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

Background: Accurate and timely prescriptions of COVID-19 therapeutics, laboratory testing, and antimicrobial stewardship have been a challenge throughout the pandemic as new evidence emerges. While universal consultation with infectious disease specialists on patients admitted with COVID-19 is desirable, it is not always feasible due to limited resources.

Observations: In this single-center study, we implemented a combined educational and laboratory stewardship intervention geared toward hospitalist practitioners resulting in improved accuracy of remdesivir and dexamethasone prescriptions, reduced laboratory use of blood cultures, interleukin 6 assay, and Legionella sputum cultures, and a decrease in antibiotic use for patients with mild-to-moderate oxygen requirements over 6 months. These improvements were seen in tandem with decreased reliance on infectious disease consultation.

Conclusions: These efforts support proof of the principle of combined educational and laboratory stewardship interventions to improve the care of COVID-19 patients, especially where infectious disease consultation may not be available or is accessed remotely.

Background: Many patients arrive in the emergency department (ED) with acute pain. Battlefield acupuncture (BFA) uses small, semipermanent acupuncture needles in 5 set points anatomically located on each ear to reduce pain in a few minutes. Pain relief can last months, depending on the pathology of the pain. At the Jesse Brown Veterans Affairs Medical Center (JBVAMC) ED, ketorolac 15 mg is the preferred first-line treatment of acute, noncancer pain. In 2018, BFA was offered first to veterans presenting with acute or acute-on-chronic pain to the ED; however, its effectiveness in pain reduction vs ketorolac has not been evaluated in this patient population. The objective of this study was to determine whether BFA monotherapy was noninferior to ketorolac 15 mg for reducing pain scores in the ED.

Methods: This study was a retrospective, electronic chart review of patients who presented to JBVAMC ED with acute pain or acute-on-chronic pain and received ketorolac or BFA. The primary endpoint was the mean difference in the numeric rating scale (NRS) pain score from baseline. Secondary endpoints included the number of patients receiving pain medications, including topical analgesics, at discharge and treatment-related adverse events in the ED.

Results: A total of 61 patients were included in the study. Baseline characteristics were similar between the 2 groups except for the average baseline NRS pain score, which was higher in the BFA group (8.7 vs 7.7; P = .02). The mean difference in NRS pain scores from baseline to post-intervention was 3.9 for the BFA group and 5.1 for the ketorolac group. The difference in reducing the NRS pain score between the intervention groups was not statistically significant. No adverse events were observed in either treatment group.

Conclusions: For treating acute and acute-on-chronic pain in the ED, BFA did not differ compared with ketorolac 15 mg in NRS pain score reduction. This study's results add to the limited existing literature suggesting that both interventions could result in clinically significant reductions in pain scores for patients presenting to the ED with severe and very severe pain, indicating BFA could be a viable nonpharmacologic treatment option.

Background: Home dialysis utilization is lower among veterans than in the general US population. Several sociodemographic factors and comorbidities contribute to peritoneal dialysis (PD) underutilization. In 2019, the Veterans Health Administration (VHA) Kidney Disease Program Office convened a PD workgroup to address this concern.

Observations: The PD workgroup was explicitly concerned by the limited availability of PD within the VHA, which frequently requires veterans to transition kidney disease care from US Department of Veterans Affairs medical centers (VAMCs) to non-VHA facilities when they progress from chronic kidney disease to end-stage kidney disease, causing fragmentation of care. Since the administrative requirements and infrastructure of VAMCs vary, the workgroup focused its deliberations on synthesizing a standard process for evaluating the feasibility and establishing a new PD program within any individual VAMC. A 3-phased approach was envisioned, beginning with ascertainment of prerequisites, leading to an examination of the clinical and financial feasibility through the process of data gathering and synthesis, culminating in a business plan that translates the previous 2 steps into an administrative document necessary for obtaining VHA approvals.

Conclusions: VAMCs can use the guide presented here to improve therapeutic options for veterans with kidney failure by establishing a new or restructured PD program.

Background: Benzodiazepines are considered the gold standard for treatment of alcohol withdrawal syndrome (AWS), a group of symptoms that occur after abrupt cessation of alcohol use, but may be associated with serious adverse effects. Given the safety concerns, alternative treatment options for AWS management have been investigated, including gabapentin and baclofen. Because no available studies have investigated the inpatient use of the gabapentin and baclofen combination for alcohol detoxification, this study aims to evaluate their efficacy and safety in the inpatient hospital setting.

Methods: This retrospective cohort study at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, included patients who were aged ≥ 18 years and who were admitted to the general acute medicine floor for the primary indication of AWS from January 1, 2014, to July 31, 2021. The primary outcome was the length of stay, defined as hours from admission to either discharge or 36 hours with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score ≤ 8. Electronic health records were reviewed to collect CIWA scores, alcohol withdrawal seizure and delirium tremens incidence, rates of conversions from gabapentin/baclofen to lorazepam, rates of transitions to a higher level of care, and readmission for AWS within 30 days.

Results: Mean length of stay in the gabapentin/baclofen group was statistically significantly shorter compared with the benzodiazepine group (42.6 vs 82.5 hours, P < .001). The study found no significant difference between the gabapentin/baclofen and benzodiazepine groups in AWS readmission, adjuvant medications for AWS management, and number of patients who transitioned to a higher level of care. Overall, the safety of gabapentin/baclofen vs benzodiazepine were comparable; however, 1 patient experienced a seizure, and 1 patient experienced delirium tremens during admission in the benzodiazepine group.

Conclusions: Gabapentin/baclofen combination seems to be an effective and safe alternative to benzodiazepines and may be considered for managing mild AWS in hospitalized patients, but additional research is needed to examine this regimen.

Background: Staphylococcus lugdunensis (S lugdunensis) is a species of coagulase-negative Staphylococcus and a constituent of human skin flora. S lugdunensis has gained notoriety for its virulence, which resembles Staphylococcus aureus (S aureus). S lugdunensis is now recognized as an important nosocomial pathogen and cause of prosthetic device infections, including vascular catheter infections.

Case presentation: A 60-year-old man with a history of uncontrolled type 2 diabetes mellitus and end-stage renal disease on home hemodialysis via arteriovenous fistula (AVF) presented to the emergency department for evaluation of subacute progressive low back pain. Initial laboratory tests were notable for elevated inflammatory markers. Magnetic resonance imaging with contrast of the thoracic and lumbar spine revealed abnormal marrow edema in the T11-T12 vertebrae with abnormal fluid signal in the T11-T12 disc space. Cultures grew methicillin-sensitive S lugdunensis. The patient's antibiotic regimen was narrowed to IV oxacillin. He was transitioned to IV cefazolin dosed 3 times weekly after hemodialysis and an outpatient dialysis center.

Conclusions: Treatment of bacteremia caused by S lugdunensis or S aureus should be managed with prompt initiation of IV antistaphylococcal therapy, a thorough evaluation for the source of bacteremia as well as metastatic complications, and consultation with an infectious disease specialist. This case highlights AVF as a potential source for infection even without localized signs of infection. The buttonhole method of AVF cannulation was thought to be a major contributor to the development and persistence of our patient's bacteremia. This risk should be discussed with patients using a shared decision-making approach when developing a dialysis treatment plan.

Background: In 2019, the Tuba City Regional Health Care Corporation on the Navajo Reservation in northeastern Arizona established facility-wide, evidence-based outpatient antimicrobial guidelines. We aimed to evaluate adherence to these guidelines.

Methods: A retrospective chart review of the electronic health record for all ages was conducted from August 1, 2020, to August 1, 2021, to evaluate antimicrobials prescribed for indications covered by the facility prescribing guidelines. The appropriateness of the antimicrobial prescribed was assessed and reported as a percentage. An educational intervention and a survey were then distributed from March 2, 2022, to March 31, 2022, to all prescribers.

Results: Overall adherence to prescribing guidelines over the period assessed was 86%, 4% short of the study goal of 90%. Before the educational intervention, 61.5% of prescribers used the prescribing guidelines to guide their antibiotic choice, while after the educational intervention, 87.1% of prescribers indicated a willingness to use the guidelines to guide their antibiotic choice.

Conclusions: Adherence to the facility guidelines was already high at 86%. Educational interventions were performed but their efficacy could not be assessed within the time constraints of the study.

Background: Augmented reality (AR) has a wide range of potential applications to enhance health care. Understanding how the introduction of a new technology may impact employees is essential for overall health care system success.

Methods: Survey responses were obtained before and after a health care-focused interactive AR demonstration at a US Department of Veterans Affairs (VA) medical center. Data were assessed with descriptive statistics, Wilcoxon signed rank matched pairs test, pooled t test, and analysis of variance.

Results: A total of 166 individuals participated in the demonstration and survey. Statistically significant improvements were seen after the use of the new AR technology in each of the categories assessed using a 5-point Likert scale. Scores for perceptions of institutional innovativeness increased from 3.4 to 4.5 (a 22% increase; P < .001); employee excitement about the VA increased from 3.7 to 4.3 (a 12% increase; P < .001); and employee likelihood to continue working at VA increased from 4.2 to 4.5 (a 6% increase; P < .001). Subgroup analysis demonstrated statistically significant differences by employee veteran status, VA tenure, and sex. Respondents felt strongly that this type of work will positively impact health care and that the VA should continue these efforts.

Conclusions: An AR demonstration significantly increased employee excitement and intention to continue employment at the VA and provided valuable insights about the most impactful uses of AR in health care.

Background: The Age-Friendly Health Systems Initiative is a quality improvement movement led by the Institute for Healthcare Improvement and supported by the John A. Hartford Foundation to improve care for older adults. The US Department of Veterans Affairs (VA) has set a goal to become the largest integrated Age-Friendly Health System in the United States.

Observations: As the veteran population ages, delivering Age-Friendly care is an urgent priority. VA clinicians should apply the 4Ms of the Age-Friendly Health Systems Initiative: Mobility, Mentation, Medications, and What Matters.

Conclusions: No matter which floor a veteran exits on a VA elevator, they should expect to receive Age-Friendly care that will meet their needs as they age.

Background: Severe falciparum malaria with renal impairment carries a significant risk of poor outcomes, including death. Previous randomized controlled trials using acetaminophen as adjunctive treatment for malaria-associated renal failure have demonstrated improvements in renal function and kidney injury progression.

Case presentation: A 50-year-old man with severe falciparum malaria presented with hemolytic anemia, oliguric acute kidney injury, nephrotic range proteinuria, and significant architectural changes on renal ultrasound. Treatment with oral acetaminophen 975 mg every 6 hours was based on the randomized controlled trial protocol to salvage his renal function and avoid dialysis. During the acetaminophen course, urine output and cystatin C level improved with only mild, asymptomatic elevations in aminotransferases that were corrected on follow-up. The patient recovered without requiring dialysis.

Conclusions: Acetaminophen's potential to mitigate the oxidative damage of hemoproteins suggests its use as a treatment in severe malaria with renal impairment.

Background: While the literature has demonstrated a higher prevalence of moderate-to-severe obstructive sleep apnea (OSA) in the general population compared with central sleep apnea (CSA), more evidence is needed on the long-term clinical impact of and optimal treatment strategies for CSA.

Observations: CSA is overrepresented among certain clinical populations, such as those with heart failure, stroke, neuromuscular disorders, and opioid use. The clinical concerns with CSA parallel those of OSA. The absence of respiration (apneas and hypopneas due to lack of effort) results in sympathetic surge, compromise of oxygenation and ventilation, sleep fragmentation, and elevation in blood pressure. Symptoms such as excessive daytime sleepiness, morning headaches, witnessed apneas, and nocturnal arrhythmias are shared between the 2 disorders. A systematic clinical approach should be used to identify and treat CSA.

Conclusions: The purpose of this review is to familiarize the primary care community with CSA to aid in the identification and management of this breathing disturbance.