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

Background: Despite the morbidity and mortality associated with COVID-19 infection, vaccine hesitancy remains a barrier to uptake. This article assessed whether unique clusters can be identified based on COVID-19-related thoughts and feelings and whether cluster membership is associated with COVID-19 vaccination. We also explored how individuals' thoughts, beliefs, and trust shape motivations and hesitancies for vaccine use.

Methods: This mixed-methods quality improvement project was conducted from July 2021 through May 2022 in Primary Care at the Veterans Affairs Pittsburgh Healthcare System. The primary outcome was self-reported COVID-19 vaccination. K-means analysis were used to identify clusters based on questionnaire responses, and multivariable logistic regression were used to assess the association between cluster membership and vaccination. We conducted qualitative interviews with patients in the 2 clusters with the lowest vaccination rates to explore vaccination motivations and hesitancies.

Results: Among 1208 respondents, 1034 (85.6%) were vaccinated. Four unique clusters were identified with vaccination rates of 29.9%, 93.3%, 93.5%, and 98.9%. Cluster membership was independently associated with vaccination, with adjusted odds ratios in the 3 most frequently vaccinated clusters of 12.1 (95% CI, 6.1-23.8), 13.0 (95% CI, 6.9-24.5), and 48.6 (95% CI, 15.5-152.0). Thematic analyses of 47 qualitative interviews found that protecting oneself and protecting others were the most common motivators for vaccination. The most common concerns were the rapid development of the vaccines and adverse effects, both more frequently endorsed in the cluster with the lowest vaccination rate.

Conclusions: Unique patient clusters based on infection- and vaccine-related thoughts and feelings are independently associated with COVID-19 vaccination. Identifiable themes regarding vaccine uptake and hesitancy vary among these clusters. These themes can be used to tailor strategies to diminish vaccine hesitancy and augment vaccination uptake among veterans.

Background: About 9% of all patients have a health record indicating penicillin allergy, but only 10% of these patients are truly allergic on confirmatory testing. This high percentage of incorrect labeling creates a burden for the health care system and patients, making the removal of this diagnosis an important priority. Until recently, penicillin delabeling has been done primarily by allergists, but integration with primary care is needed.

Observations: A program was developed that successfully trained primary care practitioners (PCPs) to use the PEN-FAST clinical criteria to identify low-risk patients and conduct an oral test for allergy. This model allows low-risk patients to undergo testing in a primary care office with resources available to treat any immunoglobulin E mediated severe reaction. Patients who test negative for a penicillin allergy can then be delabeled and receive more appropriate antibiotics during future infections. Skin testing was only used in 18% of the tested population and 94% of tested patients tolerated the antibiotic and their penicillin allergy history was delabeled.

Conclusions: In this program most penicillin allergy labels were cleared based on clinical criteria and oral challenge alone, highlighting the potential benefits of PEN-FAST. Expansion of training should be offered to PCPs to conduct oral challenges in appropriate settings in an effort to reduce this significant burden on patient care.

Background: Prostate cancer frequently metastasizes to bone and regional lymph nodes, but atypical intrathoracic presentation can occur.

Case presentation: Three cases of atypical intrathoracic manifestations of metastatic prostate cancer highlight the need to consider prostate cancer in the differential diagnosis of intrathoracic lesions, even in the absence of typical bony metastases. One case involved pleural metastatic deposits with associated malignant effusion. A second patient experienced isolated endobronchial lesions that led to obstruction. The third patient had isolated pulmonary nodules without associated bone disease years after prostatectomy. We review prevalence, diagnosis, and management issues related to these unusual prostate cancer scenarios.

Conclusions: These atypical metastatic manifestations of prostate cancer present diagnostic conundrums that may potentially delay timely diagnosis and appropriate management. A high index of suspicion, appropriate imaging, and judicious use of immunohistochemistry are paramount to ensure these atypical manifestations are identified.

Background: Understanding associations between diet and long-term risk for colorectal cancer (CRC) among US veterans may provide insight for patient-clinician decisions about lifestyle recommendations as part of a CRC screening program.

Methods: Asymptomatic US veterans aged 50 to 75 years who received screening colonoscopy between 1994 and 1997 were followed through 2009. The most significant colonoscopy findings (MSCFs) across the study period were classified as no neoplasia, not advanced adenomas, or advanced neoplasia (AN). The food frequency questionnaire was used to calculate raw and percent scores for the Healthy Eating Index (HEI), Mediterranean diet (MD), and Dietary Approaches to Stop Hypertension (DASH) dietary patterns. In cross-sectional analyses, multinomial logistic regression models tested for associations between dietary pattern scores and MSCF, controlling for demographics.

Results: Among 3023 participants with complete data, 96.7% were male, and 83.8% were non-Hispanic White. Higher dietary patterns scores (ie, healthier diet) had similar or lower adjusted odds ratios (aORs) for AN vs no neoplasia (HEI: aOR, 1.00 [95% CI, 0.99-1.01]; MD: aOR, 0.95 [95% CI, 0.90-1.00]; DASH: aOR, 0.99 [95% CI, 0.98-1.00]). Higher grain category scores generally had lower aORs for AN for each dietary pattern (HEI: aOR, 0.96 [95% CI, 0.93-0.99]; MD: aOR, 0.29 [95% CI, 0.14-0.62]; DASH: aOR, 0.86 [95% CI, 0.78-0.95]).

Conclusions: Healthy dietary patterns were associated with lower aORs for colonic neoplasia among veterans enrolled in a CRC screening program. More research is needed to determine the role of dietary assessments for tailored CRC prevention and surveillance.

Background: Rates of depression among patients with cancer have increased, illustrating the importance of mental health care during treatment. This study sought to identify antidepressants with boxed warnings for increased suicidal risk and known to have drug-drug interactions.

Methods: This retrospective analysis used the US Department of Defense Cancer Registry, Comprehensive Ambulatory/Professional Encounter Record, and Pharmacy Data Transaction Service databases. Patients with cancer were identified, and data collected included patient diagnoses and dispensed medications. Medications were divided into groups based on the pharmacy database therapeutic codes.

Results: This analysis identified 2210 patients with 2104 documented diagnoses, 2113 recorded prescriptions treated with 14 antineoplastic agents. Breast, lung, testicular, endometrial, and ovarian were the most common cancers among the 51 types treated. Of the 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer medications, including 96 different antineoplastics; 750 (35.5%) patients were prescribed 17 different types of antidepressants. In addition, 1089 unique prescriptions were filled (8 medications prescribed for ≥ 1000 patients). Patients who took antidepressants had more diagnosed health issues and received more prescription medications. The mean number of prescriptions dispensed in patients prescribed antidepressants vs those not prescribed antidepressants showed a significant difference (P < .05) in all groups, except anticonvulsants (P = .12) and other antipsychotics (P = .09). Although antidepressant treatment increased, there was no significant change in antidepressants prescribed annually (mean [SD] 23% [5%]).

Conclusions: The study provides a comprehensive overview of noncancer medication use in the Military Health System during systemic cancer treatment, specifically the use of antidepressants from 2003 to 2022, and highlights potential drug interactions that may affect treatment outcomes. Future research should prioritize the analysis of drug-drug interactions between cancer and noncancer drugs with antidepressants.

Background: Clinical training content for real-world care delivery is important to promote high-quality care. Clinical training promotes knowledge acquisition and additional implementation strategies are needed to translate those acquired skills into practice-based changes.

Observations: The Chronic Obstructive Pulmonary Disease Coordinated Access to Reduce Exacerbations (COPD CARE) Academy is a training initiative implemented at ≥ 49 US Department of Veterans Affairs (VA) medical centers. The Academy provides training on the implementation of COPD CARE programs and promotes complex care transitions. The Academy offers implementation strategies for local champions to leverage VA and academic institution partnerships.

Conclusions: The COPD CARE Academy represents an interprofessional collaboration among frontline clinicians and VA leadership to design a training program using quality improvement methodology for better care for patients with COPD.

Background: Recent phase 2 randomized clinical trials support the use of aggressive local treatment in addition to systemic therapy for oligometastatic disease (OMD) to improve progression-free survival and overall survival. These studies have mostly incorporated stereotactic body radiotherapy and serve as the foundation for multiple phase 3 trials aiming to determine how many metastases comprehensive local radiotherapy (RT) offer survival benefits, and for which cancers.

Methods: To understand clinician views on the role of local RT for OMD, a 12-question survey was developed that included case examples. The survey was distributed to Veterans Health Administration (VHA) radiation oncologists and medical oncologists.

Results: Of 106 survey respondents, 59 (55.7%) were radiation oncologists and 47 (44.3%) were medical oncologists. All respondents indicated high-dose RT has potential benefits for appropriately selected cases. Most oncologists (88.7%) responded that RT for OMD contributes to cure (88.1% radiation oncologists, 89.4% medical oncologists; P = .84). More than half (52.9%) of respondents (55.2% radiation oncologists, 50.0% medical oncologists; P = .60) indicated that local RT for OMD should not be limited by histology. Most radiation oncologists classified ≤ 5 lesions as OMD, whereas most medical oncologists classified ≤ 3 lesions as OMD (P = .006). Thirty-six medical oncologists (76.6%) has a radiation oncology department at their institution. This subgroup was more likely to consider local RT as potentially curative than peers without radiation oncology at their institution (94.4% vs 72.7%; P = .04). Management differences in the 3 oligometastatic cases were also identified.

Conclusions: The results of this study highlight ongoing support among VHA oncologists for local RT in the management of OMD and reveal specialty-based and access-based variability in treatment perspectives.

Background: Depot medroxyprogesterone acetate (DMPA) is an injectable progestin-only contraceptive available in intramuscular and subcutaneous formulations. Initially, DMPA required administration by a health care professional. The World Health Organization now recommends patients be offered the option to self-administer injectable contraception using the subcutaneous form of DMPA (DMPA-SC). Self-administered DMPA-SC removes barriers to administration, increases patient autonomy, and improves contraceptive continuation rates.

Observations: This medication use evaluation assessed the impact of an initiative at North Florida/South Georgia Veterans Health System (NFSGVHS) to offer patients self-administered DMPA-SC. A retrospective chart review of electronic health records was conducted for patients who received ≥ 1 outpatient prescription for DMPA-SC from June 1, 2022, to July 1, 2023. Forty patients initiated self-administered DMPA-SC. A subgroup of patients were contacted via telephone as a follow-up to determine if there were unmet needs for ongoing contraceptive care.

Conclusions: The uptake in prescribing suggests that clinicians and patients have embraced self-administration of DMPA-SC within the NFSGVHS.

Background: Acute lung injury and acute respiratory distress syndrome are potentially fatal complications of severe acute pancreatitis. In some cases, respiratory failure in acute pancreatitis is associated with negative radiographic findings. Hypertriglyceridemia is a known precipitant of acute pancreatitis; however, whether the severity of the hypertriglyceridemia can accurately predict the severity of the hypoxemia in acute pancreatitis remains unclear.

Case presentation: A male with morbid obesity and untreated sleep apnea presented with hypoxemia in the setting of severe hypertriglyceridemia, but with negative chest imaging. The severity of the patient's respiratory dysfunction coincided with elevations in his serum triglycerides.

Conclusions: This case demonstrates the complex relationship between hypertriglyceridemia, inflammation, and pulmonary dysfunction.