The Minneapolis Veterans Affairs Health Care System (VAHCS) is network of hospital and outpatient clinics based in Minneapolis, Minnesota, USA. It belongs to the VISN23 VA Midwest Health Care Network managed by the Veterans Health Administration of the Department of Veterans Affairs. The Minneapolis VAHCS provides healthcare for United States military veterans in areas such as medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics and extended care. As a teaching hospital, it operates comprehensive training programs for multiple treatment specialties. The Minneapolis VAHCS also hosts one of the largest research programs of any VA health care system and maintains research affiliations with the University of Minnesota.
Background The US Veterans Health Administration (VHA) has almost twenty years of experience implementing trauma-focused psychotherapies (TFPs) for posttraumatic stress disorder (PTSD). Yet, the potential of TFPs to alleviate the burden of PTSD has not been fully realized. Previous reviews focused primarily on clinician uptake and patient perceptions of TFPs with limited examination of service delivery challenges. Methods This narrative review summarizes the evidence describing practice gaps specific to TFPs within VHA, factors that contribute to these evidence gaps, and recommends strategies and research to address modifiable contributing factors. Results TFP practice gaps include limited or variable reach to patients, high dropout, and reduced effectiveness compared to randomized clinical trials. Contributing factors span patient, clinician, and healthcare organizational levels. To bridge these practice gaps, we recommend: (1) Taking patient preference and heuristic approaches to treatment decisions into account; (2) Testing novel strategies to augment patient sustained engagement through treatment completion; (3) Developing empirically adapted clinician training and consultation programs; (4) Designing clinics to facilitate delivery of these proven interventions; (5) Developing scheduling and other organizational strategies to facilitate an adequately intensive treatment course; (6) Enhancing local leadership support and the implementation climate for TFPs; and (7) Evaluating how clinician burnout symptoms impact treatment delivery and outcomes. Conclusions Narrowing the research-to-practice gap for TFPs within VHA requires addressing multi-level determinants to maximize patient engagement and facilitate effective intervention delivery. Without optimizing the conditions for intervention delivery, TFPs will remain limited in their capacity to reduce the systemic burden of PTSD.
BACKGROUND:These recommendations provide guidance on the optimal duration of antibiotics in patients with complicated urinary tract infection (cUTI), especially in presence of associated Gram-negative bacteremia. METHODS:The panel's recommendations are based upon evidence derived from systematic literature reviews which focused on comparative benefits and harms of shorter (5-7 days) vs prolonged (10-14 days) duration of antibiotics, including publications since 2000. These recommendations adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. RESULTS:The guidelines panel suggests that patients with cUTI who are improving on effective therapy can be treated with shorter duration of antimicrobials (either 5-7 days of a fluoroquinolone or 7 days of a non-fluoroquinolone) rather than longer courses of antibiotics, regardless of the presence of associated Gram-negative bacteremia. An effective antimicrobial agent achieves therapeutic levels in the urine and relevant tissue and is active against the causative pathogen. However, men with febrile UTI in whom acute bacterial prostatitis is suspected may benefit from a longer treatment duration (10-14 days), and a short courses of oral beta lactams may require higher doses for efficacy. CONCLUSIONS:Shorter durations of antibiotics for cUTI provide similar efficacy as longer courses, except in men with febrile UTI in whom acute bacterial prostatitis is suspected. This recommendation places a high value on antibiotic stewardship considerations as well as reducing the burden of antimicrobial administration from a healthcare perspective and reducing the burden of taking antibiotics from a patient perspective.
Importance:A single respiratory syncytial virus (RSV) vaccine dose is recommended for older adults and persons at increased risk for severe RSV. Clinical information on the long-term effectiveness of RSV vaccines is needed. Objective:To determine the effectiveness of RSV vaccination over 2 respiratory illness seasons. Design, Setting, and Participants:This target trial emulation used data from the Veterans Health Administration and included veterans 60 years and older who were eligible for RSV vaccination from September 2023 to March 2024. Exposure:A single dose of a recombinant stabilized prefusion F protein RSV vaccine vs no RSV vaccination. Main Outcomes and Measures:Eligible vaccine recipients were matched with up to 4 unvaccinated individuals in 7 monthly, nested sequential trials from September 1, 2023, to March 31, 2024. Outcomes were ascertained through March 31, 2025. The primary outcome was any positive RSV test result from day 14 following the matched index date. Secondary outcomes included RSV-associated emergency department or urgent care visits, hospitalizations, or intensive care unit admissions. Vaccine effectiveness was estimated as 100 × (1 - risk ratio). Results:A total of 288 111 vaccinated individuals were matched to 1 075 893 unique control individuals, weighted equally to represent 576 222 individuals, and followed up for a median of 15.8 months (IQR, 14.5-17.0). Across both groups, 544 364 of 576 222 veterans (94.5%) were male, and the median age was 76.1 years (IQR, 71.6-80.0). Vaccine effectiveness against documented RSV infections decreased from 82.5% (95% CI, 77.5%-86.9%) over 0 to 1 month to 59.4% (95% CI, 55.6%-63.5%) over 0 to 18 months of follow-up. During the same period, effectiveness decreased from 84.9% (95% CI, 78.4%-90.2%) to 60.5% (95% CI, 56.4%-65.7%) for emergency visits and 88.9% (95% CI, 77.9%-95.7%) to 57.3% (95% CI, 47.3%-66.4%) for hospitalizations and was 92.5% (95% CI, 61.1%-100.0%) and 71.9% (95% CI, 42.8%-90.0%) for intensive care unit admissions. Among immunocompromised individuals, protection against documented infections decreased from 75.2% (95% CI, 52.5%-89.3%) to 39.7% (95% CI, 23.9%-52.7%). Conclusions and Relevance:The study found that RSV vaccination was effective in preventing RSV illness and associated health care use but that protection decreased over 2 seasons. Reductions were most notable among immunocompromised persons, suggesting the need to review whether additional vaccine doses may benefit certain risk groups.
RATIONALE:A range of surgical options is available for the treatment of benign prostatic hyperplasia (BPH), including holmium laser enucleation of the prostate (HoLEP). The evidence is unclear regarding differences in functional, perioperative, and morbidity outcomes between these modalities. OBJECTIVES:To assess the effects of holmium laser enucleation of the prostate compared with other surgical treatments for lower urinary tract symptoms in men with benign prostatic hyperplasia. SEARCH METHODS:We searched multiple databases (including MEDLINE, Embase, CENTRAL, Web of Science, LILACS, and the International HTA database), trial registries, and conference abstracts through April 08, 2026. ELIGIBILITY CRITERIA:We only included randomized trials of men over 40 years of age with a prostate volume of at least 20 mL (assessed by digital rectal examination, ultrasound, or conventional imaging) who exhibited lower urinary tract symptoms (LUTS) defined by an International Prostate Symptom Score (IPSS) of eight or greater undergoing surgical interventions for BPH. OUTCOMES:The critical outcomes measured were the urologic symptoms score, the quality-of-life score, and major adverse events. The important outcomes measured were: re-treatment, erectile function, ejaculatory function, transfusions, acute urinary retention, indwelling urinary catheter duration, and hospital stay duration. RISK OF BIAS:We used the Cochrane risk of bias tool (RoB 1) to assess for potential sources of bias on a study and outcome level basis. SYNTHESIS METHODS:We pooled outcome data using the random-effects model and performed meta-analyses using the Mantel-Haenszel method. We assessed statistical heterogeneity in the pooled data by visually inspecting forest plots and using the I2 statistic to quantify it. We used the GRADE framework to assess the certainty of evidence. INCLUDED STUDIES:We included 52 trials that included 6242 participants that compared HoLEP to other surgical interventions for benign prostatic hyperplasia. The median age of participants across the studies ranged from 65 to 74 years. The baseline prostate volume ranged from 30 cc to 142 cc. Baseline IPSS scores ranged from 19.6 to 28.6 (range 0-35). SYNTHESIS OF RESULTS:We prioritized comparing HoLEP with transurethral resection of the prostate (TURP) at short-term follow-up (up to 12 months), because TURP is the long-standing reference standard and the predominant comparator in randomized surgical trials. Findings for the four remaining comparisons (laser ablation, alternative energy source enucleation, other minimally invasive therapies, and simple prostatectomy), for long-term follow-up, and for all remaining outcomes are reported in full in the review. Compared to TURP, at short-term follow-up: Critical outcomes - HoLEP may result in little to no difference in short-term urologic symptom scores measured using the IPSS (range 0 to 35; lower values reflect fewer symptoms) (MD -0.67, 95% CI -1.20 to -0.14; I² = 93%; 14 studies, 1666 participants, low-certainty evidence). - HoLEP may result in little to no difference in short-term quality of life (range 0 to 6; lower values reflect better quality of life) (MD -0.04, 95% CI -0.23 to 0.15; I² = 73%; 6 studies, 876 participants, low-certainty evidence). - HoLEP may result in little to no difference in short-term major adverse events (RR 0.75, 95% CI 0.35 to 1.58; I² = 0%; 10 studies, 1147 participants, low-certainty evidence). Important outcomes - HoLEP likely results in little to no difference in re-treatment (RR 0.45, 95% CI 0.14 to 1.50; I² = 0%; 8 studies, 813 participants, moderate-certainty evidence). - HoLEP likely results in little to no difference in erectile function (MD -0.03, 95% CI -0.47 to 0.42; I² = 0%; 3 studies, 518 participants, moderate-certainty evidence). - Ejaculatory function: we did not find any data for this outcome. - HoLEP likely reduces the need for blood transfusion (RR 0.19, 95% CI 0.09 to 0.42; I² = 0%; 15 studies, 1755 participants, moderate-certainty evidence). AUTHORS' CONCLUSIONS:Compared with TURP, HoLEP may achieve similar relief of urologic symptoms, similar quality of life, and similar rates of major adverse events in the first 12 months after surgery, and probably similar re-treatment rates and erectile function. HoLEP likely reduces the need for blood transfusion; this is the only advantage of HoLEP that the randomized evidence, as summarized here, supports as clinically important. There was insufficient evidence to assess outcomes in the subset of individuals with larger prostates or on anticoagulation. Future research should prioritize long-term trials reporting sexual function and urinary incontinence outcomes, recruit men with very large prostates (≥ 150 cc) or on anticoagulation therapy, and evaluate cost-effectiveness and training requirements. FUNDING:No external funding was received for this review. REGISTRATION:The protocol for this review was published in the Cochrane Database 2019 (https://doi.org/10.1002/14651858.CD013291).
OBJECTIVE:To determine associations between central adiposity, cognitive function, and randomized menopausal hormone therapy (MHT) in a reanalysis of the Kronos Early Estrogen Prevention Study-Cognitive and Affective (KEEPS-Cog) sub-study participants. METHODS:KEEPS randomized 727 women (ages 42-58) who were <36 months postnatural menopause to oral conjugated equine estrogens (o-CEE), transdermal 17-β-estradiol (t-E2), or placebo for 48 months. Participants with diabetes, body mass index >35 kg/m 2 , coronary artery calcium score >50 Agatston Units, and other cardiometabolic disease risk indicators were excluded from enrollment. In the ancillary KEEPS-Cog study, cognitive tests were completed at baseline, 18-, 36-, and 48-month post-randomization. In these analyses, cognitive variables were summarized as four cognitive domain-specific factor scores: verbal learning and memory, auditory attention and working memory, visual attention and executive function, and speeded language and mental flexibility. Waist-hip-ratio (WHR), an indicator of central adiposity, was measured at screening (baseline) and modeled as a covariate in linear latent growth models assessing associations of MHT with cognitive functions at baseline and over time. RESULTS:Higher baseline WHR was associated with poorer performance on all domain-specific cognitive outcomes at baseline and with changes in visual attention and executive function across time. Models including interaction effects were not significant for either o-CEE x WHR or t-E2 x WHR. CONCLUSION:Central adiposity is a risk factor for domain-specific cognitive decline, and thus, cognitive health effects should be investigated in early postmenopausal women, even in women with low cardiovascular risk statuses.
