Federal practitioner : for the health care professionals of the VA, DoD, and PHS最新文献

Background: COVID-19 imposes a special risk to the nursing home population, including community living centers (CLCs) for veterans. Cycle threshold/cycle number (CT/CN) values obtained by serial reverse transcriptase polymerase chain reaction (RT-PCR) testing could yield valuable information about viral load and potential infectiousness. Serial testing for COVID-19 with CT/CN correlates in a nursing home population during an outbreak has not yet been reported in the literature.

Methods: A retrospective review of serial RT-PCR testing for COVID-19 during an outbreak at a CLC was performed from March 28 to April 4, 2020, with follow-up of identified patients until November 10, 2020. Testing was performed on the Abbot m2000 or Cepheid platform.

Results: Of 80 patients tested, 25 (31%) were positive for COVID-19. CT/CN values corresponded to the infection course as expected.

Conclusions: Repeat testing for COVID-19 accompanied by CT/CN values could provide clinical and epidemiologic information about the likely stage of the patients' disease course, which may aid public health measures and clinical management.

Background: Pneumatosis intestinalis is the presence of gas within the walls of the intestine on imaging and has variable clinical significance, ranging from an incidental finding to a harbinger of intra-abdominal catastrophe. There are multiple mechanisms by which this radiographic finding develops, including bacterial gas production, increased intraluminal pressure within the gastrointestinal tract, mechanical disruption of the gut mucosa, and tracking of pulmonary gas along the mesenteric vasculature.

Case presentation: We present the case of a 61-year-old male veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have pneumatosis intestinalis without signs of intra-abdominal catastrophe.

Conclusions: Appropriate interpretation of this finding can lead to life-saving interventions and avoid unnecessary surgical procedures.

Background: Studies have shown that nonmedical reading is associated with low burnout and that small group study sections can promote wellness. Burnout and other psychosocial distress are common among health care professionals, necessitating additional measures to promote well-being. The field of narrative medicine is one proposed solution.

Observations: We added small narrative medicine group discussions of nonmedical fiction to our hematology oncology clinical program to promote physician resilience and decrease risk for burnout. We explored how reading and reflecting would result in profound changes in thinking and feeling and noted 7 different ways by which reading and reflecting together can increase well-being. We describe how stories led us to increase bonding, improve empathy, and promote meaning in medicine.

Conclusions: Our small group discussions showed that the intervention was feasible, improved empathy and fulfillment at work, and resulted in greater appreciation for the human dimensions of health care.

Background: Advanced cases of nasopharyngal carcinoma can present with skull base invasion. Treatment of these advanced cases with radiotherapy poses a challenge given proximity of tumor to critical neural structures as well as concern that a skull base defect and associated complications could develop with tumor regression.

Case presentation: A 34-year-old male patient presented with a 7-cm nasopharyngeal tumor invading the skull base with destruction of the clivus and intracranial extension. He underwent a course of definitive chemoradiation, requiring use of adaptive radiotherapy, that resulted in complete tumor regression and is free of disease 5 years posttreatment. Imaging done during treatment demonstrated that significant regeneration of bone occurred simultaneously with tumor regression.

Conclusions: This case demonstrates that it is possible for bony regeneration to occur simultaneously with tumor regression in a patient with skull base invasion by tumor, precluding the need for neurosurgical intervention.

Background: The aim of clinical peer review (PR) is to improve facility health care quality. However, prior authors have shown that PR may be biased, have rater reliability concerns, or be used for punitive reasons. It is important to determine whether facility PR processes are related to objective facility quality of care.

Methods: We collected proportion of PR findings that "most experienced and competent clinicians may have managed the case differently" or "most experienced and competent clinicians would have managed the case differently" as an objective measure of facility PR processes and outcomes. We correlated these with facility quality metrics for 2019.

Results: PR findings were not associated with facility quality metrics but were strongly associated with previous year findings.

Conclusions: This study describes a potentially new source of bias in PR and demonstrates that objective facility outcomes are not related to individual PR findings.

Background: Emerging data indicates that natriuretic peptide biomarker-based screening and early intervention could prevent left ventricular dysfunction or new-onset heart failure (HF). The 2017 update of the American College of Cardiology/ American Heart Association/Heart Failure Society of America guideline for managing HF provides a IIa recommendation for natriuretic peptide biomarker screening followed by a team-based approach for preventing HF.

Observations: Clinical pharmacists worked collaboratively with a cardiology specialist and primary care practitioners to establish a protocol to identify patients at risk for HF. Patients with hypertension and/or type 2 diabetes mellitus (T2DM) and without a history of HF with N-terminal pro-B-type natriuretic peptide > 125 pg/mL received follow-up from clinical pharmacists, including initiation and/or adjustment of reninangiotensin system inhibitors, discussion of echocardiogram, and comprehensive disease state management of hypertension, T2DM, atherosclerotic cardiovascular disease risk reduction, oral nonsteroidal anti-inflammatory drug reduction, and tobacco cessation.

Conclusions: By using natriuretic peptide screening, clinical pharmacists were able to identify patients with hypertension and/or T2DM who were at higher risk for HF and provide comprehensive medication management.

Background: Black individuals and veterans are at higher risk for developing lung cancer compared with that of the general population. Evidence suggests the screening criteria have been too conservative for this population.

Methods: This study is a retrospective chart review examining the applicability of the 2013 United States Preventive Services Task Force lung cancer screening guidelines in a US Department of Veteran Affairs institution that served a a predominantly black population. Patients diagnosed with stage 1 or 2 lung cancer from 2005 through 2017 were included and grouped by whether or not they met United States Preventive Services Task Force screening criteria.

Results: There was a significantly higher proportion of Black patients in the study group that did not meet screening criteria (68% vs 54%, P = .04), highlighting the concern that this population was being underscreened with the 2013 guidelines.

Conclusions: An individualized, risk-based screening model could be more effective at diagnosing early-stage lung cancer and requires more investigation.

Background: Penile leiomyosarcoma arises from smooth muscles, which can be from dartos fascia, erector pili in the skin covering the shaft, or from tunica media of the superficial vessels and cavernosa. We describe presentation, treatment options, and recurrence pattern of this rare malignancy.

Case presentation: We present a case of penile leiomyosarcoma in a 70-year-old patient who presented to the urology clinic with 1-year history of a slowly enlarging penile mass associated with phimosis.

Conclusions: Prognosis of penile LMS is difficult to ascertain because reported cases are rare. Penile leiomyosarcoma can be classified as superficial or deep based on tumor relation to tunica albuginea. Deep tumors (> 3 cm), high-grade lesions, and tumors with involvement of corpora cavernosa, tend to spread locally and metastasize to distant areas and require more radical surgery with or without postoperative radiation therapy. In contrast, superficial lesions can be treated with local excision only.

Background: The federal government responded to the early epicenter of the COVID-19 pandemic in the United States by mobilizing uniformed services and other federal medical personnel to treat patients at the Javits New York Medical Station. Deployment of large numbers of personnel required flexible psychiatric and psychological support.

Observations: This report details the establishment of mental health support services for frontline personnel in a large convention center and explores lessons learned to encourage future mental health professionals to apply creative and assertive mental health interventions in disaster settings.

Conclusions: Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating services throughout the civilian medical system. We suggest mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario.

Background: Psychosocial barriers, including low socioeconomic status, homelessness, alcohol and substance use disorders, and psychiatric disorders are prevalent in US veterans. Our study aims to identify the prevalence of psychosocial barriers in veterans diagnosed with hepatocellular carcinoma (HCC), and their impact on receipt of cancer care.

Methods: A retrospective cohort study was performed of all veterans diagnosed with HCC at the William S. Middleton Memorial Veterans' Hospital in Madison, Wisconsin, whose tumor care was coordinated through a multidisciplinary tumor board. Outcomes included receipt of any HCC-specific therapy and overall survival.

Results: From January 1, 2007, through December 31, 2016, 149 veterans were diagnosed with HCC. Substance use disorders were reported in 124 (83%) patients, psychiatric illness was documented in 55 (37%) patients, 23 (15%) patients had incomes below the poverty threshold, and 7 (5%) were experiencing homelessness. The mean (SD) distance traveled for care was 207.1 (277.9) km; travel and lodging assistance were accessed by 50 (34%) and 33 (22%) veterans, respectively. Seventy-one patients (48%) had HCC exceeding T2 stage at diagnosis. Curative treatment was offered to 78 (52%) patients, with 127 (85%) receiving any HCC-specific care. Median survival from diagnosis was 727 days (95% CI, 488-966).

Conclusions: Psychosocial barriers were common in our veteran cohort. Individualizing care, and coordination of travel and lodging, assisted in enabling high rates of receipt of HCC-specific therapy and improving patient survival.