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Objective: To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre-pregnancy and pregnancy periods. Data Sources, Study Setting, and Study Design: We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010-2019. Data Collection/Extraction Methods: Veterans aged 18-50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as [greater than or equal to]140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multi-variable logistic regression explored the association of covariates with recommended and non-recommended AHMs received 0-6 months before pregnancy and during pregnancy. Principal Findings: In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non-recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6-6.4) and diabetes (OR = 2.3; 1.7-3.0) were most strongly associated with use of a non-recommended AHM during pregnancy. Conclusions: Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential. KEYWORDS chronic hypertension, comorbidity, maternal, maternity care coordination, pregnancy, veterans, women, 1 | INTRODUCTION Rates of maternal chronic hypertension (MCH) have doubled over the past decade, increasing from 10.9 to 20.5 per 1000 live births from 2007 to 2018 in the [...]

ABSTRACTObjectivesThis review examines health care team-focused interventions on managing persistent or recurrent distress behaviors among older adults in long-term residential or inpatient health care settings.MethodsWe searched interventions addressing health care worker (HCW) knowledge and skills related to distress behavior management using Ovid MEDLINE, Elsevier Embase, and Ovid PsycINFO from December 2002 through December 2022.ResultsWe screened 6,582 articles; 29 randomized trials met inclusion criteria. Three studies on patient-facing HCW interactions (e.g. medication management, diagnosing distress) showed mixed results on agitation; one study found no effect on quality of life. Six HCW-focused studies suggested short-term reduction in distress behaviors. Quality-of-life improvement or decreased antipsychotic use was not evidenced. Among 17 interventions combining HCW-focused and patient-facing activities, 0 showed significant distress reduction, 8 showed significant antipsychotic reduction (OR = 0.79, 95%CI [0.69, 0.91]) and 9 showed quality of life improvements (SMD = 0.71, 95%CI [0.39, 1.04]). One study evaluating HCW, patient-, and environmental-focused intervention activities showed short-term improvement in agitation.Conclusions and Clinical ImplicationsNovel health care models combining HCW training and patient management improve patient quality of life, reduce antipsychotic use, and may reduce distress behaviors. Evaluation of intervention’s effects on staff burnout and utilization is needed.

Background: Refinement of the risk classification for localized prostate cancer is warranted to aid in clinical decision making. A systematic analysis was undertaken to evaluate the prognostic ability of three genomic classifiers, Decipher, GPS, and Prolaris, for biochemical recurrence, development of metastases and prostate cancer-specific mortality in patients with localized prostate cancer. Methods: Data sources: MEDLINE, Embase, and Web of Science were queried for reports published from January 2010 to April 2022. Study selection: prospective or retrospective studies reporting prognosis for patients with localized prostate cancer. Data extraction: relevant data were extracted into a customized database by one researcher with a second overreading. Risk of bias was assessed using a validated tool for prognostic studies, Quality in Prognosis Studies (QUIPS). Disagreements were resolved by consensus or by input from a third reviewer. We assessed the certainty of evidence by GRADE incorporating adaptation for prognostic studies. Results: Data synthesis: a total of 39 studies (37 retrospective) involving over 10,000 patients were identified. Twenty-two assessed Decipher, 5 GPS, and 14 Prolaris. Thirty-four studies included patients who underwent prostatectomy. Based on very low to low certainty of evidence, each of the three genomic classifiers modestly improved upon the prognostic ability for biochemical recurrence, development of metastases, and prostate cancer-specific mortality compared to standard clinical risk-classification schemes. Limitations: downgrading of confidence in the evidence stemmed largely from bias due to the retrospective nature of the studies, heterogeneity in treatment received, and era in which patients were treated (i.e., prior to the 2000s). Conclusions: Genomic classifiers provide a small but consistent improvement upon the prognostic ability of clinical classification schemes, which may be helpful when treatment decisions are uncertain. However, evidence from current management-era data and of the predictive ability of these tests is needed.

The Veterans Health Administration (VHA) is undergoing a transformational shift from disease-focused care to a Whole Health model that emphasizes physical, mental, emotional, and spiritual health and well-being. As this shift is occurring, women veterans using VHA services face challenges navigating a system that has historically served a primarily male demographic, without consistent consensus on which services require specialization by gender. A quality improvement project was conducted to solicit feedback on VHA behavioral and wellness programs from women veterans enrolled in VHA mental healthcare services. A multi-disciplinary work group of clinical researchers and healthcare providers developed a needs assessment survey to assess patient needs and preferences for behavioral health services. A convenience sample of female veterans using VHA mental healthcare services within a comprehensive Women’s Health Clinic were invited to complete this anonymous survey. 107 women Veterans 18–65+ years old (65.3% African American; 5.9% LatinX; 54.2% aged under 55) completed the survey. Over 50% of patients endorsed relationships, physical activity, sleep/nightmares, pain management, anger, or spiritual/moral pain as top wellness priorities. Programatic preferences included location (located at the main VA Hospital) and gender composition (female only group formats). Schedule conflicts were the most frequently cited barriers. Results from this quality improvement project highlight considerations for tailoring the content and delivery of behavioral services for women veterans with mental health conditions.Women veterans chose relationships and physical activity as top wellness priorities, preferred services offered at the VA Hospital with women only group formats, and often cited schedule conflicts as a barrier to care.

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With an improved life expectancy, HIV-positive patients now face interactions between antiretroviral therapy and medications for chronic medical problems. One example is thromboembolism and its treatment with oral anticoagulants. To [...]

Despite increases in BRCAmutation testing, racial/ethnic disparities in counseling and testing have persisted for decades. The purpose of the review was to summarize recent literature as it relates to detecting, understanding, and reducing disparities in BRCAcounseling and testing. This is a narrative review of articles published January 2012 to July 2017 relevant to genetic testing and counseling, breast and ovarian cancer, and minority health and heath disparities. Twenty-three articles were included in this review. Studies report lower counseling and/or testing rates for eligible racial/ethnic minorities among family members of high-risk individuals as well as among breast cancer survivors. Key barriers and facilitators of disparate BRCAcounseling/testing that emerged in this review included awareness, cost-related factors, stress and distrust, family concerns and communication, and provider communication and referral. To address differential access to and use of BRCAtesting services and expand testing in minority populations, it is necessary for interventions to focus on improving awareness, risk-perception, and family and patient-provider communication. Multi-level and targeted interventions are needed to reduce persistent racial/ethnic disparities and improve assessment, provider recommendations, counseling and testing among minority populations.

Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value.

This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.

Health-care providers and patients increasingly turn to the Internet—websites as well as social media platforms—for health-related information and support. Informed by research on audience behaviors and preferences related to digital health information, the National Kidney Disease Education Program (NKDEP) developed a comprehensive and user-friendly digital ecosystem featuring content and platforms relevant for each audience. NKDEP's analysis of website metrics and social media conversation mapping related to CKD revealed gaps and opportunities, informing the development of a digital strategy to position NKDEP as a trustworthy digital source for evidence-based kidney disease information. NKDEP launched a redesigned website (www.nkdep.nih.gov) with enhanced content for multiple audiences as well as a complementary social media presence on Twitter and Facebook serving to drive traffic to the website as well as actively engage target audiences in conversations about kidney disease. The results included improved website metrics and increasing social media engagement among consumers and health-care providers. NKDEP will continue to monitor trends, explore new directions, and work to improve communication across digital platforms.

Introduction:Maternal chronic hypertension (MCH), defined as chronic hypertension affecting pregnancy, has increased rapidly in prevalence among civilians. Although women Veterans have more risk factors for chronic hypertension than civilian women, little is known about MCH in this group.Methods:This descriptive, observational study used data from the Surgical Treatment Outcomes for Patients with Psychiatric Disorders (STOPP) project, which includes 11 million Veterans with and without mental illness using the Veterans Health Administration. Women Veterans aged 18-60 years at time of pregnancy identification were included if they had chronic hypertension before pregnancy in fiscal years 2010-2019. We identified chronic hypertension and first pregnancy based on diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year prior to pregnancy. For antihypertensive medications (AHMs) that are recommended or not recommended for use in pregnancy, multivariable logistic regression was used to assess the association of comorbidities with (a) non-recommended AHM received 0-6 months before pregnancy, (b) non-recommended AHM received during pregnancy (c) recommended AHM received 0-6 months before pregnancy, and (d) recommended AHM received during pregnancy.Results:In total, 9.9% (4,302/43,251) of women Veterans who became pregnant had MCH, with mean age 37.0 years (SD=8.2). Among those with MCH who met inclusion criteria, 62% (N=1,839) had uncontrolled blood pressure in the year prior to pregnancy. Furthermore, 20% (N=611) received a non-recommended AHM 0-6 months before pregnancy, 19% (N=564) received a non-recommended AHM during pregnancy, 26% (N=784) received a recommended AHM 0-6 months before pregnancy, and 33% (N=995) received a recommended AHM during pregnancy. Chronic kidney disease (OR 3.0, 95% CI: 1.6-5.6) and diabetes (OR 2.5, 95% CI:1.9-3.2) were most strongly associated with use of a non-recommended AHM during pregnancy.Conclusion:Interventions are needed among women Veterans to decrease the prevalence of MCH, increase blood pressure control prior to pregnancy, and ensure antihypertensives not recommended for use in pregnancy are transitioned to safe alternatives.

In the female guinea pig, estrus is inhibited after copulation. This study explored the role of the endocrine status of the male on the termination of the lordosis response in females. Ovariectomized females were treated with estradiol benzoate and progesterone to induce estrus and were then mated with males when the males were intact, castrated, and castrated and treated with testosterone propionate (TP). Lordosis responses were recorded prior to and following mating. Females who received an ejaculation from a castrated male remained sexually receptive longer than the females mated with intact males, or those males that were castrated and treated with TP. These results support the hypothesis that the factor(s) responsible for termination of estrus in females are found in the ejaculate of the male and are testosterone dependent. Copyright 1993, 1999 Academic Press

Uncontrolled blood pressure (BP) is common among Veterans. Rural Veterans are at risk for suboptimal care coordination as successful programs may be implemented at lower rates due to individual- and system-level factors. There is strong evidence to support the use of remotely delivered support and patient-generated data from home BP monitors and virtual BP visits to manage BP.