creating Options for Veterans' Expedited Recovery (COVER) Commission. She is also the San Francisco site co-lead for the VA Women’s Practice Based Research Network (PBRN) and Director of the SFVAHCS PTSD MIRECC Postdoctoral Research Fellowship.
Read More: https://onlinelibrary.wiley.com/doi/10.1002/jts.23005