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

Background: At-risk rural veterans have low rates of lung cancer screening (LCS). This proof-of-principle quality improvement project aimed to determine whether a telehealth intervention would increase referrals for at-risk veterans living in the rural upper Midwest and attending a smoking cessation program to LCS with low-dose computed tomography (LDCT) of the chest.

Methods: Sixty-eight of 74 LCS-eligible rural veterans who self-enrolled in a smoking cessation program were contacted by telephone. Those who agreed to enroll in LCS were referred to LDCT and followed for 4 months. At the conclusion of the intervention, the number of referrals and screenings performed were tabulated. LDCT reports were reviewed and scored according to Lung CT Screening Reporting and Data System (Lung-RADS) version 1.1.

Results: Only 3 of 74 LCS-eligible veterans (4%) underwent LDCT before initiation of this telehealth intervention. By the conclusion of this 4-month project, 19 of 74 veterans (26%) underwent LDCT. Forty-one veterans were successfully contacted and 29 agreed to participate in LCS. Of those who agreed to participate, 19 underwent LDCT within 4 months. Of the veterans who received LDCT, 10 were diagnosed with Lung-RADS 1, 7 with Lung-RADS 2, 1 with Lung-RADS 3, and 1 with Lung-RADS 4B. Annual follow-up LDCT or referral for further evaluation were pursued in each case.

Conclusions: Collectively, these data suggest that telehealth intervention could increase referrals of at-risk rural veterans to a centralized LCS program at a regional US Department of Veterans Affairs medical facility.

Background: Predicting life expectancy and providing an end-of-life diagnosis in hospice is very challenging for most clinicians given their generally poor training for this role and limited medical education. End-of-life diagnosis alone is often used to certify hospice appropriateness. It is essential, however, to document good supporting evidence of decline and comorbidities. Functional status can be a helpful criterion prior to hospice admission and during required 90-day certifications.

Case presentation: An 80-year-old male who was diagnosed with Stage IV glioblastoma multiforme was transferred from an acute care hospital to a community living center hospice service for end-of-life care. After 6 months of care, the veteran was able to graduate from hospice and transfer to an adult living facility with minimal care needs.

Conclusions: Recognizing the importance of documenting and using functional scales in individuals receiving hospice care is extremely helpful in prognostication.

Background: Perioperative visual loss is a potentially devastating surgical complication. Its occurrence is exceedingly rare after nonocular surgery, but recent literature has explored several etiologies contributing to its development.

Case presentation: We document a case of perioperative visual loss after a pterional craniotomy for the excision of a temporal meningioma in a 47-year-old woman with no significant medical history. The intraoperative course was uneventful, with a myocutaneous flap reflected anteriorly across the orbit. Postoperatively, the patient demonstrated a third cranial nerve palsy and an afferent pupillary defect, with visual loss that persisted > 3 months postsurgery. A diagnosis of central retinal artery occlusion secondary to intraoperative orbital compartment syndrome was considered the likely etiology. However, several alternate diagnoses could not be excluded.

Conclusions: Orbital compartment syndrome should be considered in neurosurgical patients presenting with postoperative ophthalmoplegia and central retinal artery occlusion. We recommend a multidisciplinary perioperative approach to reduce the incidence of perioperative visual loss and orbital compartment syndrome in patients undergoing pterional craniotomy.

Background: Failure to effectively treat obstructive sleep apnea (OSA) and its symptoms is incompatible with military readiness. Continuous positive airway pressure (PAP) is the gold standard treatment for OSA, but it is impractical in austere environments. Another OSA treatment, hypoglossal nerve stimulation (HGNS), which is implanted, could have advantages for military patients but is unclear whether HGNS is efficacious.

Methods: We conducted a review of randomized controlled trials and controlled trials published from 2013 to 2023. Primary outcome measures included the Apnea-Hypopnea Index and Epworth Sleepiness Scale. The quality of evidence was assessed using a rating of 1 to 5 based on a modification of the Oxford Centre for Evidence-based Medicine Levels of Evidence and Grades of Recommendation.

Results: We identified 334 studies; 318 did not meet inclusion criteria. The remaining 16 articles were classified into 9 cohorts. Six articles were based on data from the STAR trial and 4 were based on data from a German postmarket long-term follow-up of upper airway stimulation for OSA efficacy. The remaining cohorts were smaller studies that examined moderate-to-severe OSA with nonadherence or failure, a randomized controlled crossover trial, and 1 direct comparator with PAP treatment.

Conclusions: HGNS feasibility in military settings has not been adequately studied, considering the specific demands of operational settings and patient demographics. Understanding risks and benefits specific to military context will help guide practices and determine the suitability of HGNS for OSA in diverse military settings.

Background: The Olin E. Teague Veterans' Center (OETVC) is a teaching hospital with a medical ward consisting of 189 beds, 3 teaching teams with 1 resident and 2 to 3 interns, and 3 nonteaching teams. Due to the complexity of hospitalization, there are concerns that patients may not follow up with primary care or fill their prescribed medication and may have postdischarge questions.

Observations: A program was created at OETVC to bridge the gap between inpatient and outpatient care. Internal medicine residents call all teaching team patients a week following discharge. They discuss medications, changes in symptoms, follow-up plans, and address all questions. The residents also assist with missed orders and make treatment regimen changes if necessary.

Conclusions: This new program has proven to be beneficial. Residents are developing a better understanding of illness scripts and are working on communication skills without time constraints. Patients now have access to a physician following discharge to discuss any concerns with their hospitalization, present condition, and follow-up. Data show a decreased 30-day readmission rate at 6% in the transition of care group compared to 10% in all patients who participated in the program. This program will continue to address barriers to care and adapt to improve the success of care transitions.

Background: Many military members suffer from allergic rhinoconjunctivitis, which causes burdensome symptoms such as rhinorrhea, sneezing, nasal congestion, and itchy, watery eyes. These symptoms are not controlled by medications, and many require aeroallergen immunotherapy. However, many patients in the military have difficulty remaining on immunotherapy due to frequent moves, deployments, and temporary duty assignments.

Case presentation: A 34-year-old active-duty service member was referred to the Keesler Medical Center allergy clinic with severe allergic rhinoconjunctivitis. His symptoms included rhinorrhea, sneezing, nasal congestion, and itchy, watery eyes, which had been present for several years, occurring seasonally and when exposed to animals. The patient previously received aeroallergen immunotherapy but discontinued the therapy due to frequent military deployments and duty station changes. He restarted immunotherapy and received counseling on aeroallergen avoidance. However, a subsequent military deployment interrupted the continued aeroallergen immunotherapy.

Conclusions: The case highlights the difficulty of managing allergy immunotherapy in the military health system due to frequent moves, deployments, and temporary duty assignments. Access to allergists and others trained to administer immunotherapy in deployed settings may help alleviate this challenge to mission readiness.

Background: Colorectal cancer is the second-leading cause of cancer deaths in the United States. Fecal immunochemical tests (FITs) are a primary means of colorectal cancer screening at some health care institutions because of scheduling backlogs for screening, diagnostic, and surveillance endoscopies. However, delays in mail delivery can impact timely analysis of samples, possibly leading to false-negative results and the need for repeat tests. Some patients might be unwilling to submit another test when informed that an earlier sample cannot be reliably analyzed, resulting in a missed opportunity for screening.

Observations: The Jesse Brown Veterans Affairs Medical Center has experienced some success through contacting the local US Postal Service (USPS) to avoid these delays; however, the problem often unpredictably recurs with USPS staff turnover. Laboratories and health systems experiencing delays should first ensure that prepaid envelopes have the correct postage and that their USPS accounts are properly funded, to confirm that insufficient funds are not contributing to the delayed deliveries. Adding additional language to the preprinted envelopes, such as "time-sensitive," may also be helpful. Asking patients to drop off test kits at the laboratory or using private letter carriers is not feasible in some communities. Other strategies include establishing a drop-off box at clinic offices or considering other screening methods, such as colonoscopies or flexible sigmoidoscopies.

Conclusions: Clinicians who work in health care systems that use FIT kits need to be aware of the impact that local USPS delays can have on the reliability of FIT results. Health systems should be prepared to implement mitigation strategies if significant delays with mail delivery are encountered.

Background: Rosai Dorfman disease is a rare non-Langerhans cell histiocytosis that affects lymph nodes, soft tissues, and other organs. The etiology of Rosai Dorfman disease is poorly understood, though it may involve an immunologic processes or infection. Treatment varies according to the disease presentation.

Case presentation: A male aged 56 years was evaluated for a cutaneous mass on his right medial thigh. Initially, the patient received surgical debulking with subsequent observation and no systemic therapy. However, the mass recurred, prompting another surgical removal 9 years after the initial surgery. A mass biopsy showed infiltration of plasma cells, lymphocytes, histiocytes, and occasional neutrophils with noted reactivity of S-100 protein and CD163, but not CD1a. No systemic therapy was initiated, and the patient agreed to a period of watchful waiting.

Conclusions: Rosai Dorfman disease of soft tissue occurs in older adults and is often associated with soft tissue abnormalities, and more rarely, in lipomas. Multidisciplinary management of the disease and research for mutations and microenvironment of RDD is needed to better understand its clinicopathological nature and improve novel therapies.

Background: Lung cancer is the most common cause of cancer mortality, and cigarette smoking is the most significant risk factor. Among smokers at high risk for lung cancer, atherosclerotic cardiovascular disease (ASCVD) also poses a significant risk for morbidity and mortality. Fortunately, there are opportunities of the prevention of ASCVD events during lung cancer screening (LCS).

Observations: Chest low-dose computed tomography (LDCT) scans used for LCS provide information about the absence or severity of coronary artery calcification (CAC), another independent risk factor of ASCVD events. Of note, there are clinically important differences in using CAC scores to guide primary prevention and statin therapy in smokers eligible for LCS compared with those of the general population. This review article focuses on these differences.

Conclusions: We provide recommendations on using CAC scores from LDCT to guide the prevention of ASCVD events in LCS in addition to using cardiac testing and when referral to a cardiovascular specialist should be considered.

Background: First classified in 2016, high-grade B-cell lymphoma (HGBCL) is a lymphoid neoplasm that is typically seen as an aggressive lymphoproliferative disorder (LPD). In most patients with HGBCL, various oncogene rearrangements present with advanced clinical features, such as central nervous system involvement. Patients with underlying autoimmune and rheumatologic conditions, such as rheumatoid arthritis, are at higher risk for developing LPDs, including highly aggressive subtypes of non-Hodgkin lymphomas such as HGBCL.

Case presentation: We present a case of stage IV double-hit HGBCL with the presence of MYC and BCL6 gene rearrangements in an older veteran with rheumatoid arthritis treated with methotrexate. An excellent sustained response was observed for the patient's disease within 4 weeks of methotrexate discontinuation. To our knowledge, this is the first reported response to methotrexate discontinuation for a patient with HGBCL.

Conclusions: Reducing immunosuppression should be considered in all patients with LPDs associated with autoimmune conditions or immunosuppressive medications, regardless of additional multiagent systemic therapy administration.