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Background Most states have recently passed laws requiring prescribers to use prescription drug monitoring programs (PDMPs) before prescribing opioid medications. The impact of these mandates on discontinuing chronic opioid therapy among Veterans managed in the Veterans Health Administration (VA) is unknown. We assess the association between the earliest of these laws and discontinuation of chronic opioid therapy in Veterans receiving VA health care. Methods We conducted a comparative interrupted time-series study in the 5 states mandating PDMP use before August 2013 (Ohio, West Virginia, Kentucky, New Mexico, and Tennessee), adjusting for trends in the 17 neighboring control states without such mandates. We modeled 25 months of prescribing for each state centered on the month the mandate became effective. We included Veterans prescribed long-term outpatient opioid therapy (305 of the preceding 365 d). Our outcomes were discontinuation of chronic opioid therapy (primary outcome) and the average daily quantity of opioids per Veteran over the following 6 months (secondary outcome). Results We included 250 monthly cohorts with 225,665 unique Veterans and 3.4 million Veteran-months. Baseline discontinuation rates before the PDMP mandates were 0.4%-2.7% per month. Kentucky saw a discontinuation increase of 1 absolute percentage point following its PDMP mandate which decreased over time. The other 4 states had no significant association between their mandates and change in opioid discontinuation. There was no evidence of decreasing opioid quantities following PDMP mandates. Conclusion We did not find consistent evidence that state laws mandating provider PDMP use were associated with the discontinuation of chronic opioid therapy within the VA for the time period studied.

BACKGROUND Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

We determined whether including a care coordination system to manage the referral process for hematuria would lead to improved quality of care.Inflection Navigator, a protocol based, electronic medical record enabled care coordination system, was developed to support primary care physicians evaluating newly discovered hematuria. We studied the system for patients referred for microscopic and gross hematuria from May 2009 to May 2010. We compared outcomes in these 106 patients and in 105 referred to our urology department for hematuria during the same period who did not use the system.Patients in the care coordination group completed the evaluation in a significantly shorter time with more than a 1-month difference in time between referral and the completion of the imaging and cystoscopy components of the assessment (mean 40.9 vs 74.1 days, p0.05). This system potentially lowered health care costs by decreasing the mean ± SD number of urology visits needed to complete an evaluation from 2.1 ± 1.5 in the standard referral group to 1.6 ± 1.4 in the care coordination group (p0.05).A protocol based care coordination system for hematuria decreased the time needed to complete an evaluation and decreased the number of overall visits required to make a final diagnosis. Thus, the Inflection Navigator system is an example of an electronic medical record enabled process innovation that can improve the efficiency of care while potentially lowering health care costs.

We evaluated targeted antimicrobial prophylaxis in men undergoing transrectal ultrasound guided prostate biopsy based on rectal swab culture results.From July 2010 to March 2011 we studied differences in infectious complications in men who received targeted vs standard empirical ciprofloxacin prophylaxis before transrectal ultrasound guided prostate biopsy. Targeted prophylaxis used rectal swab cultures plated on selective media containing ciprofloxacin to identify fluoroquinolone resistant bacteria. Patients with fluoroquinolone susceptible organisms received ciprofloxacin while those with fluoroquinolone resistant organisms received directed antimicrobial prophylaxis. We identified men with infectious complications within 30 days after transrectal ultrasound guided prostate biopsy using the electronic medical record.A total of 457 men underwent transrectal ultrasound guided prostate biopsy, and of these men 112 (24.5%) had rectal swab obtained while 345 (75.5%) did not. Among those who received targeted prophylaxis 22 (19.6%) men had fluoroquinolone resistant organisms. There were no infectious complications in the 112 men who received targeted antimicrobial prophylaxis, while there were 9 cases (including 1 of sepsis) among the 345 on empirical therapy (p=0.12). Fluoroquinolone resistant organisms caused 7 of these infections. The total cost of managing infectious complications in patients in the empirical group was $13,219. The calculated cost of targeted vs empirical prophylaxis per 100 men undergoing transrectal ultrasound guided prostate biopsy was $1,346 vs $5,598, respectively. Cost-effectiveness analysis revealed that targeted prophylaxis yielded a cost savings of $4,499 per post-transrectal ultrasound guided prostate biopsy infectious complication averted. Per estimation, 38 men would need to undergo rectal swab before transrectal ultrasound guided prostate biopsy to prevent 1 infectious complication.Targeted antimicrobial prophylaxis was associated with a notable decrease in the incidence of infectious complications after transrectal ultrasound guided prostate biopsy caused by fluoroquinolone resistant organisms as well as a decrease in the overall cost of care.

This study describes barriers perceived by nurses to the implementation of research findings in a community hospital. The BARRIERS to Research Utilization Scale was distributed to 1100 registered nurses. Items related to characteristics of the organization, including lack of time and practice authority, were perceived as the greatest barriers. Results of this study are useful for determining strategies to facilitate clinical nursing research and integrate research findings in the practice setting.

Chronic pelvic pain syndrome (CPPS) is the most common form of prostatitis, accounting for 90-95% of all diagnoses. It is a complex multi-symptom syndrome with unknown etiology and limited effective treatments. Previous investigations highlight roles for inflammatory mediators in disease progression by correlating levels of cytokines and chemokines with patient reported symptom scores. It is hypothesized that alteration of adaptive immune mechanisms results in autoimmunity and subsequent development of pain. Mouse models of CPPS have been developed to delineate these immune mechanisms driving pain in humans. Using the experimental autoimmune prostatitis (EAP) in C57BL/6 mice model of CPPS we examined the role of CD4+T-cell subsets in the development and maintenance of prostate pain, by tactile allodynia behavioral testing and flow cytometry. In tandem with increased CD4+IL17A+ T-cells upon EAP induction, prophylactic treatment with an anti-IL17 antibody one-day prior to EAP induction prevented the onset of pelvic pain. Therapeutic blockade of IL17 did not reverse pain symptoms indicating that IL17 is essential for development but not maintenance of chronic pain in EAP. Furthermore we identified a cytokine, IL7, to be associated with increased symptom severity in CPPS patients and is increased in patient prostatic secretions and the prostates of EAP mice. IL7 is fundamental to development of IL17 producing cells and plays a role in maturation of auto-reactive T-cells, it is also associated with autoimmune disorders including multiple sclerosis and type-1 diabetes. More recently a growing body of research has pointed to IL17's role in development of neuropathic and chronic pain. This report presents novel data on the role of CD4+IL17+ T-cells in development and maintenance of pain in EAP and CPPS.

Background/Objective: Stroke patients may be unable to provide medical history. Given the urgency of decision-making in acute stroke and importance of medication compliance post-stroke, prompt access to prior health records could reduce delays and errors. We hypothesized that stroke patients often have fragmented care in the Chicago Health Atlas. Methods: The Chicago Health Atlas encompasses clinical data on over 1 million unique patients within the 606xx ZIP codes of Chicago. A unique ID is created for each patient through the use of a secure one-way hash function. The creation of a unique ID enables longitudinal tracking of a patient’s care across participating sites. We identified all acute stroke admissions to any of 4 Chicago Health Atlas hospitals using ICD-9 codes (430-436) and searched for prior inpatient or outpatient encounters at any of those sites. Fragmented care was defined as having prior encounters at a site different from the site of stroke hospitalization. In the same cohort, we assessed post-hospitalization outpatient encounters within the Health Atlas. Results: There were 5,980 stroke patients with emergency department or inpatient visits between 2006 and 2010. Of these, 3,732 (62.4%, mean age 61.1 years, 47% black) had non-fragmented care prior to stroke while 2,066 (34.5%, mean age 58.1 years, 31% black) were completely new encounters (first-ever) in the Health Atlas and only 182 (3.0%, mean age 57.5 years, 59% black) had fragmented care. The percent with fragmented care increased from 1.3% in 2006 to 3.3% in 2010 (p Conclusions: Two-thirds of stroke patients have previously accessed the health care system, with a majority having records at the same site of stroke hospitalization. However, 3% of patients have fragmented care, a rate that is increasing over time. Our estimate of fragmentation may be an underestimate since only 4 sites were included in this analysis. Having health information exchange may be valuable in reducing fragmentation of care for stroke patients.

INTRODUCTION AND OBJECTIVES: Small cell bladder cancer (SCBC) is a rare and aggressive histologic subtype of bladder cancer thought to be derived in part from neuroendocrine cells. Given its rarity, the natural history, prognosis, and response to treatment have not been described. METHODS: From the Surveillance, Epidemiology and End Results (SEER) National Cancer Registry, 498 patients with SCBC were identified between the year of 1998 and 2007. For comparison, 33624 patients with urothelial bladder cancer (UC) were identified for comparison. RESULTS: The incidence of SCBC has increased over time from 0.8% to 2% of all cases of bladder cancer (p 0.0001) with an absolute increase of 14 to 77 cases per year from 1998 to 2007. The median age of diagnosis was 72 years, and 80% were male compared to 74% male of UC. The majority of patients with SCBC were white (89%). SCBC was more aggressive, with greater frequency of high grade compared to UC (42% vs. 31%), and muscle invasive disease at presentation (T2, 45% vs. 31%, p 0.001). In terms of treatment, a similar percentage of patients underwent radical cystectomy (18% with SCBC vs 19% with UC) and 19% had a lymph node dissection. Patients with SCBC were more likely to receive adjuvant radiotherapy (23% vs. 9%). Patients with SCBC had a higher rate of metastatic disease to regional lymph nodes (19% vs. 10%), with SCBC patients having higher rates of N1 (13% vs. 7%), N2 (6% vs. 3%) and N3 (0.4% vs. 0.3%) disease. Distant metastasis were present in 18% of SCBC compared to 7.5% in UC. At the time of diagnosis, 18% of patients with SCBC and only 8% of UC had evidence of metastatic disease. A significantly higher percentage of patients with SCBC died of bladder cancer compared to UC (54% vs. 32%, p 0.0001). For nearly every stage, SCBC had a higher cancer specific mortality including T1 (25% vs 14%, p 0.06), T2 (43% vs. 35%, p 0.04) and T3 (55% vs. 38%, p 0.02). Of those patients that died of bladder cancer, the mean time of survival was significantly shorter for SCBC (11 months vs. 15 months, p 0.0001). CONCLUSIONS: SCBC is a rare and aggressive form of bladder cancer, with increasing incidence. Compared to standard UC, SCBC has a higher grade, stage, rate of metastasis and cancerspecific mortality. Patients with SCBC may benefit from early aggressive multi-modal therapy.

for unilateral adrenalectomies and 80 ml (50–300ml) for bilateral ones. No major complication occurred. The median time to discharge was 3 days (range 2 to 6). The median tumor size was 5,5 cm (range 3.5 to 10). The pathologic analysis revealed renal cell carcinoma metastases in 10 patients and transitional cell carcinoma metastases in two men who underwent bilateral laparoscopic adrenalectomy. Metastasis from papillary renal cell carcinoma, poorly differentiate lung carcinoma, colorectal carcinoma and melanoma were respectively detected in the other four patients. Surgical margins were negative in all patients and local recurrence occurred in one patient. At a mean follow-up of 39 months 75% of patients were alive and 25% were disease free. The mean time to recurrence was 15 months (range 4–50). When analyzed for primary tumor histology, recurrence free survival rate in the group of patients with renal cell carcinoma metastasis was 40% and cancer specific survival rate was 91%. No patients with primary tumor histology different by renal cell carcinoma was recurrence free and 4 out of 5 five patients died of disease. CONCLUSIONS: Laparoscopic removal of adrenal metastasis is minimally invasive and oncologically effective. The final outcome of patients mainly depends on the primary tumor histology and on the chances of treatment of metastases subsequently developed.