Cognitive function among military veterans with STEM occupations

Dear Editor,There is limited research on the relationship between science,technology,engineering,and mathematics(STEM)occupational history and cognitive function in later life,especially among military veterans,who may be at greater risk for later-life cognitive decline.This study examines a nationally representative sample of military veterans to address this gap in knowledge.

Analysis of the Influence of Woodcut Works of Anti-Japanese War on the National Spiritual Identity of Young People

As one of the important art forms during the Anti-Japanese War in China, woodcut is not only a tool for literary and artistic workers to express the spirit of Anti-Japanese War, but also a medium to inspire the people and arouse patriotic feelings. Through a systematic analysis of the historical background and artistic characteristics of woodcuts of the Anti-Japanese War and their impact on the national spiritual identity of young people, this paper aims to explore how woodcuts enlightens and inspires young people’s national consciousness through visual language and spiritual connotation, and enhances their sense of belonging to the country and the nation.

A Study of the People’s Nature in Woodcuts During the Anti-Japanese War in Shanxi

The anti-Japanese woodcuts focus on the red revolutionary culture and describe the connotation of the Anti-Japanese War era,which is self-evident in the commemorative value of China’s revolutionary struggle history.For example,in Shanxi,China,woodcut art activities and social practice promotion activities organized around the theme of the Anti-Japanese War are also everywhere,which all show the people’s nature of the Chinese people during the revolutionary struggle from the two aspects of the red culture of the Anti-Japanese War and traditional art and culture,and its humanistic connotation is quite profound.In this paper,we first introduce the historical origin of woodcut during the Anti-Japanese War,and then show the people’s value connotation of woodcut art activities in Shanxi.This paper mainly discusses the image narration,language and picture narration and construction significance of woodcuts in Shanxi’s War of Resistance,fully reveals the narrative nature of image media,strives to arouse people’s recognition of this period of Shanxi’s War of Resistance culture and history,and reflects the realistic value and significance of Shanxi’s War of Resistance Woodcuts art activities.

Lethal means and suicide prevention among military veterans

Dear Editor,Suicide amongst the military veteran population is a significant publichealthproblemintheUnitedStates.TheNational VeteranSuicidePreventionAnnualReportrevealedthat6261 died by suicide in 2019[1]. The lingering effects of the coronavirus disease 2019 (COVID-19) pandemic may account for an increase in veteran suicide rates[1].

Veterans utilizing a federally qualified health center: a clinical snapshot

Dear Editor,Te Veterans Health Administration(VHA)provides healthcare for over 9 million enrolled veterans with approximately 2.7 million of those residing in rural areas[1].Te MISSION Act of 2018 emphasizes VHA collaboration with Federally Qualifed Healthcare Centers(FQHC)to serve rural residing veterans and nearly all existing collaborations involve arrangement of payment for community-based care by VHA to FQHCs.Unfortunately,there is a paucity of descriptive clinical data on existing cross-system collaborations which may help characterize these veterans and aid understanding of conditions for which they may receive treatment across systems.Such data has implications for workforce training,development,and resource allocation[2].Te objective of this report is to describe diferent clinical profles between two mutually exclusive samples:veterans engaged in FQHC only use,and VHA-enrolled veterans engaged in dual VHA and FQHC use.

The relationship between chronic PTSD,cortical volumetry and white matter microstructure among Australian combat veterans

Background:Posttraumatic stress disorder(PTSD)has been associated with volumetric and white matter microstructural changes among general and veteran populations.However,regions implicated have greatly varied and often conflict between studies,potentially due to confounding comorbidities within samples.This study compared grey matter volume and white matter microstructure among Australian combat veterans with and without a lifetime diagnosis of PTSD,in a homogenous sample assessed for known confounding comorbidities.Methods:Sixty-eight male trauma-exposed veterans(16 PTSD-diagnosed;mean age 69 years)completed a battery of psychometric assessments and underwent magnetic resonance and diffusion tensor imaging.Analyses included tractbased spatial statistics,voxel-wise analyses,diffusion connectome-based group-wise analysis,and volumetric analysis.Results:Significantly smaller grey matter volumes were observed in the left prefrontal cortex(P=0.026),bilateral middle frontal gyrus(P=0.021),and left anterior insula(P=0.048)in the PTSD group compared to controls.Significant negative correlations were found between PTSD symptom severity and fractional anisotropy values in the left corticospinal tract(R^(2)=0.34,P=0.024)and left inferior cerebellar peduncle(R^(2)=0.62,P=0.016).No connectome-based differences in white matter properties were observed.Conclusions:Findings from this study reinforce reports of white matter alterations,as indicated by reduced fractional anisotropy values,in relation to PTSD symptom severity,as well as patterns of reduced volume in the prefrontal cortex.These results contribute to the developing profile of neuroanatomical differences uniquely attributable to veterans who suffer from chronic PTSD.

Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans

Background:Large numbers of post-deployment U.S.veterans are diagnosed with post-traumatic stress disorder(PTSD)and/or traumatic brain injury(TBI),leading to an urgent need for effective interventions to reduce symptoms and increase veterans’coping.PTSD includes anxiety,flashbacks,and emotional numbing.The symptoms increase health care costs for stress-related illnesses and can make veterans’civilian life difficult.Methods:We used a randomized wait-list controlled design with repeated measures of U.S.military veterans to address our specific aim to test the efficacy of a 6-week therapeutic horseback riding(THR)program for decreasing PTSD symptoms and increasing coping self-efficacy,emotion regulation,social and emotional loneliness.Fiftyseven participants were recruited and 29 enrolled in the randomized trial.They were randomly assigned to either the horse riding group(n=15)or a wait-list control group(n=14).The wait-list control group experienced a 6-week waiting period,while the horse riding group began THR.The wait-list control group began riding after 6 weeks of participating in the control group.Demographic and health history information was obtained from all the participants.PTSD symptoms were measured using the standardized PTSD Checklist-Military Version(PCL-M).The PCL-M as well as other instruments including,The Coping Self Efficacy Scale(CSES),The Difficulties in Emotion Regulation Scale(DERS)and The Social and Emotional Loneliness Scale for Adults-short version(SELSA)were used to access different aspects of individual well-being and the PTSD symptoms.Results:Participants had a statistically significant decrease in PTSD scores after 3 weeks of THR(P≤0.01)as well as a statistically and clinically significant decrease after 6 weeks of THR(P≤0.01).Logistic regression showed that participants had a 66.7%likelihood of having lower PTSD scores at 3 weeks and 87.5%likelihood at 6 weeks.Under the generalized linear model(GLM),our ANOVA findings for the coping self-efficacy,emotion regulation,and social and emotional loneliness did not reach statistical significance.The results for coping self-efficacy and emotion regulation trended in the predicted direction.Results for emotional loneliness were opposite the predicted direction.Logistic regression provided validation that outcome effects were caused by riding longer.Conclusion:The findings suggest that THR may be a clinically effective intervention for alleviating PTSD symptoms in military veterans.

Risk factors for 90-day readmission in veterans with inflammatory bowel disease——Does post-discharge follow-up matter?

Background: Repeat hospitalizations in veterans with inflammatory bowel disease(IBD) are under studied. The early readmission rate and potentially modifiable risk-factors for 90-day readmission in veterans with IBD were studied to avert avoidable readmissions.Methods: A retrospective cohort study was conducted using the data from veterans who were admitted to the Minneapolis VA Medical Center(MVMC) between January 1, 2007, and December 31, 2013, for an IBD-related problem. All-cause readmissions within 30 and 90 days were recorded to calculate early readmission rates. The multivariate logistic regression was used to identify the potential risk factors for 90-day readmission.Results: There were 130 unique patients(56.9% with Crohn's disease and 43.1% with ulcerative colitis) with 202 IBD-related index admissions. The mean age at the time of index admission was 59.8±15.2 years. The median time to re-hospitalization was 26 days(IQR 10-49), with 30-and 90-day readmission rates of 17.3%(35/202) and 29.2%(59/202), respectively. Reasons for all-cause readmission were IBD-related(71.2%), scheduled surgery(3.4%) and non-gastrointestinal causes(25.4%). The following reasons were independently associated with 90-day readmission: Crohn's disease(OR 3.90; 95% CI 1.82-8.90), use of antidepressants(OR 2.19; 95% CI 1.12-4.32), and lack of follow-up within 90 days with a primary care physician(PCP)(OR 2.63; 95% CI 1.32-5.26) or a gastroenterologist(GI)(OR 2.44; 95% CI 1.20-5.00). 51.0% and 49.0% of patients had documentation of a recommended outpatient follow-up with PCP and/or GI, respectively.Conclusion: Early readmission in IBD is common. Independent risk factors for 90-day readmission included Crohn's disease, use of antidepressants and lack of follow-up visit with PCP or GI. Further research is required to determine if the appropriate timing of post-discharge follow-up can reduce IBD readmissions.

Revascularization and outcomes in Veterans with moderate to severe ischemia on myocardial perfusion imaging

Background： The prevalence of ischemia on nuclear myocardial perfusion imaging （MPI） has been decreasing. Recent research has questioned the benefit of invasive revascularization for patients with moderate to severe ischemia. We hypothesized that patients with moderate to severe ischemia could routinely undergo successful revascularization. Methods： We analyzed data from 544 patients who underwent an MPI at a single academic Veterans Affairs Medical Center. Patients with moderate to severe ischemia, defined as a summed difference score （SDS） 8 or greater, were compared to the rest of the cohort. Results： Of the total cohort （n=544）, 39 patients had MPI studies with resultant moderate to severe ischemia. Patients with ischemia were more likely to develop coronary artery disease （74.4% versus 38.8%, P〈0.0001） and have successful revascularization （38.5% versus 4.0%, P〈0.0001） during the following year. Revascularization was attempted in 31 patients with moderate to severe ischemia, though only 15（47%） of these attempts were successful, Ischemia was predictive of myocardial infarction （5.1% versus 0.8%, P=0.01） within I year. Conclusion： Moderate to severe ischemia is an uncommon finding in a contemporary nuclear laboratory. Among patients with ischemia, revascularization is typically attempted but is frequently unsuccessful. Trial registration： This trial does not appear on a registry as it is neither randomized nor prospective.

Validation of Veterans Specific Activity Questionnaire to assess exercise tolerance of Chinese elderly with coronary heart disease

Objective The Veterans Specific Activity Questionnaire （VSAQ） has been used to assess exercise tolerance. Nevertheless, there is no val- idated Chinese version. The aim of this study is to determine whether a questionnaire-based method using the Chinese version of VSAQ （the modified VSAQ） is a practical tool to assess exercise tolerance of Chinese elderly with coronary heart disease. Methods One hundred thirty consecutive elderly patients who were diagnosed with coronary heart disease （CHD） （mean age 68.9 -4- 6.0 years） referred for treadmill exercise testing （TET） for clinical reasons were included in the study. They were asked to complete a questionnaire for clinical characteristics information on age, sex, history, exercise habits, medications, the original VSAQ and the modified VSAQ. We investigated the relationship between exer- cise tolerance in metabolic equivalents （METs） estimated by VSAQ and that obtained by TET. Results The METs by the original VSAQ and the modified VSAQ did not difference significantly （P = 0.528）. The modified VSAQ scores were significantly correlated with the METs oh- mined by TET （r = 0.819, 95% CI： 0.7534）.873, P 〈 0.01）, and the scores of original VSAQ also correlated with the METs by TET （r = 0.804, 95% CI： 0.7454）.854, P 〈 0.01）. The Bland-Altman graph analysis showed few values outside the limits of agrcement, suggesting good precision between the METs estimated by questionnaire and the METs obtained by TET. Conclusions The Chinese version of the VSAQ confirmed its validity and equivalence to the original version, especially when evaluating individuals with coronary heart disease and older adults. The results showed that the VSAQ is a valuable tool to assess the exercise tolerance.

Veterans health administration hepatitis B testing and treatment with anti-CD20 antibody administration

AIM: To evaluate pretreatment hepatitis B virus (HBV) testing, vaccination, and antiviral treatment rates in Veterans Affairs patients receiving anti-CD20 Ab for quality improvement.METHODS: We performed a retrospective cohort study using a national repository of Veterans Health Administration (VHA) electronic health record data. We identified all patients receiving anti-CD20 Ab treatment (2002-2014). We ascertained patient demographics, laboratory results, HBV vaccination status (from vaccination records), pharmacy data, and vital status. The high risk period for HBV reactivation is during anti-CD20 Ab treatment and 12 mo follow up. Therefore, we analyzed those who were followed to death or for at least 12 mo after completing anti-CD20 Ab. Pretreatment serologic tests were used to categorize chronic HBV (hepatitis B surface antigen positive or HBsAg+), past HBV (HBsAg-, hepatitis B core antibody positive or HBcAb+), resolved HBV (HBsAg-, HBcAb+, hepatitis B surface antibody positive or HBsAb+), likely prior vaccination (isolated HBsAb+), HBV negative (HBsAg-, HBcAb-), or unknown. Acute hepatitis B was defined by the appearance of HBsAg+ in the high risk period in patients who were pretreatment HBV negative. We assessed HBV antiviral treatment and the incidence of hepatitis, liver failure, and death during the high risk period. Cumulative hepatitis, liver failure, and death after anti-CD20 Ab initiation were compared by HBV disease categories and differences compared using the χ2 test. Mean time to hepatitis peak alanine aminotransferase, liver failure, and death relative to anti-CD20 Ab administration and follow-up were also compared by HBV disease group.RESULTS: Among 19304 VHA patients who received anti-CD20 Ab, 10224 (53%) had pretreatment HBsAg testing during the study period, with 49% and 43% tested for HBsAg and HBcAb, respectively within 6 mo pretreatment in 2014. Of those tested, 2% (167/10224) had chronic HBV, 4% (326/7903) past HBV, 5% (427/8110) resolved HBV, 8% (628/8110) likely prior HBV vaccination, and 76% (6022/7903) were HBV negative. In those with chronic HBV infection, ≤ 37% received HBV antiviral treatment during the high risk period while 21% to 23% of those with past or resolved HBV, respectively, received HBV antiviral treatment. During and 12 mo after anti-CD20 Ab, the rate of hepatitis was significantly greater in those HBV positive vs negative (P = 0.001). The mortality rate was 35%-40% in chronic or past hepatitis B and 26%-31% in hepatitis B negative. In those pretreatment HBV negative, 16 (0.3%) developed acute hepatitis B of 4947 tested during anti-CD20Ab treatment and follow-up.CONCLUSION: While HBV testing of Veterans has increased prior to anti-CD20 Ab, few HBV+ patients received HBV antivirals, suggesting electronic health record algorithms may enhance health outcomes.

What priorities should be considered for Iranian veterans with ankle-foot injuries？ A health needs assessment study, 25 years post-conflict

Despite the passage of time,a large number of veterans are still affected by injuries acquired during Iran-Iraq war.In addition to their primary injuries,the majority of veterans also experience difficulty with long-term,secondary effects.Studies have shown that the most common of these include a range of disabilities,pain,and dramatic decline in mental health and quality of life.Improving living conditions and providing rehabilitation services to veterans has always been a main priority of authorities.The goal of this study was to explain the methods and materials with which these priorities were explored.

Mental health among Iranian combat veterans with ankle-foot neuromusculoskeletal injuries

Background:Veterans with purely physical disorders,such as ankle-foot neuromusculoskeletal disorders,are often neglected in psychological assessments because mental health evaluations are usually focused on those with a psychological disturbance or with a high percentage of injury.The purpose of this study was to evaluate the psychological condition of veterans with ankle-foot neuromusculoskeletal disorders.Methods:A cross-sectional study was performed between 2014 and 2016 on veterans with war-related ankle-foot injuries living in two provinces of Iran.An information form for demographic data and injury-related factors was used.Additionally,the previously validated Persian version of the Symptom Checklist-90-Revision(SCL-90-R)questionnaire was used for data collection.Results:The respondents were 215 male veterans with a mean age of 51.7±7.5 years.The most common mental health problems were observed for the somatization(24.7%),obsessions-compulsions(14.4%),and anxiety(12.6%).Based on the Global Severity Index(GSI),48.6%of individuals had a possible psychiatric/psychological illness.According to the multivariate regression analysis,GSI scores were significantly higher among veterans who were older than 27 years at the time of injury(P=0.005),had an associated injury(P=0.002),and had a history of hospitalization within the past 12 months for reasons other than their injury(P=0.035).Conclusion:Approximately half of the combat veterans with ankle-foot neuromusculoskeletal disorders likely had psychological problems.The evaluation of the patterns and predicting factors of psychological conditions may inform strategic planning efforts and decision-making,which,in turn,may provide a better quality of life for veterans.Further studies that utilize longitudinal designs are needed to evaluate and compare the psychological status of different groups of veterans and other groups in the general population.

Assessment of orthotic needs in Iranian veterans with ankle and foot disorders

Background: War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma. Orthotic treatment as a rehabilitation process aims to enable people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels. This study aimed to investigate the rate of using orthoses among Iranian veterans with neuromuscular and skeletal disorders of the ankle and foot. Furthermore, the priorities of orthotic treatment in those veterans were explored.Methods: This qualitative study was a national health needs assessment conducted in 11 provinces of Iran during 2011–2016. A stakeholder research group was established to survey the veterans in respect to their demographic variables, activities of daily living, current health conditions, and rate of using orthoses.Results: Overall, 907 of the 1124 veteran participants completed the survey(response rate: 80.7%). Most of the veterans were men(97.7%), and their age and disability rate were 52.07±8.13 years and 31.92%±14.93%, respectively. Nearly 42% of the veterans had experience in using orthoses on a daily and weekly basis. As physical ambulation was the main problematic activity in veterans, most of them were using medical shoes and foot orthoses. Nearly 37% of veterans were in need of some type of lower limb orthoses on the contralateral side to compensate for their hip inequality. In sequential order, the most in need orthoses for veterans were foot orthoses(n=538), medical shoes(n=447), lower limb orthoses on the contralateral side(n=320), spinal orthoses(n=273), and upper limb orthoses(n=86).Conclusion: In spite of the high demands for orthoses among Iranian veterans with ankle and foot disorders, the use of orthoses is insufficient. Hence, there is a discrepancy between the current rate of orthoses use and its ideal situation, and more resources should be provided for service providers to be able to serve veterans. Moreover, veterans should be educated regarding orthoses, their use, and their impacts on the user's health status. The findings of a needs assessment of orthoses can be used in strategic planning and decision making to improve health care services for Iranian veterans.

Preliminary Investigation of Sex Differences in Procedural Skill Learning in Veterans with Co-Morbidities

Sex differences in procedural skill learning have not been well characterized. Skill learning is an important area to explore in clinical settings that involve rehabilitation and deficit remediation, especially for returning Veterans that have a range of co-morbid conditions (traumatic brain injury, posttraumatic stress disorder, and depression) and possess impairments in multiple domains. Sixty-five (55 males, 10 females) Veterans completed two procedural learning tasks and answered self-report questionnaires. Participants’ performance and total learning slope were analyzed to determine sex differences in learning. Our results revealed sex differences in both tasks demonstrating females tend to perform better than males with a large effect size for these mean differences. While females performed better on the procedural learning tasks compared to males, their rate of learning was equivalent. Skill learning is an important requisite for rehabilitation, as skill learning is necessary to perform daily activities in new settings. Ultimately, these results provide insight into skill learning in Veterans with a range of co-morbid conditions and provide support for further investigation of sex differences in procedural learning.

Social support and coping as moderators of perceived disability and posttraumatic stress levels among Vietnam theater veterans

The dual purpose of this study is to investigate whether disability predicts posttraumatic stress levels among Vietnam theater veterans, and whether coping and/or social support moder- ates the impact of disability on PTSD levels, after controlling for demographic, pre-military, military, and post-military factors. This research analyzed data from the U.S.’s National Vietnam Veterans Readjustment Study (NVVRS), which was a nationally representative, stratified, random sample of 3,016 Vietnam veterans. The results indicated that disability, emotional support, instrumental support, and wishful – thinking coping significantly predicted PTSD, when controlling for demographic, pre-military, military, and post-military factors. Further, interactions indicated that both emotional social support and problem-solving coping significantly decreased the impact of disability on PTSD levels. Implications of this research are briefly discussed.

Using GIS to Plan Specialty Health Services for Veterans: The Example of Acute Stroke Care

The Department of Veterans Affairs (VA) manages the largest healthcare system under a single management structure in the United States. Providing access to high quality healthcare to the VA’s nearly 9 million enrollees is a mission priority for the Veterans Health Administration (VHA), the arm of the VA that oversees all medical facilities and operations. Geographic Information Systems (GIS) tools enable analysts to construct data-driven recommendations to policy makers for providing the best and most timely healthcare to those individuals who have honorably served their country. This paper illustrates how GIS is being used by the VHA and provides the example of acute stroke care access for Veterans in one Veterans Integrated Service Network (VISN) within the VHA.

Investigating the Relationship between Sleep Quality and Mental Health in Chemical Veterans in Comparison with Their Spouses and a Control Group

Aim: This study was aimed to determine the relationship between sleep quality and mental health of veterans in comparison with that of their spouses and a control group. Methods: Thirty-seven chemical veterans with moderate to severe injury based on the standards of Foundation of Martyrs and Veterans Affairs were selected from Mazandaran province. Then, the spouses of 31 of them were selected and 15 of their close relatives also enrolled in the study as the control group. The three groups were evaluated by GHQ for their mental health and Pittsburg Sleep Quality Index (PSQI) for sleep quality. Collected data were analyzed using SPSS software 16 and descriptive and analytic statistical methods. Results: The mean score of mental health in veterans, their spouses and close relatives were 44.13 ± 14.4, 34.19 ± 15.2 and 21.73 ± 17.32, respectively. The mean scores of PSQI test in veterans, their spouses, and their close relatives were 10.94 ± 5.6, 8.7 ± 5.5 and 4.27 ± 1 that the difference was statistically significant among the three groups (P ≤ 0.0001). A positive relationship was seen between mental health and sleep quality in veterans and their spouses respectively (r = 0.4, P = 0.02) and (r = 0.83, P < 0.0001). Conclusion: Poor sleep quality in chemical veterans compared to their spouses and close relatives could be due to mental health, rather than chemical effects and chronic lung disease. Therefore, treatment of mental health might be an important step to improve the sleep quality of veterans.

Critical Analysis of the Healthcare Response to Burn-Pit-Related Illnesses for Post-9/11 Iraq and Afghanistan Veterans

A serious concern among post-9/11 Iraq and Afghanistan veterans (IAV) are health conditions from military and environmental exposure while serving. Many veterans are becoming suddenly ill and experiencing symptoms that have been associated with exposure to burning trash or “burn pits” set up to destroy waste produced by the military. IAVs are exhibiting respiratory conditions and other numerous health issues from exposure to burn pits during deployments. From the US military operations to the Middle East, 70% of the military personnel reported respiratory illnesses, with 17% experiencing symptoms serious enough to require medical care. Despite growing concerns, little research has been conducted on the health conditions of returning veterans. Many veterans have difficulty gaining appropriate access to care, unable to travel long distances to Veterans health facility, or have to deal with long wait times to see a provider. As a result, many veterans utilize civilian emergency rooms and healthcare facilities. Most healthcare facilities are not familiar with military-related health conditions. To address and prevent delays in care, it is helpful to have a veteran-specific screener questionnaire at the point of healthcare access. Getting a better understanding of the background and history of veterans can aid in accurately triaging this community and lead to better health care outcomes. Collecting and maintaining data regarding health issues that can arise from burn pit exposures can help direct the care of this specific community of veterans. In seeking to improve the understanding of IAV health issues from exposure to burn pits, the aim of this article is to help educate and raise awareness, and assist health care professionals to better triage and direct the care or resources necessary to help this underserved and at-risk community of our veterans.

Characterization of Veterans’ Poisoning Events in the State of Florida

Increasing numbers of veterans are returning home with chronic pain and mental health disorders. Pharmacological treatments may be effective, but may also be increasing the incidence of poisonings among younger as well as older veterans, requiring greater resource expenditures at Veterans Administration (VA) facilities. Our objective was to characterize patterns of the poisoning among the veterans in Florida, using data obtained from the Florida Poisoning Control Information Network (FPCIN). We evaluated retrospective cohort data from 2005 to 2009 of 601 poisoning cases treated at Florida VA medical facilities with consultations from FPCIN. Intentional (suspected suicide) was the most common reason. Major adverse clinical outcomes were associated with the use of NSAIDs or alcohol. Antidepressants and anti-anxiolytics had the strongest association with intentional self-poisoning. Since medications are the major substances for the poisoning among the veterans, our study suggests that pharmaceutical treatments of veterans should include stronger prescribing guidelines and consideration of alternative therapies.