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The goal of this study was to describe the cohort of women prescribed PrEP at the Veterans Health Administration. We used a cross-sectional study of electronic health record data. We used descriptive statistics and calculated estimated average percent change by year of prescription. A total of 417 women were prescribed PrEP over the study period. The most substantial change over time in PrEP prescribing occurred among women aged 18–24, in Other race group, and in the Western US. Though PrEP prescribing increased since its approval, more research is needed to identify barriers and expand PrEP access for women Veterans.

Background Intravenous dantrolene is often prescribed for hypermetabolic syndromes other than the approved indication of malignant hyperthermia (MH). To clarify the extent of and indications for dantrolene use in conditions other than MH, we sought to document current practices in the frequency, diagnoses, clinical characteristics and outcomes associated with dantrolene treatment in critical care settings. Methods Inpatients receiving intravenous dantrolene from October 1, 2004 to September 30, 2014 were identified retrospectively in the U.S. Veterans Health Administration national database. Extracted data included; diagnoses of hypermetabolic syndromes; triggering drugs; dantrolene dosages; demographics; vital signs; laboratory values; in-hospital mortality; complications; and lengths of stay. Frequency and mortality of patients who did not receive dantrolene were obtained in selected diagnoses for exploratory comparisons. Results Dantrolene was administered to 304 inpatients. The most frequent diagnoses associated with dantrolene treatment were neuroleptic malignant syndrome (NMS; N  = 108, 35.53%) and sepsis ( N  = 47, 15.46%), with MH accounting for only 13 (4.28%) cases. Over half the patients had psychiatric comorbidities and received psychotropic drugs before dantrolene treatment. Common clinical findings in patients receiving dantrolene included elevated temperature (mean ± SD; 38.7 ± 1.3 °C), pulse (116.33 ± 22.80/bpm), respirations (27.75 ± 9.58/min), creatine kinase levels (2,859.37 ± 6,646.88 IU/L) and low pO 2 (74.93 ± 40.16 mmHg). Respiratory, renal or cardiac failure were common complications. Mortality rates in-hospital were 24.01% overall, 7.69% in MH, 20.37% in NMS and 42.55% in sepsis, compared with mortality rates in larger and possibly less severe groups of unmatched patients with MH (5.26%), NMS (6.66%), or sepsis (41.91%) who did not receive dantrolene. Conclusions In over 95% of cases, dantrolene administration was associated with diagnoses other than MH in critically-ill patients with hypermetabolic symptoms and medical and psychiatric comorbidities. Exploratory survey data suggested that the efficacy and safety of dantrolene in preventing mortality in hypermetabolic syndromes other than MH remain uncertain. However, randomized and controlled studies using standardized criteria between groups matched for severity are essential to guide practice in using dantrolene.

This book examines the key motivations for and challenges to greater regional integration in Southeast Asia. It demonstrates how security and economic concerns -domestic, regional and international - have either contributed to, or detracted from, an increased level of unity and cooperation in ASEAN. It also explores how the patterns of interaction and socialization generated by these issues, together with the nature of domestic political systems, have affected the emergence of common values, norms and interests. It covers the full range of issues confronting ASEAN at present, and the full range of ASEAN countries, and discusses both developments in ASEAN to date and also likely future developments.

Seed-mediated growth of gold (Au) nanorods with highly controllable length, width, and aspect ratio was accomplished via carefully size-controlled synthesis of the original Au seeds. A slow dynamic growth of Au nanoparticle seeds was observed after reduction of the Au salt (i.e., hydrogen tetrachloroaurate (III) hydrate) by sodium borohydride (NaBH 4 ) in the presence of cetyltrimethyl ammonium bromide (CTAB). As such, the size of the Au nanoparticle seeds can therefore be manipulated through control over the duration of the reaction period (i.e., aging times of 2, 8, 48, 72, and 144 h were used in this study). These differently sized Au nanoparticles were subsequently used as seeds for the growth of Au nanorods, where the additions of Au salt, CTAB, AgNO 3 , and ascorbic acid were employed. Smaller Au nanoparticle seeds obtained via short growth/aging time resulted in Au nanorods with higher aspect ratio and thus longer longitudinal surface plasmon wavelength (LSPW). The larger Au nanoparticle seeds obtained via longer growth/aging time resulted in Au nanorods with lower aspect ratio and shorter LSPW.

Background. Influenza is a significant cause of morbidity and mortality in older adults. High-dose (HD) trivalent inactivated vaccine has increased immunogenicity in older adults compared with standard-dose (SD) vaccine. We assessed the relative effectiveness of HD influenza vaccination (vs SD influenza vaccination). Methods. We conducted a retrospective cohort study among patients who receive primary care at Veteran Health Administration (VHA) medical centers, and who received influenza vaccine in the 2010–2011 influenza season. The primary outcome was hospitalization for influenza or pneumonia. We also conducted an analysis in subgroups defined by age. Results. We evaluated 25 714 patients who received HD vaccine and 139 511 who received SD vaccine in 23 VHA medical centers. The rate of hospitalization for influenza or pneumonia was 0.3% in both groups in the influenza season. After accounting for patient characteristics in propensity-adjusted analyses, the risk of hospitalization for influenza or pneumonia was not significantly lower among patients receiving HD vaccine vs those receiving SD vaccine (risk ratio, 0.98; 95% confidence interval, .68–1.40). In the subgroup of patients ≥85 years of age, receiving HD (compared with SD) vaccine was associated with lower rates of hospitalization for influenza or pneumonia. Conclusions. HD vaccine was not found to be more effective than SD vaccine in protecting against hospitalization for influenza or pneumonia; however, we found a protective effect in the oldest subgroup of patients. Additional studies are needed to evaluate the effectiveness of HD vaccine.

ObjectiveTo determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes.DesignDifference-in-difference study.SettingUS Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls.ParticipantsAll individuals receiving primary care from 2009 to 2019.InterventionLimits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians.Main outcome measuresThe primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions.ResultsThe number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval −7.6% to −7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (−12.0% to −10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (−6.08% to −5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions.ConclusionsThe multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.

BackgroundExperience of intimate partner violence (IPV) can have adverse health impacts and has been associated with elevated rates of healthcare service utilization. Healthcare encounters present opportunities to identify IPV-related concerns and connect patients with services. The Veterans Health Administration (VHA) conducts IPV screening within an integrated healthcare system.ObjectiveThe objectives of this study were to compare service utilization in the 6 months following IPV screening between those screening positive and negative for past-year IPV (IPV+, IPV−) and to examine the timing and types of healthcare services accessed among women screening IPV+.DesignA retrospective chart review was conducted for 8888 female VHA patients across 13 VHA facilities who were screened for past-year IPV between April 2014 and April 2016.Main MeasuresDemographic characteristics (age, race, ethnicity, marital status, veteran status), IPV screening response, and healthcare encounters (based on visit identification codes).Key ResultsIn the 6 months following routine screening for past-year IPV, patients screening IPV+ were more likely to utilize outpatient care (aOR = 1.85 [CI 1.26, 2.70]), including primary care or psychosocial care, and to have an inpatient stay (aOR = 2.09 [CI 1.23, 3.57]), compared with patients screening IPV−. Among those with any utilization, frequency of outpatient encounters within the 6-month period following screening was higher among those screening IPV+ compared with those screening IPV−. The majority of patients screening positive for past-year IPV returned for an outpatient visit within a brief time frame following the screening visit (> 70% within 14 days, >95% within 6 months). More than one in four patients screening IPV+ had an emergency department visit within the 6 months following screening.ConclusionsWomen who screen positive for past-year IPV have high rates of return to outpatient visits following screening, presenting opportunities for follow-up support. Higher rates of emergency department utilization and inpatient stays among women screening IPV+ may indicate adverse health outcomes related to IPV experience.

Objective. This study examined veterans' responses to the Veterans Health Administration's (VHA's) universal screen for homelessness and risk of homelessness during the first 12 months of implementation. Methods. We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen. Results. More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability. Conclusion. To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.

Iron oxide nanoparticles exhibit highly size-dependent physicochemical properties that are important in applications such as catalysis and environmental remediation. In order for these size-dependent properties to be effectively harnessed for industrial applications scalable and cost-effective techniques for size-controlled synthesis or size separation must be developed. The synthesis of monodisperse iron oxide nanoparticles can be a prohibitively expensive process on a large scale. An alternative involves the use of inexpensive synthesis procedures followed by a size-selective processing technique. While there are many techniques available to fractionate nanoparticles, many of the techniques are unable to efficiently fractionate iron oxide nanoparticles in a scalable and inexpensive manner. A scalable apparatus capable of fractionating large quantities of iron oxide nanoparticles into distinct fractions of different sizes and size distributions has been developed. Polydisperse iron oxide nanoparticles (2–20 nm) coated with oleic acid used in this study were synthesized using a simple and inexpensive version of the popular coprecipitation technique. This apparatus uses hexane as a CO 2 gas-expanded liquid to controllably precipitate nanoparticles inside a 1L high-pressure reactor. This paper demonstrates the operation of this new apparatus and for the first time shows the successful fractionation results on a system of metal oxide nanoparticles, with initial nanoparticle concentrations in the gram-scale. The analysis of the obtained fractions was performed using transmission electron microscopy and dynamic light scattering. The use of this simple apparatus provides a pathway to separate large quantities of iron oxide nanoparticles based upon their size for use in various industrial applications. Graphical Abstract