Tamsulosin does not increase 1-week passage rate of ureteral stones in ED patients.

OBJECTIVE: The objective of the study is to determine if tamsulosin initiated in the emergency department (ED) decreases the time to ureteral stone passage at 1 week or time to pain resolution, compared to placebo. METHODS: We performed a prospective, randomized, double-blinded, placebo-controlled trial of tamsulosin vs placebo in ED patients with ureterolithiasis on computed tomography. Patients were identified and enrolled between April 2007 and February 2009 and were randomized to either 0.4 mg of tamsulosin or placebo for 1 week. We contacted participants using a telephone survey on post-ED visit days 1, 2, 3, and 7. The primary outcome was time to stone passage, with secondary outcomes being maximum pain score and amount of pain medication required. RESULTS: Of the 127 patients enrolled during this study, 15 were lost to follow-up, and 12 required surgical interventions before the 7-day mark, leaving 100 patients for analysis. Of the 100 patients, 53 received tamsulosin and 47 received placebo. There was no difference between groups in percentage of male, mean age, initial serum creatinine, average stone size, stone location, and history of prior stone. The probability that the patient did not pass a stone at 7 days was not different between tamsulosin and placebo, 62.1% (95% confidence interval, 49.1%-75.1%) vs 54.4% (95% confidence interval, 40.3%-68.6%; P = .58). There was no significant difference in the high pain score (P = .12) or hydrocodone/acetaminophen intake (P = .76) between treatment groups at any of the time points. CONCLUSION: This study reveals no difference in the proportion of stone passage or high pain score and pain medication utilization at 7 days between tamsulosin and placebo.

Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans.

Importance: Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. Objective: To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. Design, Setting, and Participants: This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Exposures: Receipt of any family psychotherapy and subtype of family-based psychotherapy. Main Outcomes and Measures: Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Results: Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). Conclusions and Relevance: In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.

Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System.

BACKGROUND: Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system. METHODS: Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. RESULTS: Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard's use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period. CONCLUSIONS: There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.

Development and Validation of the Veterans Health Administration Patient Safety Culture Survey.

RATIONALE, AIMS, AND OBJECTIVES: Patient safety culture (PSC) is an important concept in healthcare organization, and measuring it can lead to improved patient safety event reporting. We sought to test and validate an abbreviated version of a PSC measure within the Veterans Health Administration (VHA). METHODS: An initial set of 34 items was identified to represent the VHA Patient Safety Culture Survey (VHA-PSCS). The items were administered as part of an annual survey administration in June 2019 (N = 205,117, 66.1% response rate). We derived a split-half sample and conducted exploratory and confirmatory factor analysis to identify factors. We examined reliability along with construct and criterion validity of the VHA-PSCS in relation to other workplace attitudes and behaviors. RESULTS: The final instrument includes 20 items with 4 scales derived from factor analysis: (a) risk identification and just culture; (b) error transparency and mitigation; (c) supervisor communication and trust; and (d) team cohesion and engagement. Reliability was supported based on Cronbach α coefficients and split-half testing. For criterion validity, Spearman correlations were greater than 0.40 between VHA-PSCS scales and employee satisfaction and intrinsic work experience. Correlations were greater than 0.20 between VHA-PSC scales and intent to leave, burnout, and self-rated reporting of error incidents. CONCLUSIONS: The VHA-PSCS reflects 4 dimensions of patient safety. The instrument can be used to benchmark and compare progress of VHA's PSC transformation across the organization and within medical centers, to strengthen patient safety event reporting, investigation, and quality of care.

Opportunistic Screening for Exposure to Bullying in the Pediatric Emergency Department.

To assess opportunistic screening for exposure to bullying in the pediatric emergency department (ED), an anonymous survey inquiring about exposure to physical, verbal, social, and cyber bullying behaviors was given to ED patients 5 to 18 years old. The survey asked about being the recipient, perpetrator, and/or witness of bullying; the frequency of exposure; liking school; missing school; and presenting complaint. Either the child or parent could complete the survey. A total of 909 surveys were analyzed. Exposure was 78.7%. A greater proportion of females reported being victims and witnesses. Youth who reported being both victims and witnesses represented the largest group, with witness-only the second largest. Parents reported less cyber-bullying and witness status to all types of bullying. For children who did not like school, there was a significant difference in exposure versus nonexposure. There was no association with presenting complaint. Opportunistic screening for bullying exposure in pediatric ED patients warrants consideration as it may increase detection of preclinical status and clinical sequelae.

Atrial fibrillation and chronic kidney disease requiring hemodialysis - Does warfarin therapy improve the risks of this lethal combination?

INTRODUCTION: Warfarin therapy for stroke prevention is recommended for patients with AF, but its value in patients with chronic kidney disease on HD is unknown. METHODS: The anticoagulation regimens of patients with a prior history of AF hospitalized for initiation of chronic HD, and of patients receiving chronic HD who had a new diagnosis of AF between 2009 and 2012 were reviewed. Exclusions were renal transplant, peritoneal dialysis, rheumatic valve disease, prosthetic heart valve, GI bleeding, malignancy with chemotherapy in last 6months or still undergoing treatment, a history of AF ablation, a history of ICD implantation, or those receiving warfarin for non-AF indications. RESULTS: Among 302 patients included in the study, 119 (39%) were prescribed warfarin and 183 (61%) were not. The two groups were similar regarding demographics, and prevalence of comorbidities including diabetes, heart failure, coronary artery disease, hypertension, use of antiplatelet agents and prior stroke. Warfarin use did not lower risk for ischemic stroke (HR 0.93; 95% CI 0.49-1.82, P=0.88) or improve overall survival (HR 1.02; 95% CI 0.91-1.15, P=0.62), but trended toward higher risk of bleeding complications (HR 1.53; 95% CI 0.94-2.51, P=0.086) after adjusting for potential confounders. CONCLUSION: Warfarin use was not associated with reduction in stroke risk or mortality in patients with AF on chronic HD, but trended toward greater bleeding risk. The benefit of warfarin therapy in these patients may be outweighed by its risks.

Trajectories of Outdoor Mobility in Vulnerable Community-Dwelling Elderly: The Role of Individual and Environmental Factors.

OBJECTIVE: Outdoor mobility is critical for healthy aging, yet little is known about the factors influencing mobility in the frail elderly. We investigated the role of individual and community risk factors on trajectories of mobility in a population of vulnerable community-dwelling elderly. METHOD: Using data from 1,188 older adults in Detroit, MI, who qualify for federally funded home care, a latent class growth analysis was used to model the frequency of going outside over a 15-month period. RESULTS: Four latent trajectories were found: those with a low, high, and declining frequency of going outdoors over time, and those who do not go outdoors on a regular basis. Risk factors for membership in the homebound and infrequent mobility groups were older age, more severe mobility impairment, and fear of falling. Barriers at the entry to the home were associated with being homebound. DISCUSSION: Declining health status and functional limitations are risk factors that pose a threat to outdoor mobility in the frail elderly, while housing barriers and community accessibility also merit attention.

Pilot Study Exploring Chronic Pudendal Neuromodulation as a Treatment Option for Pain Associated with Pudendal Neuralgia.

OBJECTIVES: Pudendal neuralgia can cause significant voiding and pain symptoms. We explored the effects of chronic pudendal neuromodulation (CPN) and nerve blocks on pain associated with pudendal neuralgia. METHODS: Patients with pudendal neuralgia and tined lead placed at the pudendal nerve were reviewed. History and initial improvement after lead placement were collected from medical records. Demographics, symptom characteristics and changes after various treatments were assessed by mailed survey. Descriptive statistics were performed. RESULTS: Of 19 patients (mean age 54.8 years, 63% female), 6/19 (32%) had previous sacral neuromodulation. Before CPN, 18 patients had 77 nerve blocks (median six blocks per patient); most blocks (60/77; 78%) provided at least some relief. After lead placement, pain relief was complete in three patients, almost complete in three, significant/remarkable in 10, and small/slight in three. All 19 patients had a permanent generator placed. Five were ultimately explanted at (mean) 2.95 years: one had total symptom resolution, one had stopped using the device, and three lost efficacy. Survey respondents (n = 10) indicated that they had been experiencing pain for (median) 4.42 years before CPN. The most helpful pain treatment cited was medication for 6/10 and neuromodulation for 4/10; 8/9 rated neuromodulation as more helpful than nerve block, while one subject felt that the two treatments were equally helpful. Compared to sacral neuromodulation, 3/4 rated CPN as more effective for pain. Overall, 8/10 were satisfied with CPN; only 1/9 was mildly satisfied with nerve block. CONCLUSIONS: Chronic pudendal neuromodulation can improve pain in patients with pudendal neuralgia.