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

Background: Pancytopenia is a result of increased destruction or decreased production of bone marrow cells and has a broad differential. Pernicious anemia commonly presents as a macrocytic anemia and is typically autoimmune in nature and the result of vitamin B₁₂ deficiency. Pancytopenia is a rare presentation of this disorder especially in the setting of hemolysis. Testing in the deployed setting may be limited and/or challenging.

Case presentation: A 24-year-old female patient with a history of Hashimoto thyroiditis presented during an overseas deployment with a witnessed syncopal episode and was found to be pancytopenic with a mild transaminitis and laboratory tests demonstrating hemolysis. Though initially she was hypotensive, tachycardic, and febrile, her vitals improved after multiple transfusions, but she had persistent cytopenia with transfusion dependence, concerning for aplastic anemia or acute leukemia.

Conclusions: Testing for B₁₂ deficiency is crucial in symptomatic, patients with pancytopenic to either diagnose or exclude pernicious anemia and conserve resources by preventing costly workup and transfer/escalation of medical care, especially in the deployed setting. A predeployment screening in those with history of autoimmune disorders may be warranted.

Background: Priapism is a disorder that occurs when the penis maintains a prolonged erection in the absence of appropriate stimulation. Conditions that result in hypercoagulable states and hyperviscosity are associated with ischemic priapism. COVID-19 is increasingly associated with coagulopathy. To date, there are 6 reported cases of priapism occurring in patients with COVID-19, 5 occurring in the setting of critical illness.

Case presentation: We present a case of ischemic priapism which we suspect resulted from COVID-19-associated coagulopathy in a patient without severe COVID-19 presentation.

Conclusions: Although there have been only a handful of reported cases of COVID-19-associated coagulopathy leading to ischemic priapism, it is possible that the true incidence is much higher. While our case highlights the importance of considering COVID-19 infection in the differential diagnosis of ischemic priapism, more research is needed to understand incidence and definitively establish a causative relationship.

Background: Several studies indicate that when patients transition from one level of care to another, errors may occur. Pharmacists can play an integral role in the transitions of care process. At Michael E. DeBakey Veteran Affairs Medical Center, the Home-Based Primary Care (HBPC) service has implemented a streamlined hospital discharge plan to improve 30-day readmission rates after 1 year of HBPC enrollment.

Methods: Our aim was to identify specific pharmacist interventions to improve the HBPC discharge process and ultimately, improve hospital readmission rates. A Plan-Do-Study-Act quality improvement project was initiated. We conducted a review of veterans enrolled in HBPC from October 2019 to March 2020.

Results: Of 175 patients assessed postdischarge, a medication reconciliation was completed by an HBPC pharmacist in 118 (67.4%) patients. Of the 118 medication reconciliations completed, 92 (78%) interventions were made by HBPC pharmacists. During the 6-month study period, 30-day hospital readmission rates decreased from 19% to 13%.

Conclusions: This study demonstrates several opportunities for interventions to lower readmission rates. Using the results from this study, education has been provided for the HBPC service and its readmission committee.

Background: Rhabdomyolysis is caused by muscle overuse, trauma, prolonged immobilization, drugs, or toxins. As rhabdomyolysis progresses, swelling and edema can compress surrounding structures. Few cases of the phenomenon occurring as a sequela of substance use have been described.

Case presentation: We present a 68-year-old male patient with rhabdomyolysis following use of crack cocaine contaminated with fentanyl. The patient had 0/5 strength bilaterally and bilateral absent reflexes in the upper extremities. Sensation was markedly decreased, as he was unable to feel temperature, pinprick sensation, or general touch. Creatine phosphokinase level was elevated at 21,292 IU/L. On magnetic resonance imaging, there was abnormal signal in the lower neck bilaterally. It is presumed that muscular edema resulted in partial narrowing of the thoracic outlet bilaterally with corresponding mass effect on the traversing brachial plexus.

Conclusions: This is the seventh case of brachial plexopathy secondary to rhabdomyolysis precipitated by opioid use that has been reported in the literature. Prospective studies should examine treatment for this condition.

Background: Geospatial analyses illustrating where the Home Improvements and Structural Alterations program (HISA) have been prescribed suggest that home modification (HM) services under US Department of Veterans Affairs (VA) is not prescribed and used uniformly across the US.

Methods: The objective of this study was to identify county characteristics associated with HISA use rates, such as county-level measures of clinical care and quality of care, variables related to physical environment, and sociodemographic characteristics. Multiple regression analysis was used to predict county-level utilization rate from county-level variables.

Results: County-level HISA use was highly skewed and ranged from 0.09 to 59.7%, with a mean of 6.6% and median of 5%. Percent uninsured adults and rate of preventable hospital stays emerged as significant predictors of county-level HISA utilization rate. Specifically, county percentage of uninsured adults was negatively related to county-level HISA utilization rate (b = -8.99, P = .005). The higher the proportion of uninsured adults the lower the HISA utilization rate. The county rate of preventable hospital stays was positively related to county-level HISA utilization rate (b = .0004, P = .009). County-level predictors of housing quality were not significantly associated with county-level HISA utilization rate.

Conclusions: Our research fills a gap in the literature about the impact of county-level variables and the geographic distribution and use of HISA. More research is needed to understand and account for geographical variation in HISA use. This work serves as a first step at quantifying and predicting HISA utilization rate at a broad level, with the goal of increasing access to HMs for veterans with disabilities.

Background: Rheumatologic conditions share many symptoms with infectious processes. The immunosuppressive therapies used in rheumatology unfavorably impact any underlying infection. Nontuberculous mycobacteria (NTM) are difficult to grow in culture media and may affect the musculoskeletal system, developing manifestations that may imitate rheumatic inflammatory arthritis. For this reason, surgical debridement and biopsy culture are essential in cases where suspicion remains high.

Case presentation: We present the case of a patient with progressively worsening right-hand tenosynovitis who was evaluated for rheumatic conditions given initial negative synovial tissue biopsy cultures. He was finally diagnosed with Mycobacterium marinum infectious tenosynovitis after repeated surgical debridement.

Conclusions: Our case reinforces the vital role of history gathering in establishing diagnoses and underscores the value of clinical suspicion in patients unresponsive to standard treatment for inflammatory arthritis. Tissue biopsy with culture for acid-fast bacilli is crucial for accurate diagnosis in NTM infection, which may imitate rheumatic inflammatory arthritis. Physicians should be keenly aware of this fastidious, indolent organism in the setting of persistent localized tenosynovitis.

Background: Hospital in Home (HIH) involves the delivery of acute care services in a patient's home. There is currently a paucity of published information regarding nutrition care in HIH.

Observations: The registered dietitian nutritionist (RDN) contributes to HIH by providing personalized medical nutrition therapy and collaborating with the HIH interdisciplinary team for optimal health care delivery. Tips for utilizing RDN services are also discussed.

Conclusions: As HIH becomes more widely adopted within the Veterans Health Administration and other health care systems, it is crucial to consider the value and expertise of the RDN for guiding nutrition care in the HIH setting.

Background: The US Department of Veterans Affairs designated education officer (DEO) is a unique facility-based leadership role responsible for training of > 40 health professions in cooperation with affiliated academic institutions.

Methods: We conducted mixed methods analyses of data from a DEO needs assessment. Quantitative analysis identified differences between DEOs who are physicians and DEOs who are other professions on role characteristics and self-perceived task effectiveness. Qualitative analysis using rapid analysis procedures was applied to open-ended responses on facilitators and barriers.

Results: Responses were received from 127 DEOs (96% response rate). About 80% were physicians. There were no statistically significant differences between physician and other professional DEOs self-ratings for general tasks. For profession-specific tasks, physician DEOs were significantly less confident than other professional DEOs in working with associated health (P < .001-.01) and nurse training programs (P < .001-.03). DEOs identified multiple facilitators that assist their individual effectiveness (eg, training, mentorship, communication) and common barriers (eg, not enough staff).

Conclusions: Our findings are supportive of individuals from various health disciplines serving in the DEO role with responsibilities that span multiple health profession training programs. Future quantitative and qualitative work should include additional measures of individual and organizational characteristics, and actual measures of educational effectiveness.