text:
Add Document
Sign In
Create An Account
Factors associated with suicidal ideation in OEF ... - Semantic Scholar
Recommend Documents
No documents
Factors associated with suicidal ideation in OEF ... - Semantic Scholar
Download PDF
2 downloads
0 Views
233KB Size
Jan 1, 2011 -
Blue Ribbon
Work Group, chartered to promote improvement in veteran suicide prevention efforts, found inconsistent reporting of veteran ...
University of Nebraska - Lincoln
DigitalCommons@University of Nebraska - Lincoln Public Health Resources
Public Health Resources
Factors associated with suicidal ideation in OEF/ OIF veterans Chad M. Lemaire Baylor College of Medicine & Legacy Community Health Services
David P. Graham Baylor College of Medicine & Department of Veterans Affairs Medical Center
Follow this and additional works at: http://digitalcommons.unl.edu/publichealthresources Part of the Public Health Commons Lemaire, Chad M. and Graham, David P., "Factors associated with suicidal ideation in OEF/OIF veterans" (2011). Public Health Resources. Paper 181. http://digitalcommons.unl.edu/publichealthresources/181
This Article is brought to you for free and open access by the Public Health Resources at DigitalCommons@University of Nebraska - Lincoln. It has been accepted for inclusion in Public Health Resources by an authorized administrator of DigitalCommons@University of Nebraska - Lincoln.
Journal of Affective Disorders 130 (2011) 231–238
Contents lists available at ScienceDirect
Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d
Research report
Factors associated with suicidal ideation in OEF/OIF veterans Chad M. Lemaire a,b, David P. Graham a,c,d,e,⁎ a
The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA Legacy Community Health Services, Houston, TX, USA Neurorehabilitation: Neurons to Networks TBI Center of Excellence, Rehabilitation Research and Development Service, Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, TX, USA d Houston Center for Quality of Care and Utilization Studies, Health Services Research and Development Service, Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, TX, USA e Mental Health Care Line, Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, TX, USA b c
a r t i c l e
i n f o
Article history: Received 30 August 2010 Accepted 10 October 2010 Available online 4 November 2010
Keywords: Veterans Suicide Posttraumatic Stress Disorder Depression
a b s t r a c t Background: The purpose of this project was to examine factors associated with suicidal ideation in returning Iraq and Afghanistan war veterans. Methods: A cross-sectional review of 1740 veterans' initial mental health screening evaluations. One-hundred and thirteen (6.5%) OEF/OIF veterans reported active suicidal ideation at the time of the interview. Results: Prior exposures of physical or sexual abuse and having a history of a prior suicide attempt(s) were associated with the presence of current suicidal ideation, as were having a diagnosis of a psychotic disorder, a depressive disorder, or posttraumatic stress disorder (PTSD). Deployment concerns related to training (protective), the deployment environment, family concerns, deployment concerns, post-deployment support (protective), and postdeployment stressors were also associated with current suicidal ideation. Logistic regression analysis revealed the major risk factors were having a prior suicide attempt, female gender, and a depressive disorder diagnosis; while more perceived current social support was a protective factor. Logistic regression analysis also revealed having comorbid PTSD and depression carried a higher odds ratio for risk than did having either PTSD or depression alone; and that the PTSD avoidance symptom-cluster was associated with more risk than either the re-experiencing or hyper-arousal symptom clusters for current suicidal ideation. Limitations: As a cross-sectional retrospective medical chart review, limitations include limited generalizability and causal relationships cannot be evaluated. Conclusions: Further investigation of these risk factors is warranted to aid in suicide risk assessment and in the development of targeted interventions to mitigate the identified risk factors and bolster the identified protective factor. Published by Elsevier B.V.
1. Introduction Suicidal thoughts and behaviors are encountered on a daily basis in mental health care. In 2006, suicide was the 11th
⁎ Corresponding author. Michael E. DeBakey VA Medical Center (116A), Mental Health Care Line, 2002 Holcombe Blvd., Houston, Texas, 77030, USA. Tel.: +1 713 794 8700; fax: +1 713 794 7083. E-mail address:
[email protected]
(D.P. Graham).
leading cause of death in the United States, accounting for 33,289 deaths (Centers for Disease Control and Prevention, 2006). The Blue Ribbon Work Group, chartered to promote improvement in veteran suicide prevention efforts, found inconsistent reporting of veteran suicide rates across various studies (Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population, 2008). Although many studies report similar rates of suicide for veterans and demographically matched members of the general US
0165-0327/$ – see front matter. Published by Elsevier B.V. doi:10.1016/j.jad.2010.10.021
This article is a U.S. government work, and is not subject to copyright in the United States.
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
population, some report lower rates of suicide among veterans and others higher rates (Miller et al., 2009). A fourteen year summary of active duty military deaths in the years 1980 through 1993 found that suicide was the third leading major cause of death among males and the fourth leading cause of death among females (Helmkamp and Kennedy, 1996). More recently, suicide has been cited as the second leading cause of death in the U.S. military (Ritchie et al., 2003). One study found that although veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) as a group did not have significantly different rates of suicide than the general population, subgroups including those with mental disorders may be more vulnerable (Kang and Bullman, 2008). A recent study of 272 OEF/OIF veterans reported 12.5% had contemplated suicide in the 2 weeks preceding the survey (Pietrzak et al, 2010a). Studies are investigating suicide risk factors in the veteran population (Guerra et al., 2010), and the Army recently entered into an agreement with the National Institute of Mental Health to collaborate on a 5-year, $50-million prospective study of suicidal thoughts and behavior among soldiers (Kuehn, 2009). Many previous studies have investigated potential risk factors for suicidal ideation in the veteran population. Much of the literature relating demographic factors to suicide in veterans supports what has been found in the general population. With regard to gender, most data for veterans agrees with the general population with males being at higher risk for suicide completion than females, though females attempt suicide more often (Allen et al., 2005; Desai et al., 2008; Zivin et al., 2007). Most studies in veterans concur with general population studies that Caucasians are at higher risk for suicide (Allen et al., 2005; Desai et al., 2005; Desai et al., 2008; Kaplan et al., 2007; Zivin et al., 2007), though one study reported that the proportion of deaths due to suicide in a VA medical center were similar in African American and White patients (Thompson et al., 2002). With regard to age, the data is more scattered with studies showing increased risk among younger veterans only (Zivin et al., 2007), older veterans only (Desai et al., 2005), and biphasic associations with both younger and older veterans (Desai et al., 2008). Finally, one study reported finding no association between suicide rates and marital status (Desai et al., 2005). Having a diagnosable mental illness has been shown to increase the risk of suicide (Department of Veterans Affairs Office of Inspector General, 2007). Most studies have found that depression increases suicidal thoughts in veterans (Desai et al., 2005; Freeman et al., 2000; Guerra et al., 2010; Hendin and Haas, 1991; Kang and Bullman, 2008; Kramer et al., 1994; Pietrzak et al., 2010a; Waller et al., 1999). Bipolar disorder has similarly been found to increase the risk of suicidal thoughts and behaviors (Waller et al., 1999). With regard to substance use disorders, some studies have found an increased risk of suicidal ideation in veterans (Kang and Bullman, 2008; Waller et al., 1999; Zivin et al., 2007). Similarly, some studies have found that PTSD increases the risk of suicidal ideation in veterans (Guerra et al., 2010; Jakupcak et al., 2009; Kramer et al., 1994; Pietrzak et al., 2010a). However, conflicting reports exist as two studies reported co-morbid diagnoses of PTSD and depression within a veteran population were associated with lower suicide rates (Pfeiffer et al., 2009; Zivin et al., 2007). There is further evidence that even sub-threshold PTSD symptoms
may be a risk factor for suicidal ideation, comparable to that of a diagnosis of full PTSD (Marshall et al., 2001). Past research found that in a population of Vietnam–era Veterans diagnosed with PTSD that the re-experiencing PTSD symptom cluster was significantly associated with suicidal ideation, but the other two PTSD symptom clusters (avoidance/numbing and increased arousal) were not (Bell and Nye, 2007). Recently, there has been interest in evaluating resilience among active duty military personnel and veterans. A recent study showed that increased post-deployment social support was negatively associated with suicidal ideation in OEF/OIF veterans (Pietrzak et al., 2010a). Though predicting which individuals are at risk of actually completing suicide remains a challenging and complex task, identifying risk factors for suicidal ideation, a known correlate with suicide completion (Department of Veterans Affairs Office of Inspector General, 2007), can assist greatly in helping a practitioner determine when a patient may need further screening and more focused interventions. To date, there is limited data regarding these factors in the OEF/OIF veteran population with only one study (Pietrzak et al., 2010a) having examined the OEF/OIF veteran population. The purpose of this study was 1) to investigate the associations of currently recognized risk factors for suicidal ideation in a cross-section of OEF/OIF veterans, 2) to more closely evaluate the effects of co-morbid PTSD and depression in this population, and 3) to evaluate the relative contribution of the 3 PTSD symptom clusters for suicidal ideation. We have included an evaluation of the Deployment Risk and Resilience Inventory (DRRI, King et al., 2003, 2006) for associations with suicidal ideation. The DRRI is a self-report research inventory of risk and resilience measures associated with military deployment. The DRRI assesses 14 risk and resilience factors that fall into 3 categories: 2 predeployment/pre-war factors, 10 deployment/war-zone factors, and 2 post-deployment/post-war factors. We expect that substance use, major depression, bipolar disorder, and PTSD will all be associated with increased risks of suicidal ideation in OEF/OIF veterans as has been reported in other veteran populations. We also anticipate, when evaluating PTSD symptom clusters, that re-experiencing symptoms will show an increased risk for suicidal ideation, in accords with recent findings in the Vietnam-era veteran population (Bell and Nye, 2007). Finally, regarding DRRI measures, we expect higher rates of combat exposure, perceived threat, and post-deployment stress to be associated with suicidal ideation; and more current post-deployment support to be negatively associated with suicidal ideation. 2. Methods 2.1. Data source All returning OEF/OIF veterans registering with the Houston Veterans' Affairs Medical Center are routinely scheduled for a mental health screening and evaluation with clinicians in the Trauma Recovery Program (TRP). Each veteran was clinically assessed for PTSD, substance use, depression, and overall functioning by professional mental health psychologists, social workers, and psychiatrists. Psychological evaluations were semi-structured clinical interviews and included a measure of risk and protective factors pre, during, and post deployment.
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Evaluations are centrally stored in the veteran's medical record through the VA's electronic Clinical Patient Record System. TRP maintains a demographic database of all OEF/OIF veterans that includes the date of the initial screening and evaluation. Following IRB approval, this secure database was used to identify records of 1740 veterans initially screened between May 24, 2004 and March 26, 2008.
discriminative validity for OIF veterans (Vogt et al., 2008) as well as the original Gulf War I veterans (King et al., 2003). The intention of the developers was that each of the 14 measures could be used as a "stand-alone" instrument or all-together for a more comprehensive evaluation to better identify risks and/or protective factors to post-deployment, health-related sequelae. A full description of each scale can be found in King et al. (2003, 2006) and Vogt et al. (2008).
2.2. Study sample and design 2.4. Data analysis As part of a broader cross-sectional retrospective review of the delimited 4-year period, findings indicated that screenings were conducted for 1740 OEF/OIF veterans. Records were examined plus or minus 30 days from the date of the evaluation. Professional mental health clinicians were recruited to conduct the record reviews. Clinical raters met with the Investigators for several hours of training with the electronic medical record. Inter-rater reliability was established initially for four clinicians on 10 electronic records, with Intra-class Correlations (IC) for the demographic and diagnosis variables = 0.988 (95% CI: .980–.994), p b 0.001. Two additional raters were later added for additional demographic and diagnostic data extraction and, following training, were analyzing data consistently with the original raters (IC = 0.980 (95% CI:0.970–0.988), p b 0.001). 2.3. Variables 2.3.1. Suicidal ideation and prior suicide attempts The clinical suicide evaluation directly specified the presence/absence of any current suicidal ideation and any history of prior suicide attempts. 2.3.2. Demographics Age at time of screening, Gender, Ethnicity, Marital Status, and Education. The presence/absence of the following issues was also documented: military sexual trauma, physical abuse (pre-military), sexual abuse (pre-military). 2.3.3. Clinical diagnosis Dichotomous presence/absence of following diagnostic categories: psychotic disorders (schizophrenia, schizoaffective disorder, and psychotic disorder NOS), depressive disorders (major depressive disorder, depressive disorder NOS, and dysthymia), bipolar disorders (bipolar disorder I or II, bipolar disorder NOS, and cyclothymic disorder), other anxiety disorders (anxiety disorder NOS, obsessive–compulsive disorder, generalized anxiety disorder), panic disorder (with or without agoraphobia), substance use disorders (abuse or dependence for alcohol, tobacco, cannabis, and cocaine). Those diagnoses not listed in the final evaluation coding were defaulted to not being present. 2.3.4. Deployment Risk and Resiliency Inventory (DRRI) The DRRI (King et al., 2003, 2006) is a self-report research inventory of risk and resilience measures associated with military deployment. The DRRI assesses 14 risk and resilience factors that fall into 3 categories: 2 pre-deployment/pre-war factors, 10 deployment/war-zone factors, and 2 post-deployment/post-war factors. The DRRI has recently been shown to have strong internal consistency, and both criterion and
Sociodemographic variables were evaluated by the Kruskal– Wallis test for categorical variables and analysis of variance (ANOVA) for continuous variables as each variable related to the presence or absence of suicidal ideation, including for all 14 DRRI scales. Logistic regression was performed using a forward stepwise method. Variable selection followed the recommendations of Hosmer and Lemeshow (2000). The logistic regression's dependent variable was the presence of current suicidal ideation. Models were evaluated using the following sets of independent variables: 1) the socio-demographic and full set of clinical diagnostic and DRRI variables, 2) a comparison of depression, PTSD, and both to a neither reference group, and 3) the three PTSD symptom clusters. Co-linearity diagnostics were reviewed to evaluate for possible interactions. If an interaction was found, each potential interaction term was added individually and evaluated for retention. All data analyses were performed using SPSS for Windows version 15.0 (SPSS, Inc., Chicago, IL). As a total of 5 statistical tests were run (1 ANOVA, 1 Kruskal–Wallis, and 3 forward stepwise logistic regressions), we applied the Bonferroni correction with a final alpha of p≤.01 to prevent increasing the risks of making type 1 errors. 3. Results Please refer to Table 1 for the socio-demographic comparisons between those with and without suicidal ideation at the time of evaluation and Table 2 for comparisons of those with and without each clinical diagnosis for participants with suicidal ideation at the time of evaluation. No statistically significant differences between those with and without suicidal ideation at time of evaluation were noted for age, gender, ethnicity, marital status or education (Table 1). However, those with suicidal ideation showed a larger percentage with premilitary physical abuse, pre-military sexual abuse, prior suicide attempt(s), psychotic disorders, depressive disorders, and PTSD. Those with suicidal ideation were trending statistically towards higher percentages with panic disorders and endorsing current cocaine use than did those without active suicidal ideation (Table 2). We suggest restraint in interpreting the cocaine use result given its extremely wide confidence interval, and at best consider this finding preliminary. The DRRI scales were evaluated for associations with the presence of current suicidal ideation. Neither pre-deployment scale was associated with current suicidal ideation. Four deployment scales were statistically significant in their association with current suicidal ideation: Training/Preparation (a protective factor), Deployment Environment, Family/Life Concerns, and Deployment Concerns. Three deployment scales
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Table 1 Demographics and the percentages (categorical variables) or the mean (standard deviations, continuous variables) for the two groups: those with versus those without current suicidal ideation at the time of the initial evaluation. With suicidal ideation Variable Age Age Gender Male Female Ethnicity White African American Hispanic Other Marital status Married Separated Divorced Widowed Never married Education High school Some college College or more
No suicidal ideation
F or U statistic p-value
% or Mean (SD)
% or Mean (SD)
29.4 (8.4)
29.4 (7.5)
95 18
84.1% 15.9%
1424 179
88.8% 11.2%
49 41 19 4
43.4% 36.3% 16.8% 3.5%
811 415 294 77
50.8% 26.0% 18.4% 4.8%
53 12 11 1 36
46.9% 10.6% 9.7% 0.9% 31.9%
679 84 240 6 589
42.5% 5.3% 15.0% 0.4% 36.9%
39 66 7
34.8% 58.9% 6.3%
524 864 199
33.0% 54.4% 12.5%
were statistically trending towards significance (p-value less than 0.05, but not meeting Bonferroni corrected alpha of p ≤ 0.01): General Harassment, Post-Battle Aftermath exposures, and perceived Nuclear/Biological/Chemical Exposures. Both post-deployment scales, post-deployment support (a protective factor) and post-deployment life events, were statistically significant in their association with current suicidal ideation. Please refer to Table 3 for details. Finally, we performed the three logistic stepwise regressions (see Table 4). The first model was evaluating the general case with all variables as potential explanatory factors. The final stepwise model revealed 4 factors strongly associated (three with increased risk, one with lower risk) with the presence of current suicidal ideation: having a prior suicide attempt (OR 4.71, 95% CI: 1.87–12.16, p = 0.001), female gender (OR 3.18, 95% CI: 1.51–6.72, p = 0.002), the presence of a depressive disorder diagnosis (OR 3.79, 95% CI: 1.87–7.71, p b 0.001), and having sources of current social support (OR 0.94, 95% CI: 0.91–0.97, p b 0.001). The second logistic regression examined the comparison of depressive disorders and PTSD regarding suicidal ideation. When compared to a group diagnosed with neither depressive disorders nor PTSD, having depressive disorders alone (OR 15.20, 95% CI: 7.05–32.80, p b 0.001), PTSD alone (OR 10.02, 95% CI: 4.02–24.97, pb 0.001), or co-morbid depressive disorder and PTSD (OR 18.83, 95% CI: 8.85–40.10, pb 0.001), all were associated with the presence of current suicidal ideation. Finally, our third logistic regression examined the comparison of the presence of each PTSD symptom cluster for their relative association to current suicidal ideation. The avoidance cluster was the only one to meet statistical significance (OR 2.49, 95% CI: 1.43–4.35, p = 0.001). The re-experiencing cluster trended towards statistical significance (OR 2.05, 95% CI: 1.04–4.03, p = 0.037) but did not meet the Bonferroni correction alpha of ≤0.01.
4. Discussion Our review of risk and protective factors associated with suicidal ideation in returning OEF/OIF veterans takes advantage of having a fairly large database of returning veteran intake evaluations for analysis. These findings may help practitioners focus on some of the factors that may be increasing or decreasing the risk of suicidal thoughts and behaviors in the returning veteran population. Somewhat surprising given the substantial associations noted in the literature, other than replicating the well-known findings that prior suicide attempts (Bebbington et al., 2010) and being of female gender as both being associated with higher rates of suicidal ideation (Fairweather-Schmidt et al., 2010), no demographic data (including age, ethnicity, marital status, and level of education) evaluated had an association with current suicidal ideation. These findings are consistent with two recent studies in OEF/OIF veterans that found no significant differences across most of the same demographic factors for those with versus without suicidal ideation (Jakupcak et al., 2009; Pietrzak et al., 2010a). The clinical diagnoses of psychotic disorders, depressive disorders and PTSD were associated with suicidal ideation, as were having previous suicide attempts. Of these, depressive disorders carried the most elevated risk followed by PTSD. This was consistent with two recent studies in OEF/OIF veterans that showed elevated risk of suicidal ideation with diagnoses of either PTSD or major depressive disorder (Jakupcak et al., 2009; Pietrzak et al., 2010a). In our sample, having co-morbid depressive disorders and PTSD increased the risk of current suicidal ideation even more than having either diagnosis alone. This is in keeping with prior studies (Marshall et al., 2001; Oquendo et al., 2003), and Sher has coined the term "posttraumatic mood disorder" noting that a number of studies suggest these co-morbid diagnoses differ from either alone, including increasing the risk of suicidality (Sher, 2005, 2009).
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Table 2 The percentage of cases with suicidal ideation for two groups: those with and without each co-morbid condition. Variable
N with co-morbidity
% Suicidal with co-morbidity
N without co-morbidity
% suicidal without co-morbidity
Prior exposures MST Physical abuse Sexual abuse Prior suicide attempt
23 216 117 111
13.0% 10.6% 16.2% 32.2%
1691 1716 1599 1525
6.5% 6.0% 5.9% 5.8%
0.210 NS 0.010** b 0.001** b 0.001**
36.4% 20.0% 13.5% 12.9% 7.4% 12.1% 4.5% 8.0% 7.1% 7.6% 6.9% 18.8%
1705 1706 1026 1219 1338 1609 1628 1327 825 1184 1629 1685
6.4% 6.5% 1.9% 4.0% 6.4% 6.2% 6.7% 6.2% 6.1% 6.0% 6.6% 6.5%
b 0.001** 0.086 NS b 0.001** b 0.001** 0.466 NS 0.017* 0.428 NS 0.208 NS 0.382 NS 0.202 NS 0.900 NS 0.049*
Psychiatric co-morbid conditions Psychotic 11 Bipolar 10 Depressive 690 PTSD 497 Other anxiety 378 Panic 107 Adjustment 88 TBI 387 Using alcohol 886 Using tobacco 523 Using cannabis 72 Using cocaine 16
*: p-value ≤ 0.05, but not meeting Bonferroni correction alpha ≤0.01. **: p-value significant, meeting Bonferroni correction alpha ≤ 0.01. NS: non-significant. MST: Endorses Military Sexual Trauma. Physical abuse: refers to pre-military. Sexual abuse: refers to pre-military. Psychotic: refers to diagnoses of schizophrenia, schizoaffective disorder, or psychosis NOS. Bipolar: refers to diagnoses of bipolar I, bipolar II, and cyclothymia. Depressive: refers to diagnoses of major depressive disorder, dysthymia, and depression NOS. PTSD: refers to a clinical diagnosis of Post Traumatic Stress Disorder. Other Anxiety: refers to diagnoses of generalized anxiety disorder, obsessive-compulsive disorder, and anxiety NOS. Panic: refers to diagnoses of panic disorder with or without agoraphobia. Adjustment: refers to any adjustment disorder diagnosis. TBI: Traumatic Brain Injury screen was rated as positive, suggesting ongoing post-concussive syndrome/mild TBI. Using alcohol, tobacco, cannabis, and cocaine: refers to subject endorsing current use of these substances at the time of the initial screening evaluation.
It was unexpected that some other psychiatric diagnoses were not associated with current suicidal ideation. It is clear that bipolar disorders were not well represented here (only 11 veterans), much as psychotic diagnoses were not (n = 10). The restricted sample of these diagnoses may be limiting our ability to determine an impact on the dependent variable. Similarly, those veterans who endorsed current cocaine use only trended towards a positive association, but a limited sample (n = 16) again may be a factor limiting our ability to detect an association. As such, our findings may not generalize to suicidal ideations associated with acute substance intoxication. We found that meeting criteria for the PTSD avoidance symptom cluster was significantly associated with suicidal ideation at the time of interview, with the re-experiencing symptom cluster trending towards significance. Either of these clusters had a greater than two-fold increase in their association with the presence of current suicidal ideation. This supports recently published work (Guerra et al., 2010; Pietrzak et al., 2010b; Shea et al., 2010) showing that avoidance symptoms are associated with psychosocial difficulties. A potential explanation for the avoidance symptom cluster being significant in our data is that there is overlap between avoidance/numbing symptoms and depression. There is a growing body of evidence suggesting that PTSD and generalized anxiety disorder have more in common with major depression than other anxiety disorders (Gamez et al., 2007). This is an important consideration, as depressive disorders carried more of the risk for our
outcome variable of suicidal ideation than did PTSD in this sample. Also, our results differed some from the Bell and Nye study (2007), which showed that re-experiencing was the only PTSD symptom cluster significant for increasing the odds ratio of suicidal ideation in Vietnam veterans. Potential explanations for the differing results include different populations (veteran era versus OEF/OIF), a much larger sample size in our study, and our use of clinical interview data in this retrospective crosssectional study compared to Bell & Nye's use of standardized scales. The findings on the DRRI suggest that having more current social support is protective against current suicidal ideation. This supports a prior finding (Pietrzak et al., 2010a) in the literature. Our data show that while both post-deployment scales assessing recent social stressors and social support are individually associated with suicidal ideation, the presence of social support was the one factor retained in the logistic regression. This suggests that with sufficient support, most stressors may not be considered excessive or uncontrollable, allowing for improved coping mechanisms. This is in line with the findings of Pietrzak et al. (2010a), which provided a thorough detailing of how interventions meant to improve social support and resilience may be helpful in preventing suicidal ideation. From a broader perspective, our findings suggest that the risks of PTSD (particularly avoidance symptoms), depression, concerns about being less prepared for deployment, concerns
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Table 3 The mean and standard deviation of each completed Deployment Risk and Resiliency Inventory (DRRI) scale for cases with and without suicidal ideation. DRRI Scale
Mean (SD) with suicidal ideation
Mean (SD) without suicidal ideation
Pre-deployment A: Life events (stressors) B: Childhood experiences
69 71
3.6 (3.1) 52.3 (12.1)
1092 1104
2.9 (2.9) 53.8 (11.2)
Deployment C: Training/preparation D: Deployment environment E: Family/life concerns F: Unit support G1: General harassment G2: Sexual harassment H: Deployment concerns I: Combat exposure J: Post-battle aftermath K: NBC exposures
71 70 71 71 71 71 70 69 68 67
46.0 (10.5) 65.2 (12.6) 31.1 (8.6) 36.3 (12.0) 15.8 (6.1) 8.0 (2.4) 53.6 (12.2) 7.7 (4.6) 8.6 (5.0) 21.7 (8.8)
1106 1106 1104 1103 1102 1102 1099 1082 1085 1080
50.0 60.1 28.1 39.0 14.3 7.8 46.9 6.8 7.1 19.4
Post-deployment L: Social support M: Life events (stressors)
69 67
46.8 (10.4) 4.7 (2.8)
1082 1074
55.4 (10.3) 2.8 (2.6)
(10.9) (13.2) (8.5) (11.6) (5.9) (2.2) (12.6) (4.7) (5.2) (8.1)
p-value 0.058 NS 0.272 NS
0.002** 0.001** 0.004** 0.056 NS 0.033* 0.335 NS b 0.001** 0.116 NS 0.014* 0.027*
b 0.001** b 0.001**
*: p-value ≤ 0.05, but not meeting Bonferroni correction alpha ≤0.01. **: p-value significant, meeting Bonferroni correction alpha ≤ 0.01. NS: non-significant.
about the deployment environment, and concerns about their family and work back home may all be suggesting a related underlying concept. We can easily envision how a deployed soldier who perceives they are less prepared or equipped for their assignment, and who is having more concerns about what is going on back home with their job and family, may be more prone to having low mood, worries, and negative cognitions associated with a diagnosis of depression. When the avoidance symptoms of PTSD (isolation resulting from avoidance of persons/places/topics of conversation, emotional numbing, decreases in participation in prior pleasurable activities) are superimposed on this presentation, it is easy to see how the protective factor of a supportive network could be eroded. Our data is unable to speak to the point of actual causality, with the described exposures and cognitions causing the loss of the supportive network. However, this is a point that deserves further investigation so the relevant associated components can be better elucidated and possibly targeted for intervention. It is worth noting that each component risk or exposure we identified does have a currently available intervention(s) that may help mitigate the associated risks. We will not repeat the discussion well documenting options for social support that Pietrzak et al. (2010a) have already delineated. Similarly, interventions for depression are a staple of mental health treatment involving medications and/or variety of therapies either in individual or group format (Davidson, 2010), and even by use of complimentary or alternative medicines (Freeman et al., 2010). Even PTSD has evidence supporting some medications (Baestien, 2010) and therapies including prolonged exposure therapy (Powers et al., 2010) and cognitive processing therapy (Veterans Health Administration, 2004; Monson et al., 2006; Resick et al., 2007; Foa et al., 2008). It would seem the larger system problem for reduction of suicidal ideation may be: 1) how to best identify the person needing the interventions as that
individual may not actively seek out help themselves, 2) how to overcome barriers to treatment access, and 3) how to best coordinate and integrate these various treatments in a timely and efficacious manner. Although this study adds to the sparse literature on risk and protective factors for suicidal ideation in returning OEF/OIF veterans, there are several limitations. The retrospective data extraction was obtained via electronic chart review of clinical screening intake interviews of returning OEF/OIF veterans, and this cross-sectional group, while being a specific group of interest for this study, lends itself to some methodological problems. First, the results may not generalize to other populations, including the general population, veterans from other eras, OEF/OIF veterans at other sites, or even active military personnel still in combat. Also, the risk factor analysis does not necessarily address causal relationships, and the interpretations of the results are speculative. The use of a non-standardized interview format is another potential limitation; the evaluations were clinical interviews and not formalized research evaluations. While interviewers used a template, not all questions were asked of all individuals, and there may have been occasions where some answers may not have documented in the chart and thus were unavailable for extraction. Further, not all possible substances of abuse were asked about (only tobacco, alcohol, cocaine, and cannabis), and there was no way to objectively evaluate for use retrospectively. Finally, there are many potential problems with suicide reporting in general, including inconsistent definitions for the range of suicidal behaviors, including ideation and attempts (Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population). Having evaluated all OEF/OIF veterans who presented to the VA, many as part of their initial enrollment and application for VA services, we consider our study population strengthened this project in that the sample was not drawn from a group solely seeking medical or mental health care. Therefore,
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Table 4 The odds ratios, 95% confidence intervals for the odds ratios, and p-values, for variables associated with increased frequency of suicidal ideation at the time of clinical evaluation for 3 models: 1) general forwards stepwise logistic regression model; 2) comparison of effects of Depressive Disorders, PTSD, or co-morbid Depressive Disorders and PTSD compared to a group with neither Depressive Disorders or PTSD; and 3) assessment of affects for the three PTSD symptom clusters. Variable
General logistic regression Prior suicide attempt Female gender Bipolar disorders Depressive disorders DRRI-F: unit support DRRI-L: post-deployment social support scale Constant
4.71 3.18 9.57 3.79 1.04 0.95 0.10
1.87–12.16 1.51–6.72 0.75–122.22 1.87–7.71 1.01–1.07 0.92–0.98 –
0.001** 0.002** 0.082 NS b 0.001** 0.023* b 0.001** 0.010**
Depressive disorders/PTSD diagnoses logistic regression No depressive disorder or PTSD (reference group) Depressive disorders PTSD Co-morbid depressive disorders and PTSD Constant
– 15.20 10.02 18.83 0.01
– 7.05–32.80 4.02–24.97 8.85–40.10 –
– b 0.001** b 0.001** b 0.001** b 0.001**
Effects from the three PTSD symptom clusters logistic regression Re-experiencing (B-symptoms) cluster Avoidance (C-symptoms) cluster Hyper-arousal (D-symptoms) cluster Constant
2.05 2.49 1.10 0.03
1.04–4.03 1.43–4.35 0.55–2.20 –
0.037* 0.001** 0.791NS b 0.001**
*: p-value ≤ 0.05, but not meeting Bonferroni correction alpha ≤0.01. **: p-value significant, meeting Bonferroni correction alpha ≤ 0.01. OR: Odds Ratio. CI: 95% Confidence Interval for the Odds Ratio. Depressive disorders: refers to diagnoses of major depressive disorder, dysthymia, or depression NOS. PTSD: Post Traumatic Stress Disorder. DRRI: Deployment Risk and Resiliency Inventory. NS: non-significant.
we do consider our data to be a fair representation of the general returning veteran population, not that of a selective subset such as only mental health or primary care users. In conclusion, the three factors associated with increased suicidal ideation were a history of prior suicide attempts, female gender, and having a diagnosed depressive disorder; while the one factor associated with a decreased risk was the perception of having more current social support. Further investigation of these risk factors is warranted to aid in suicide risk assessment and in the development of targeted interventions to mitigate the identified risk factors and bolster the identified protective factor, especially as more OEF/OIF military personnel return from active duty. Role of funding source None of the funding sources had a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. Conflict of interest Neither author has any conflicts of interest.
Acknowledgements We would like to thank all the helpers and assistants whose hard work helped to perform the chart reviews and data extraction, and particularly all the veterans who, through their time and efforts to become familiar with VA services, underwent a Mental Health evaluation, without which this project could not have been done. This project was funded by a grant from the
Veterans' Affairs Administration's Substance Use Disorders Quality Enhancement Research initiative (SUD-QUERI) Program. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs. References Allen, J.P., Cross, G., Swanner, J., 2005. Suicide in the Army: a review of current information. Mil. Med. 170, 580–584. Baestien, D.L., 2010. Pharmacological treatment of combat-induced PTSD: a literature review. Br. J. Nurs. 19, 318–321. Bebbington, P.E., Minot, S., Cooper, C., Dennis, M., Meltzer, H., Jenkins, R., Brugha, T., 2010. Suicidal ideation, self-harm and attempted suicide: results from the British psychiatric morbidity survey 2000. Eur. Psychiatry Epub ahead of print. PMID: 20627465. Bell, J.B., Nye, E.C., 2007. Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder. Mil. Med. 172, 1144–1147. Centers for Disease Control and Prevention – National Suicide Statistics at a Glance. Twenty leading causes of death highlighting suicide among persons ages 10 years and older, United States, 2006. Last accessed June 4, 2010. http:// www.cdc.gov/violenceprevention/suicide/statistics/leading_causes.html. Davidson, J.R., 2010. Major depressive disorder treatment guidelines in America and Europe. J. Clin. Psychiatry 71 (Suppl E1), e04. Department of Veterans Affairs Office of Inspector General, 2007. Implementing VHA's mental health strategic plan initiatives for suicide preventionRetrieved August 3, 2009 from http://www.va.gov/oig/54/reports/VAOIG-0603706-126.pdf2007. Desai, R.A., Dausey, D.J., Rosenheck, R.A., 2005. Mental health service delivery and suicide risk: the role of individual patient and facility factors. Am. J. Psychiatry 162, 311–318. Desai, M.M., Rosenheck, R.A., Desai, R.A., 2008. Time trends and predictors of suicide among mental health outpatients in the Department of Veterans Affairs. J. Behav. Health Serv. Res. 35, 115–124.
C.M. Lemaire, D.P. Graham / Journal of Affective Disorders 130 (2011) 231–238
Fairweather-Schmidt, A.K., Anstey, K.J., Salim, A., Rodgers, B., 2010. Baseline factors predictive of serious suicidality at follow-up: findings focusing on age and gender from a community-based study. BMC Psychiatry 10, 41–50. Foa, E.B., Keane, T.M., Friedman, M.J., Cohen, J.A., 2008. Effective treatments in PTSD: Practice guidelines from the International Society for Traumatic Stress Studies, 2nd Ed. Guilford Press, New York. Freeman, T.W., Roca, V., Moore, W.M., 2000. A comparison of chronic combat-related posttraumatic stress disorder (PTSD) patients with and without a history of suicide attempt. J. Nerv. Ment. Dis. 188, 460–463. Freeman, M.P., Fava, M., Lake, J., Trivedi, M.H., Wisner, K.L., Mischoulon, D., 2010. Complimentary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J. Clin. Psychiatry 71, 669–681. Gamez, W., Watson, D., Doebbeling, B.N., 2007. Abnormal personality and the mood and anxiety disorders: implications for structural models of anxiety and depression. J. Anxiety Disord. 21, 526–539. Guerra, V.S., Mid-Atlantic Mental Illness Research, Education and Clinical Center Workgroup, Calhoun, P.S., 2010. Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. J. Anxiety Disord. July 7., Epub ahead of print. PMID: 20709493. Helmkamp, J.C., Kennedy, R.D., 1996. Causes of death among U.S. military personnel: a 14-year summary, 1980–1993. Mil. Med. 161, 311–317. Hendin, H., Haas, A.P., 1991. Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. Am. J. Psychiatry 148, 586–591. Hosmer, D.W., Lemeshow, S., 2000. Applied logistic regression, 2nd ed. John Wiley & Sons, Inc., New York. Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., McFall, M., 2009. Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans. J. Trauma. Stress 22, 303–306. Kang, H.K., Bullman, T.A., 2008. Risk of suicide among US veterans after returning from the Iraq or Afghanistan war zones. JAMA 300, 653. Kaplan, M.S., Huguet, N., McFarland, B.H., Newsom, J.T., 2007. Suicide among male veterans: a prospective population-based study. J. Epidemiol. Community Health 61, 619–624. King, D.W., King, L.A., Vogt, D.S., 2003. Manual for the Deployment Risk and Resilience Inventory (DRRI): A Collection of Measures for Studying Deployment-Related Experiences of Military Veterans. National Center for PTSD, Boston, MA. King, L.A., King, D.W., Vogt, D.S., Knight, J., Samper, R.E., 2006. Deployment Risk and Resilience Inventory: a collection of measures for studying deploymentrelated experiences of military veterans. Mil. Psychol. 18, 89–120. Kramer, T.L., Lindy, J.D., Green, B.L., Grace, M.C., Leonard, A.C., 1994. The comorbidity of post-traumatic stress disorder and suicidality in Vietnam veterans. Suicide Life-Threat. Behav. 24, 58–67. Kuehn, B.M., 2009. Soldier suicide rates continue to rise – military, scientists work to stem the tide. JAMA 301, 1111–1113. Marshall, R.D., Olfson, M., Hellman, F., Blanco, C., Guardino, M., Struening, E.L., 2001. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am. J. Psychiatry 158, 1467–1473. Miller, M., Barber, C., Azrael, D., Calle, E.E., Lawler, E., Mukamal, K.J., 2009. Suicide among US veterans: a prospective study of 500,000 middle-aged and elderly men. Am. J. Epidemiol. 170, 494–500.
Monson, C.M., Schnurr, P.P., Resick, P.A., Friedman, M.J., Young-Xu, Y., Stevens, S.P., 2006. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J. Consult. Clin. Psychol. 74, 898–907. Oquendo, M.A., Friend, J.M., Halberstam, B., Brodsky, B.S., Burke, A.K., Grunebaum, M.F., Malone, K.M., Mann, J.J., 2003. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. Am. J. Psychiatry 160, 580–582. Pfeiffer, P.N., Ganoczy, D., Ilgen, M., Zivin, K., Valenstein, M., 2009. Comorbid anxiety as a suicide risk factor among depressed veterans. Depress. Anxiety 26, 752–757. Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C., Southwick, S.M., 2010a. Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J. Affect. Disord. 123, 102–107. Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Southwick, S.M., 2010b. Structure of posttraumatic stress disorder symptoms and psychosocial functioning in Veterans of Operations Enduring Freedom and Iraqi Freedom. Psychiatry Res. 178, 323–329. Powers, M.B., Halpern, J.M., Ferenschak, M.P., Gillihan, S.J., Foa, E.B., 2010. A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clin. Psychol. Rev. 30, 635–641. Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population. Washington, DC: US Department of Veterans Affairs. Last accessed June 4, 2010. http://www.mentalhealth.va.gov/suicide_prevention/Blue_Ribbon_Report-FINAL_June-30-08.pdf. Resick, P.A., Monson, C.M., Chard, K.M., 2007. Cognitive processing therapy treatment manual: veteran/military version. Veterans Administration, Boston. Ritchie, E.C., Keppler, W.C., Rothberg, J.M., 2003. Suicidal admissions in the United States military. Mil. Med. 168, 177–181. Shea, M.T., Vujanovic, A.A., Mansfield, A.K., Sevin, E., Liu, F., 2010. Posttraumatic stress disorder symptoms and functional impairment among OEF and OIF National Guard and Reserve veterans. J. Trauma. Stress 23, 100–107. Sher, L., 2005. The concept of post-traumatic mood disorder. Med. Hypotheses 65, 205–210. Sher, L., 2009. Suicide in war veterans: the role of comorbidity of PTSD and depression. Expert Rev. Neurother. 9, 921–923. Thompson, R., Kane, V.R., Sayers, S.L., Brown, G.K., Coyne, J.C., Katz, I.R., 2002. An assessment of suicide in an urban VA Medical Center. Psychiatry 65, 327–337. Veterans Health Administration, Department of Defense, 2004. VA/DoD clinical practice guideline for the management of post-traumatic stress (version 1.0). Veterans Health Administration, Department of Defense, Washington, DC. Vogt, D.S., Proctor, S.P., King, D.W., King, L.A., Vasterling, J.J., 2008. Validation of scales from the Deployment Risk and Resilience Inventory in a sample of Operation Iraqi Freedom veterans. Assessment 15, 391–403 PMID: 18436857. Waller, S.J., Lyons, J.S., Costantini-Ferrando, M.F., 1999. Impact of comorbid affective and alcohol use disorders on suicidal ideation and attempts. J. Clin. Psychol. 55, 585–595. Zivin, K., Kim, H.M., McCarthy, J.F., Austin, K.L., Hoggatt, K.J., Walters, H., Valenstein, M., 2007. Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. Am. J. Public Health 97, 2193–2198.
Report "Factors associated with suicidal ideation in OEF ... - Semantic Scholar"
Your name
-Select Reason-
Other Terms Of Service Violation
File a copyright complaint
Sign In
Remember me
Forgot password?
Sign In
Our partners will collect data and use cookies for ad personalization and measurement.
Learn how we and our ad partner Google, collect and use data
Agree & close


text:
Celebrity fragrances boost Parlux results
The Florida-based company has reported a preliminary increase in sales of 43 percent for the quarter ending September 30, in comparison to the same quarter last year.
Resolved inventory problems
However, this figure was enhanced by delayed shipments resulting from inventory problems the company experienced in the first quarter of this fiscal year. Sales growth for the six month period came in at just over 10 per cent.
"We experienced a problem in the first quarter of this year, in that we ran short on a number of products and were unable to ship international sales," Parlux CFO Raymond J Balsys told CosmeticsDesign.com.
Therefore shipments that should have gone out in the first quarter were distributed during the second, he explained.
Celebrity fragrances, including the new perfumes from Jessica Simpson and Paris Hilton, contributed considerably to the quarter's results.
Jessica Simpson's Fancy, which was launched in August 2008, accrued an estimated $6.5m in sales, and Fairy Dust from Paris Hilton, which the company is pushing for the upcoming holiday season, has recorded an estimated $1.5m.
Department stores looking good
The company also reported significant increases in department store sales in a period when many analysts are predicting lower performances from this retail sector.
Domestic department store sales for the quarter are estimated to have increased 190 per cent on the same period last year. The increase for the six months ending September 30 comes in at 82 per cent.
Balsys explained that this increase could be attributed to the restructuring of the company's sales department.
"Over the course of the last year our new vice president for domestic sales has been realigning personnel and has added a new layer to the team dealing with department store sales. We now have people who work in department stores to facilitate sales of the products to customers. As a result our brands are doing well," he said.
Even in light of the current economic climate, Parlux remains quietly confident about the coming months.
"We continue to see consumer demand for our brands increase, even in the light of the very difficult economic environment. Despite the difficulty in predicting the outcome of the upcoming holiday season, we remain cautiously optimistic," said CEO Neil J. Katz in a statement.

subset: commoncrawl


text:
Country Blues > Weenie Campbell Main Forum
Mack McCormack Folkways Box Set coming in August
Check it out.
Thanks for posting that, btasoundsradio! All of those unfamiliar names in the track list are pretty tantalizing, as are the familiar ones, of course.
Too cool bta, thanks for posting! Just amazing that we are still getting new releases of these old, new to us and forgotten musicians.
I've just recently been recalling the Folkways double albums that taught me about Sonny & Brownie, Lightnin' Hopkins, Leadbelly and others. While two-fers ain't what they used to be, this looks like a reason to hook up the turntable.
Agree completely Jed. I recently hooked up my turntable (bought long ago, so essentially new) to have a 'vinyl party' amongst my old fogey friends (a blast, all agreed worth repeating). So I'm definitely in for the LPs.
[0] Message Index
[#] Next page
Go to full version


text:
Apolipoproteins are involved in normal cholestrol trafficking, but we now know that they can have much broader impacts on our health when misregulated. From cancer to cardiovascular disease and Alzheimer's disease, apolipoproteins can serve as powerful biomarkers. Discover more about these fascinating proteins and see how they may be connected to your research.
What are Apolipoproteins?
Apolipoproteins are amphipathic molecules that, along with other proteins, surround oil-soluble fats and cholesterols to form lipoproteins that transport lipids through the circulatory and lymphatic systems. Apolipoproteins can also serve as enzyme cofactors, receptor ligands, and lipid transfer carriers that regulate the metabolism of lipoproteins and their uptake in tissues. Apolipoproteins are biomarkers for various conditions, including cardiovascular diseases, diabetes, Alzheimer's disease, cancer, and sepsis.
Apolipoproteins and Disease
Apolipoproteins are commonly known for their amphipathic properties and consequent role in lipid protein formation. But they also serve many other functions in the human body.
Hover over the image below to find interesting publications that outline the connection between apolipoproteins and disease.
Apolipoprotein E plays a role in various conditions such as Alzheimer's disease and traumatic brain injury.
Selected Publications
- Zhou S and Sun XC (2012). Influence of apolipoprotein E and its receptors on cerebral amyloid precursor protein metabolism following traumatic brain injury. Chin J Traumatol 15, 183–187.
- Kim J et al. (2009). The Role of Apolipoprotein E in Alzheimer's Disease. Neuron 63, 287–303.
- Miners JS et al. (2017). Clusterin levels are increased in Alzheimer's disease and influence the regional distribution of Aβ. Brain Pathol 27, 305–313.
From disease risk factors to protective functions, apolipoproteins are intimately involved in cardiovascular disorders.
Selected Publications
- Sniderman AD et al. (2016). Age and cardiovascular risk attributable to apolipoprotein B, low‑density lipoprotein cholesterol or non‑high‑density lipoprotein cholesterol. J Am Heart Assoc 5, e003665.
- Valleix S et al. (2016). D25V apolipoprotein C-III variant causes dominant hereditary systemic amyloidosis and confers cardiovascular protective lipoprotein profile. Nat Commun 7, 10353.
Apolipoproteins A1 and E are involved in many lung and respiratory conditions, including pulmonary fibrosis and apnea.
Selected Publications
- Dai C et al. (2012). Apolipoprotein A-I attenuates ovalbumin-induced neutrophilic airway inflammation via a granulocyte colony-stimulating factor-dependent mechanism. Am J Respir Cell Mol Biol 47, 186–195.
- Kim TH et al. (2010). Role of lung apolipoprotein A-I in idiopathic pulmonary fibrosis: antiinflammatory and antifibrotic effect on experimental lung injury and fibrosis. Am J Respir Crit Care Med 182, 633–642.
- Tisko R et al. (2014). Effects of apolipoprotein E genotype on serum lipids in obstructive sleep apnoea. Eur Respir J 43, 1097–1105.
Apolipoproteins are associated with non-alcoholic fatty liver disease and cell death.
Selected Publications
- Yang MH et al. (2010). The associations between apolipoprotein B, A1, and the B/A1 ratio and nonalcoholic fatty liver disease in both normal-weight and overweight Korean population. J Clin Lipidol 10, 289–298.
- Paiva AA et al. (2017). Apolipoprotein CIII overexpression-induced hypertriglyceridemia increases nonalcoholic fatty liver disease in association with inflammation and cell death. Oxid Med Cell Longev 2017, 1838679.
Apolipoproteins are associated with metabolic syndrome inflammation such as Crohn's disease and irritable bowel syndrome (IBS).
Selected Publications
- Michalak A et al. (2016). Common links between metabolic syndrome and inflammatory bowel disease: current overview and future perspectives. Pharmacol Rep 68, 837–846.
- Vaiopoulou A et al. (2015). Serum protein profiling of adults and children with Crohn disease. J Pediatr Gastroenterol Nutr 60, 42–47.
Apolipoproteins play multiple roles in cancer. Apo A1 has been shown to have a protective role in tumor progression while elevated levels of Apo E have been associated with tumor metastasis.
Selected Publications
- Zamanian-Daryoush M and DiDonato JA (2015). Apolipoprotein A-I and cancer. Front Pharmacol 6, 265.
- Luo J et al. (2016). Elevated serum apolipoprotein E is associated with metastasis and poor prognosis of non-small cell lung cancer. Tumour Biol 37, 10,715–10,721.
Changes in high-density lipoproteins (HDLs) and apolipoprotein concentrations may indicate serious systemic conditions like sepsis.
Selected Publications
- Cao Z et al. (2014). Proteomics reveals age-related differences in the host immune response to sepsis. J Proteome Res 13, 422–432.
- Sharifov OF et al. (2013). Anti-inflammatory mechanisms of apolipoprotein A-I mimetic peptide in acute respiratory distress syndrome secondary to sepsis. PLoS One 8, e64486.
- Morin EE et al. (2015). HDL in sepsis — risk factor and therapeutic approach. Front Pharmacol 6, 244.
Apolipoproteins and C‑reactive protein play key roles in the development and progression of type II diabetes.
Selected Publications
- Mao Y et al. (2017). The nonlinear association between apolipoprotein B to apolipoprotein A1 ratio and type 2 diabetes. Medicine (Baltimore) 96, e5834.
- Aroner SA et al. (2017). Apolipoprotein C‑III and high-density lipoprotein subspecies defined by apolipoprotein C‑III in relation to diabetes risk. Am J Epidemiol [published online ahead of print May 18, 2017]. Accessed September 7, 2017.
- Borja MS et al. (2017). Apolipoprotein A‑I exchange is impaired in metabolic syndrome patients asymptomatic for diabetes and cardiovascular disease. PLoS One 12, e0182217.
Maternal and Infant Health
Apolipoprotein activity is especially important during pregnancy. Dysregulation of lipid metabolism can have serious effects on maternal and infant health.
Selected Publications
- Ba HJ et al. (2017). Dyslipidemia in pregnancy may contribute to increased risk of congenital heart defects. Int J Clin Exp Med 10, 3526–3532.
- Spracklen CN et al. (2014). Maternal hyperlipidemia and the risk of preeclampsia: a meta-analysis. Am J Epidemiol 180, 346–358.
Introducing the Bio-Plex Pro™ Apolipoprotein Panel
Key Advantages
- Focused panel — obtain biologically relevant results from a single assay
- Robust performance — gain confidence in your results with sensitive, accurate, and reproducible assays
- Rapid assay protocol — save time and effort with short turnaround times
- Easy to use — simplify your workflow with clear and easy assay protocols
- Streamlined data analysis — analyze and manage your data efficiently with Bio-Plex Data Pro™ Software
- Flexible instrumentation options — use with any Luminex platform:
- – Bio-Plex® 200 (LX200)
- – Bio-Plex 3D (FLEXMAP 3D)
- – Bio-Plex® MAGPIX™ (MAGPIX)
- – Bio-Plex Pro Wash Station
Pricing and Ordering Information
Why Multiplex?
Immunoassays allow sensitive and highly specific detection of analytes in a wide range of biological samples while traditional assays are limited in throughput. Bio-Plex® Mulitplex Immunoassay Systems let you detect and quantify up to 100 different biomarkers in a single well and thus provide a more complete picture of human health.


text:
Welcome to the ultimate guide to online slots 918kiss in Thailand! In this extensive write-up, we will discover whatever you need to recognize about slot online Thailand, including its popularity, guidelines, finest methods, and also regularly asked inquiries.
Port Online Thailand: What Makes It Popular?
Online slots have gained tremendous popularity in Thailand for many years. The convenience of playing from anywhere at any moment, paired with the excitement of winning real money, has brought in a lot of gamers to the virtual fruit machine. Port online Thailand provides a variety of games, motifs, and includes that cater to every gamer's choices.
On-line gambling establishments in Thailand give a fair and secure gaming atmosphere. Accredited and controlled drivers ensure that gamers can appreciate their favorite ports with comfort, understanding that their monetary as well as individual info is secured. The innovation of modern technology has also added to the appeal of on-line ports, with magnificent graphics, immersive sound effects, and also ingenious gameplay functions that enhance the general video gaming experience.
The Legality of Online Slot Machine in Thailand
As an accountable gamer, it's important to understand the lawful landscape bordering on the internet ports in Thailand. The present laws in Thailand restrict land-based gambling activities; nevertheless, there is no certain regulations resolving on the internet gaming. This legal gray area has enabled offshore on the internet gambling establishments to cater as well as operate to Thai players.
It is very important to keep in mind that while playing on global systems is not explicitly illegal, it is necessary to select qualified as well as reliable online casinos. These gambling establishments operate under the territories of governing bodies that ensure fair play, player protection, and also responsible gaming practices. When engaging in online port games, prioritizing your safety and security should be critical.
Picking the Right Online Casino
With various online gambling enterprises offered to Thai players, picking the right one can be an overwhelming job. Right here are some essential factors to think about when selecting an on-line gambling enterprise for your slot gaming experience:
Licensing and Guideline: Guarantee that the on-line casino is qualified and controlled by a reliable authority, such as the Malta Video Gaming Authority or the UK Gaming Commission.
Video Game Choice: Search for a casino site that offers a variety of port video games from prominent software program service providers. Variety makes sure that you never ever lack exciting options to check out.
Perks and also Promos: Look for appealing welcome perks, cost-free rotates, as well as recurring promotions that enhance your pc gaming experience as well as enhance your opportunities of winning.
Settlement Options: Guarantee that the gambling establishment supports convenient and also safe payment techniques, consisting of preferred e-wallets, bank card, and financial institution transfers.
Client Assistance: A reliable and also receptive client assistance team is vital for dealing with any type of inquiries or problems that might occur during your pc gaming trip.
By taking into consideration these factors, you can make an educated decision and also select an on the internet gambling enterprise that lines up with your choices and also gives a enjoyable as well as safe gaming atmosphere.
FAQs (Frequently Asked Questions).
1. What is slot online Thailand?
Port online Thailand refers to the on the internet version of conventional fruit machine, which can be accessed through internet-enabled gadgets such as computer systems, tablets, and also smart devices. These online ports provide the exact same gameplay technicians and possibilities of winning actual cash as their land-based counterparts.
2. Is it lawful to play slot online Thailand?
While land-based gambling is banned in Thailand, playing on overseas online gambling establishments is not explicitly unlawful. It is essential to select accredited as well as credible online gambling establishments that make sure player protection and also reasonable gaming techniques.
3. Are online slots in Thailand fair?
Accredited on-line gambling enterprises in Thailand run under the guidance of governing bodies that impose strict criteria of justness as well as gamer protection. Trustworthy gambling enterprises use random number generators (RNGs) to make sure that the outcomes of the games are objective and entirely random.
4. Can I play port online Thailand completely free?
Yes, lots of on-line gambling establishments supply free play options for port games. These complimentary ports allow players to discover the game mechanics, functions, as well as themes without running the risk of real money. It's a terrific method to familiarize on your own with various slots prior to determining to have fun with real cash.
5. What are modern jackpot slots?
Modern jackpot ports are a type of slot game where the reward increases with each bet placed by players. These pots can get to incredible quantities, typically in the millions, as well as give players with the chance to win life-altering sums of cash.
6. Exactly how do I boost my opportunities of winning at port online Thailand?
While winning in on-line ports is ultimately based upon good luck, there are a couple of tips that can help enhance your pc gaming experience:.
Select the best slot video game: Select ports with high return-to-player (RTP) percentages and desirable volatility levels.
Handle your bankroll: Set a budget and also stick to it. Avoid chasing losses as well as recognize when to quit playing.
Utilize promotions and bonuses: Benefit from the incentives and promos used by on the internet gambling establishments to maximize your winning potential.
Practice liable betting: Establish restrictions on your having fun time and wagering quantities. Bear in mind that gaming ought to be taken pleasure in as a type of entertainment, and also never ever exceed what you can manage to lose.
Finally, port online Thailand uses a hassle-free and exciting way to enjoy the adventure of slot pc gaming from the convenience of your very own home. With a wide array of video games, safe platforms, and also the possible to win genuine money, it's no surprise that on the internet ports have come to be exceptionally popular in Thailand. By selecting credible online casino sites, understanding the lawful landscape, as well as carrying out responsible gambling techniques, you can embark on a satisfying port video gaming journey. What are you waiting for? Dive into the world of slot online Thailand and also allow the reels spin in your support!
In this thorough write-up, we will check out whatever you require to recognize concerning slot online Thailand, including its popularity, laws, finest techniques, as well as regularly asked inquiries. Port online Thailand uses a vast variety of video games, motifs, as well as includes that cater to every gamer's preferences.
As an accountable gamer, it's critical to comprehend the lawful landscape bordering online ports in Thailand. In final thought, port online Thailand provides a interesting and hassle-free way to delight in the excitement of slot pc gaming from the convenience of your own home. With a vast variety of games, secure systems, and the potential to win actual cash, it's no wonder that online slots have ended up being profoundly prominent in Thailand.


text:
There's something magical about flipping through interior design magazines, dreaming of that perfect wide skirting board to accentuate your living room. But what truly turns this dream into reality is the ease of getting it delivered right to your doorstep. That's where Skirting World steps in with its nationwide delivery service, ensuring your design aspirations are only a click away.
Now, let's say you're nestled in the cozy corners of Cornwall, or perhaps you're basking in the bustling vibes of Birmingham. Regardless of your UK location, Skirting World has got your back. Picture this: you've just found the perfect skirting board design online, maybe a chic modern design or a classic Victorian flair. You're thrilled! But then there's that niggling question – "How do I get this beauty home?"
Enter Skirting World's stellar delivery network. Their dedicated team ensures that each skirting board, be it narrow, wide, or anywhere in between, is packed with utmost care. No one likes dents, scratches, or any form of imperfection, right? So, from the moment it leaves the workshop, your chosen skirting board is treated like royalty.
But wait, there's more to this delivery saga. You see, it's not just about getting it to your home; it's about getting it there on time. Nobody likes to play the waiting game, especially when you're buzzing with decorating enthusiasm. Skirting World's track record? Well, let's just say they've got a knack for punctuality.
Plus, for the environmentally conscious (which, let's face it, should be all of us), there's an added layer of cheer. Skirting World is continually refining its delivery processes to reduce its carbon footprint. So, while your home gets a facelift, the planet gets a little breather too.
Then there's the cherry on top: the friendly delivery folks. A smile, a cheerful greeting, and sometimes even a helpful tip or two about installation – it's these small gestures that make the whole experience memorable.


text: Tiger shark tagging Bahamas (IMAGE) Trinity College Dublin Caption Lucy Harding and Dr Nick Payne work with their collaborators from Beneath the Waves to tag a 3 m tiger shark in the Bahamas in May 2019. Photo credit: Diego Camejo. Credit Diego Camejo. Usage Restrictions None License Original content Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.


text:
My horse was in a wedding today! Her previous owner owned her for 10 years and said it was always her dream to have Heather in her wedding! Everything was perfect ! They were beautiful together. The wind was really blowing so the poor girl couldn't keep her veil under control and her train kept blowing around...luckily Heather is a as steady as they come. Such a good girl!
Last edited:


text:
Purchasing your first training bra was a significant milestone, and it was most certainly seen as a vital and thrilling rite of passage as a tween. However, bras lose their novelty with time, and for many women, the desire to purchase lacy breast-hiking lingerie will ultimately fade. Some may even object to wearing these constrictive undergarments as all.
Dropping your bra may be a game-changer whether you want to make a feminist statement, wear a seductive halter top without your straps showing, or work from home more comfortable. To begin with, if you quit wearing a bra, your garments will begin to fit your body differently. This is a plus for many, but a disadvantage for others. Beyond the aesthetics, however, choosing not to wear a bra can have both small and severe physical and emotional consequences. There are plenty of advantages and disadvantages, so consider it carefully and get the facts before you burn your bras.
13/ If you quit wearing a bra every day, your breasts will not sag anymore.
If you don't wear a bra, will gravity take its course? You can keep your thoughts under control if you have fantasies of your breasts dropping to the floor. Contrary to popular belief, removing the boob-enhancing undergarment may actually make your breasts look perkier. In a research published by Medical News Today, sports science specialist Jean-Denis Rouillon examined changes in the breasts of hundreds of women over a 15-year period and discovered that those who did not wear bras had higher nipples and better placement than those who did. It is worth noting that the women who participated in this study ranged in age from 18 to 35 years at the start of the study.
Rouillon also recognized that a braless lifestyle may not be suitable for many women. According to Reuters, middle-aged women who are overweight and have 2.4 children would most likely benefit from not wearing bras.
Furthermore, according to Dr. Dan Mills, breasts break down as you age. A bra will always give you the shape and look you want by keeping your breast up, however it will not prevent future sagging, says one expert.


text:
UAFS Alumni Prepare for Inaugural Game
Some of the greatest Lions to ever dig, set, or spike a volleyball, along with many
fan favorites, will once again return to Stubblefield Center at the University of
Arkansas – Fort Smith on Saturday, Aug. 19, 2023, at 2 p.m.
So, what's the occasion? The inaugural UAFS Volleyball Alumni Game will kick off the start of the semester and act as a fun tune-up for the current
team before the season begins on Friday, Sept. 1, in the Newberry Invitational.
The free event will feature former players like Deb Rogers, 2018 Heartland Conference Offensive Player of the Year, Anna Demmer, 2017 Heartland Conference Player of the Year, and Payton Northington (Hamilton), an assistant volleyball coach at Southside High School. Fans of UAFS
Volleyball are in for a treat to see former players back in action, even if it means
"a lot of missed hits, pretty slow reactions, and diving for a ball but staying there
for a while because it hurts too bad to get up," Northington joked. Head coach Jane Sargent echoed Northington by ensuring "ice baths will be at the ready."
For the last 25 years, Sargent has witnessed hundreds of players play for UAFS, and
she will soon get to coach them again. When asked if any one player who will be participating
in the alumni game stands out, Sargent said both past and present players are her
babies, and it would be difficult to pick just one.
"Every kid that's played for our program has left their own unique brand on it. From
the local players to our Internationals, to all the out-of-state players…they are
UAFS Volleyball, and I'm excited about seeing everyone," Sargent explained.
But Sargent isn't the only one brimming with excitement when it comes to seeing familiar faces. In her first competitive game back on an indoor court, Demmer is looking forward to seeing UAFS Volleyball fans. She hopes the game will be a chance for new and returning fans to see the successes of the program and continue to support the team. Demmer also expressed her excitement to connect with the players, past and present, that make up UAFS Volleyball.
"What's really cool about the alumni that come out of UAFS, especially for volleyball is that we all stay pretty connected. I've been able to build some relationships with some of the current players, and all we want to do as alumni, is see this program continue to win, continue to succeed, and continue to grow," Demmer said.
The alumni game will be Rogers and Northington's first game at UAFS since their respective
graduations – an experience Rogers has had on her mind since her playing days between
2015 and 2018.
"I remember being like, 'Oh my gosh, I want to be that alumni who comes back and still
is really good,' and I'm glad I have the opportunity," Rogers said as she recounted
what she first thought when asked to play. Always the competitor, she laughed, saying
how some of the former players have already been working together, and the alumni
are going to "kick their butt."
As for Northington, her competitive spirit will shine on the court, but the alumni
game is more about connecting with old friends, teammates, and coaches. She shared
that she is looking forward to "reminiscing on all of the great times" and hopes that
"the alumni game boosts team spirit by allowing the current girls to see the importance
of the program and how it has had a positive impact on so many former players."
If it weren't for needing her arms and legs to run practice, Sargent said she'd be
playing with all her players on the court. Instead, fans will see her on the sidelines
doing what she does best: coaching hard and pushing every current and former player
because she knows what they can do.
While the alumni volleyball game will be a fun experience for fans and players alike,
what stands out most is the excitement shared amongst players to come back to the
program and university they called home.
"This program molded me into the person I am today," Northington shared. Rogers shared
a similar feeling, capping it off by saying, "Once you are a UAFS Lion, you are for
- Tags:
- Volleyball
- Alumni
- Athletics


text:
Pupil Technology Center
Students are given a variety of arms-on experiences to prepare them for computer associated careers.
Students are given a variety of arms-on experiences to prepare them for computer associated careers. There are alternatives for employment in a wide range of settings together with software assist, computer restore, information management, networking and schooling. The Department of Computer and Information Systems Technology is dedicated to fulfill the needs of the students who are enrolled in our applications. We provide quality switch programs Computer, basic training courses, conditions inside vocational applications, and vocational programs. In addition, college students might be made aware of the usage of functions of computer systems within the residence, schooling, and business. An introduction to software software and its uses in, however not limited to, word processing, spreadsheets, database and multimedia, must be included.
Table of Contents
Now for AI's Latest Trick: Writing Computer Code – WIRED
Now for AI's Latest Trick: Writing Computer Code.
Posted: Fri, 23 Apr 2021 07:00:00 GMT [source]
The Certificate II for Computer Technology is designed for students who have coursework in the computer subject and/or work experience within the computer networking trade. Both the certificates I and certificates II computer technology pgorams are designed for college kids who have had previous coursework or work expereince with PC computer technology.
What Computer Technology Degree Options Exist?
For eligibility necessities for military discounts on the doctoral stage, please review the online benefits web page. Add all aid (scholarships, grants, and so on.) you propose to obtain all through your degree for an estimated complete cost. Opened software program, audio books, DVDs, CDs, music, and small electronics will not be returned. All prospects who buy software Technology by way of the IT Marketplace can obtain installation help by Liberty University'sIT HelpDeskfor free. You can call, stop in, or visit the HelpDesk website free of charge IT help. Dell machines bought online or in-retailer are eligible for Dell's prolonged manufacturer's guarantee and accidental coverage. Our professionals understand how multiple technologies and patents hinge on each other.
- Whether you are new to tech or a seasoned veteran, Per Scholas will allow you to remain aggressive within right now's most dynamic business.
- Platforms which harnessed the power of the Cloud (e.g. cell), interconnecting customers via their handheld units, blurred the road between the digital and the true world.
- When designing a network, computer network architects should research new technology and decide what works best with the corporate's targets, in addition to contemplate info security.
In the tech trade, a degree is only a piece of paper when you can't do the job. Earn a grade of "C" or higher in all direct and indirect stipulations courses listed in the catalog before advancing to the following stage course in a sequence for English, Mathematics, and Science course. Earn an overall Computer & Technology grade point common of 2.0 or better in programs taken outdoors of the division. Our Assured Print Pricing program provides predictable monthly pricing and capped year-over-yr worth will increase.
Cooperative Training
All newbie computer technology courses require a basic working information of computers, including navigating in a windows setting and using a mouse. AAS levels are generally non-switch levels which are designed for college students to enter the workforce. While many sectors of the American job market have been stagnant for years, computer and technology careers are nonetheless on the way in which up, at all ranges, from entry-level programmer to administration. According to the Bureau of Labor Statistics, the sphere is rising at 12% overall, with some specializations, like Information Security, growing even quicker. This program offers fundamentals to allow college students to apply as engineering design and CADD drafting specialists. We strive to keep up with the latest technical developments so that our graduates are prepared with fashionable skill sets most sought out by business.
Students at any Maricopa Community College may have to complete courses at a couple of of our faculties. Shop round for the most effective deals utilizing the specifications given above. NWACC recommends that college students use a Windows desktop or laptop computer computer. Chromebooks usually are not really helpful as a result of they aren't appropriate with software required for some courses. At about half the price of a 4 yr university you will full your whole basic schooling necessities for the bachelor's and may take electives geared toward a selected major.
University News
In some circumstances, this course may be used to fulfill one other General Education Requirement. Minimum grade of "C" required in all Major core and subplan programs. If you have already began the program, click on right here for the archived Academic Pathways. If you're starting this system this term, click here to entry the really helpful Academic Pathway. Highly informative sources to keep your schooling journey on track.
How is computer useful for students?
Classes by purposeMicrocomputers (personal computers)
Minicomputers (mid-range computers)
Mainframe computers.
Information appliances.
Embedded computers.
More items
The Biomedical Electronics Technology specialty focuses on the usage of technical and theoretical features of biomedical instrumentation and tools presently utilized in the medical field. A not-for-revenue group, IEEE is the world's largest technical professional organization devoted to advancing technology for the good thing about humanity. Explain how software is developed and write a primary program script. Explain how computer systems use binary number techniques to symbolize numbers, textual content, and graphic images. In this week's class, we'll discuss the roles performed by system software and software software, and take a close take a look at the software program that's important to design professionals. In the assignment, you will develop two person personas for your computerized gadget and chart a primary algorithm for a perform it performs. View all Computer and Information Technology applications offered at Maricopa Community Colleges.


text:
When I was a kid, my Mom brought me to a farm supply store to buy bulk bird seed. They had these big open barrels full of different animal feeds, dried corn, sunflower seeds, millet, you name it. In typical child fashion, I had to touch the bird seed, and by the time my mom turned around, I was elbow deep in the chicken feed!
Looking back, I know that my sensory-seeking behavior had a purpose. The ability to recognize and tolerate different tactile sensations in childhood helps in several aspects of development. Every food you eat or piece of clothing you wear gives your tactile system information. For most of us, this is completely subconscious until something is wrong, food having an unexpected texture or clothing fitting poorly, but this comes with experience. Letting your child encounter various tactile sensations will help them build a library. The goal is for a child to differentiate between sticky, tacky, slimy, wet, gummy, dusty, chalky, scratchy, etc. Eventually, they will be able to associate those sensations with the things that invoke them.
When someone with a well-stocked library walks barefoot, they can recognize what stepping on different things feels like. They realize what's safe and unsafe. Stepping on a single smooth pebble can be uncomfortable, but it's safe. Stepping on a sharp pebble might hurt, and you might look at the bottom of your foot to see if it caused any damage, but usually, you can keep going like nothing happened. Stepping on broken glass will give you a sharp stab, and you'll know to stop and address the situation.
Imagine if you didn't have this library of sensations to refer to subconsciously. If you step on a smooth pebble, ouch! That felt bad. But how bad? Is it safe to keep going? What if I step on another one? A child without this library may appear to be 'misbehaving' to an outsider. They might slow down, refuse to keep walking, cry, or meltdown. If a rock gets in their shoe, they might not be able to process anything except that it hurts. They stop walking and can't communicate to you why because they might not fully understand it themselves.
One of our favorite tactile tools is dry beans. They're inexpensive, and if they eat one or two, it's just beans. Pinto beans are usually the cheapest. Dry rice is another good option. A bucket of beans can be a fun way to provide tactile input to a child. Getting multiple bags and putting them in a kiddy pool becomes a full-body experience. Standing in beans lets you feel them with your feet. It's bumpy, hard, and they move when you step on them. Ask them what they feel and if they like the way it feels. Ask yourself the same questions!
Next time you're at the grocery store, pick up a bag of beans!


text:
There's a difference between successful people and unsuccessful people….
Unsuccessful people make excuses of why they can't do something.
Successful people make decisions to do something.
For example….
We are all busy. We all have stuff going on. The kids have soccer practice. You have an important project due. You need to watch walking dead.
Insert your thing here!
We also all have 24 hours in a day.
Do you think Oprah is any less busy than you?
Do you think Tony Robbins doesn't have things going on?
Ultra successful people make a decision to be successful and work towards that decision. They schedule their life around those goals.
How does this relate to you?
In fitness you must make a decision to focus on the behaviors that matter to help you reach those goals.
What are those behaviors? Be consistent with your training. Eat well. Get sleep.
All of those things translate into better fitness goals, and they also translate into happier, better fulfilled, more productive lives in general.
So my question to you is why don't you plan your day around those things?
Make a decision to set yourself up for success and stick to it.
What behavior can you decide on today that will make you successful?
Back Squat, while resting complete sets of auxiliary work
Box Jumps x 5
Push Ups x 10
Sit Ups x 20
AMRAP 12 minutes