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

Background: Justice-involved veterans demonstrate greater mental health and psychosocial needs relative to justice-involved nonveterans and veterans without a criminal history. Veterans treatment courts (VTCs) serve as an alternative to incarceration for veterans whose criminogenic risk is believed to be related to mental health symptoms. Despite observed improvements in functioning and recidivism risk following successful VTC completion, little is known about factors that impede engagement with VTCs. This paper describes a trauma-informed training program that included psychoeducation, skills training, and consultation and was developed for court professionals to facilitate veteran engagement in VTCs.

Observations: Needs assessments and court observations informed program development. Based on identified needs, the training incorporated skills from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing. Two VTCs in the Rocky Mountain region participated in the pilot trauma-informed training, each lasting about 90 to 120 minutes. Feedback from attendees indicated that the focus on skills training-specifically, managing intense emotions, addressing ambivalence, and approaching sanctions and rewards-was uniquely helpful. The function of posttraumatic stress disorder symptoms and structure of evidence-based treatments were identified as useful educational components.

Conclusions: Veterans Health Administration mental health professionals can serve an important role in facilitating effective practices for professionals working within VTCs. This pilot program provided preliminary support for skills-based training to bolster communication, motivation, distress tolerance, and engagement among veterans court participants. Future directions of this program may include expanding the training into a full-day workshop, conducting comprehensive needs assessments, and examining program outcomes.

Background: The rarity and heterogeneity of mucormycosis make treatment variable, and no prospective or randomized clinical trials exist in plastic surgery literature. The use of wound vacuum-assisted closure in combination with the instillation of amphotericin B to treat cutaneous mucormycosis is not well documented.

Case presentation: A 53-year-old man underwent left Achilles tendon reconstruction with allograft after a complete tear during exercise. About 1 week after the operation, he began having incisional breakdown later found to be secondary to mucormycosis infection, prompting presentation to an emergency department. The use of negative pressure wound therapy with wound vacuum-assisted closure and intervals of instilling amphotericin B facilitated infection control in this lower extremity mucormycosis infection.

Conclusions: Patients with a localized mucormycosis infection may benefit from treatment with an instillation wound vacuum-assisted closure with topical amphotericin B as presented in this case study.

Background: Statins and PCSK9 inhibitors (PCSK9i) are used to lower low-density lipoprotein cholesterol and reduce cardiovascular events, yet some patients are unable to tolerate statin therapy due to muscle-related adverse events (AEs). The effect of PCSK9i on muscle-related AEs is not well studied, and available data show inconsistent incidence rates.

Methods: The primary study outcome was to determine the percentage of patients who developed muscle-related PCSK9i AEs. A secondary outcome was to analyze data based on 4 subgroups: tolerated a full PCSK9i dose; tolerated alternative PCSK9i following initial intolerance; required a PCSK9i dose reduction, or discontinued PCSK9i. In addition, the percentage of statin- and/or ezetimibe-intolerant patients in these 4 groups was determined. Another secondary outcome was the management strategies taken for patients who were on a reduced (monthly) dose of PCSK9i who did not reach their low-density lipoprotein cholesterol goal. Statin intolerance was defined as intolerable skeletal muscle AEs on at least 3 different statins. We conducted a single-center, retrospective review of patients prescribed a PCSK9i between December 1, 2017, and September 1, 2021, at a patient aligned care team clinic at the Wilkes-Barre Veterans Affairs Medical Center.

Results: The study included 137 veterans. Twenty-four patients (17.5%) developed a muscle-related AE while on a PCSK9i. In predefined subgroups studied, statin intolerance ranged from 68.1% to 100%, ezetimibe intolerance ranged from 41.6% to 83.3%, and both statin and ezetimibe intolerance ranged from 36.3% to 83.3%.

Conclusions: In this study, muscle-related PCSK9i AEs occurred at a similar incidence rate to that reported in previous clinical trials and exceeded the incidence rate reported in the prescribing information for alirocumab and evolocumab. It also appears that patients who have a prior muscle-related intolerance to a statin and/or ezetimibe have a higher likelihood of developing a muscle-related AE to a PCSK9i.

Background: The US Department of Veterans Affairs (VA) is the largest educator of health professions trainees in the country, but the roles and responsibilities of the modern clinician educator are increasingly challenging and complex. Most VA academic hospitalists with access to professional and faculty development receive it through academic affiliates. Many VA hospitalists lack this option, and teaching within the VA is unique given its specific health system, clinical environments, and patient population.

Observations: Teaching the Teacher is a facilitation-based educational series for inpatient hospitalists at VA medical centers that is tailored to self-reported needs and provides faculty development through the lens of VA medicine. The transition from in-person to synchronous virtual programming allowed for wider dissemination of the program, and to date, 10 VA hospitalist sections across the country have participated in the series.

Conclusions: VA clinicians want and deserve dedicated training to optimize their confidence and skills in their roles as health professions educators. Teaching the Teacher is a pilot faculty development program that has met success based on its goal of meeting the specific needs of VA clinician educators in hospital medicine. It has the potential to serve as a model for clinical educator onboarding and to allow for the rapid spread of best teaching practices among clinical educators.

Background: Aspirin is commonly used for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) but may cause more harm than benefit. This study aimed to assess the percentage of patients who were inappropriately prescribed aspirin in the veteran patient population and to assess safety outcomes associated with inappropriate aspirin use.

Methods: Retrospective chart reviews were conducted on up to 200 patients with active prescriptions for 81-mg aspirin tablets filled between October 1, 2019, and September 30, 2021, at the Captain James A. Lovell Federal Health Care Center in Illinois. The primary endpoint was the percentage of patients inappropriately on aspirin therapy and whether these patients were being followed by a clinical pharmacy practitioner. Each patient record was reviewed to determine the appropriateness of aspirin therapy by assessing the indication for use. Safety data were collected for patients who were deemed to be using aspirin inappropriately, including documentation of any major or minor bleeding events.

Results: A total of 105 patients were included in this study. For the primary endpoint, 31 patients (30%) had a possible ASCVD risk and were taking aspirin for primary prevention, while 21 patients (20%) had no ASCVD and were taking aspirin for primary prevention. For the secondary endpoint, 25 patients were aged > 70 years, 15 patients were concurrently taking medications that might increase bleeding risk, and 11 patients had chronic kidney disease. Looking at the entire study patient population, for the safety endpoint, 6 patients (6%) experienced a major bleeding event while on aspirin, and 46 (44%) experienced a minor bleeding event while on aspirin.

Conclusions: Common factors seen in this study to warrant deprescribing aspirin for primary prevention included individuals aged > 70 years, concurrent use of medications that increase bleeding risk, and patients with chronic kidney disease. By assessing ASCVD and bleeding risks and having a risk/benefit discussion with patients and prescribers, aspirin used for primary prevention can be appropriately deprescribed when the risks of bleeding outweigh the benefits.

Background: The use of biologic agents for severe asthma has transformed management, decreasing asthma exacerbations, improving lung function, reducing corticosteroid use, and decreasing hospitalizations. However, numerous financial and logistic barriers have complicated the implementation of biologic agents, including long wait times to see specialists and insurance coverage.

Observations: A retrospective chart review was performed for 15 patients enrolled in this severe allergy clinic at the Washington DC Veterans Affairs Medical Center over 30 months. Outcomes examined included emergency department visits, hospitalizations, intensive care unit (ICU) stays, forced expiratory volume (FEV₁), and steroid use. The average use of steroids decreased from 4.2 to 0.6 tapers per year following the initiation of biologics. There was an average 10% improvement in FEV₁ after starting a biologic. Thirteen percent of patients (n = 2) had an emergency department visit for an asthma exacerbation since starting a biologic agent, 0.6% of patients (n = 1) had a hospital admission for an asthma exacerbation, and no patients had an ICU stay.

Conclusions: Biologic agents have significantly improved outcomes for patients with severe asthma. The model of a combined allergy/pulmonology clinic can be particularly efficacious in the treatment of severe asthma, as it reduces the need for multiple appointments with different specialties, reduces wait time before starting a biologic agent, and offers the perspective of 2 specialists.

Background: Kikuchi-Fujimoto disease (KFD) is a rare cause of rapidly evolving tender cervical lymphadenopathy. It is often initially misdiagnosed and managed as infectious lymphadenitis. Although most cases of KFD are self-limited and improve with antipyretics and analgesics, some are more refractory and may require corticosteroids or hydroxychloroquine therapy.

Case presentation: A 27-year-old White man presented for evaluation of fevers and painful cervical lymphadenopathy. He was found to have KFD on excisional lymph node biopsy. His symptoms proved challenging to manage with corticosteroids but eventually improved with hydroxychloroquine monotherapy.

Conclusions: KFD diagnosis should be considered irrespective of geographic location, ethnicity, or patient sex. Hepatosplenomegaly is a relatively rare manifestation of KFD that can make it especially difficult to distinguish from lymphoproliferative disorder, such as lymphoma. Lymph node biopsy is the preferred diagnostic approach to achieve a timely and definitive diagnosis. Although usually self-limited, KFD has been associated with autoimmune conditions, including systemic lupus erythematosus. Securing the diagnosis of KFD is therefore crucial to ensuring patients are monitored appropriately for the development of associated autoimmune conditions.

Background: Limited information exists to guide shared clinical decision making on COVID-19 vaccination in persons with a prior history of vaccine-associated myocarditis, pericarditis, or myopericarditis (VAMP). The objective of this retrospective observational case series was to characterize cardiac outcomes within 30 days following receipt of 1 or more COVID-19 vaccinations during 2021 in US service members diagnosed with prior non-COVID-19 VAMP between 1998 and 2019.

Methods: As part of the collaborative public health mission with the Centers for Disease Control and Prevention for enhanced vaccine adverse events surveillance, the Defense Health Agency Immunization Healthcare Division maintains a clinical database of service members and beneficiaries referred for suspected adverse events following immunizations. Cases in this database recorded between January 1, 2003, and February 28, 2022, were reviewed to identify individuals with prior VAMP who received a COVID-19 vaccine in 2021 and developed signs or symptoms suggestive of VAMP within 30 days following COVID-19 vaccination.

Results: Before the COVID-19 pandemic, 431 service members had verified VAMP. Among these 431 patients, 179 had records that confirmed receipt of a COVID-19 vaccine in 2021. Of these 179 patients, 171 (95.5%) were male. Their median age was 39 years (range, 21-67) at the time of COVID-19 vaccination. Most (n = 172; 96.1%) experienced their original VAMP episode after receipt of the live replicating smallpox vaccine. Eleven patients experienced cardiac-suggestive symptoms (chest pain, palpitations, or dyspnea) within 30 days of COVID-19 vaccination. Four patients met the criteria for recurrent VAMP. Three men aged 49, 50, and 55 years developed myocarditis within 3 days of an mRNA COVID-19 vaccine. One 25-year-old man developed pericarditis within 4 days of receiving an mRNA vaccine. All 4 COVID-19 recurrent VAMP cases fully recovered with minimal supportive care within weeks (myocarditis) to months (pericarditis).

Conclusions: As demonstrated by this case series, albeit rare, VAMP may reoccur after COVID-19 vaccination among patients who experienced cardiac injury after smallpox vaccination. The clinical characteristics and course of the 4 recurring cases were mild, appearing similar to the post-COVID-19 VAMP described in individuals without a history of VAMP. More research is warranted on factors that may predispose patients to vaccine-associated cardiac injury and which vaccine platforms or schedules may reduce the risk of recurrence among patients who have experienced these events.