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

Background: Veterans represent a unique patient population with various exposures that may predispose them to cancer. Mutational signatures associated with these exposures are described in other tumor types.

Methods: This retrospective review analyzes the comprehensive genomic profiling reports of 35 veterans with metastatic melanoma at a large US Department of Veterans Affairs medical center. The genomic findings were compared with those from the Catalogue of Somatic Mutations in Cancer and The Cancer Genome Atlas.

Results: The melanomas found in these veterans showed a significantly higher frequency of variants in CDKN2A/B; a significantly lower frequency of variants in ROS1, GRIN2A, KDR, KMT2C (MLL3), KMT2D (MLL2), LRP1B, PTPRT, PTCH1, FAT4, and PREX2; and a significantly higher frequency of tumor mutational burdens exceeding 10 mutations/megabase.

Conclusions: The presence of statistically significant differences between the genomic findings from the veterans' melanomas and those of general population melanomas from reference databases suggests that additional research is warranted to corroborate these differences and clarify their etiologic, prognostic, and therapeutic relevance.

Background: Syringe services programs (SSPs) aim to prevent the transmission of blood-borne pathogens, tissue infections, and overdose among people who use drugs (PWUD). This article describes the implementation of SSPs at 2 US Department of Veterans Affairs (VA) medical centers.

Observations: SSPs can increase access to sterile equipment, promote safe disposal, reduce health care costs, and improve patient access to care. Despite these developments, SSPs remain limited. Established SSPs at the Alaska VA Healthcare System and VA Southern Oregon Healthcare System have allowed for quality harm reduction services to be provided to PWUD.

Conclusions: The newly established SSPs help clinicians provide high-quality care to PWUD. Implementation of SSPs at VA facilities (where permitted by local law) may improve patient care and reduce negative consequences associated with injection drug use.

Background: Concerns have been raised regarding the potential for COVID-19 infection to precipitate the development of systemic lupus erythematosus (SLE). This surveillance analysis was conducted to determine the incidence of SLE among US Department of Defense (DoD) beneficiaries before and during the COVID-19 pandemic.

Methods: Outpatient encounters, private sector care records, and laboratory data from January 1, 2018, through December 31, 2022, were analyzed. Data from 2017 were used to exclude previously diagnosed cases. Inpatient data also were excluded. Positive lupus cases were identified through a combination of laboratory results and relevant International Classification of Diseases, 10th Revision, Clinical Modification diagnostic codes.

Results: A consistent decrease in SLE incidence was observed during the COVID-19 pandemic, with total cases declining from 2866 in 2018 to 1399 in 2022 among DoD health care beneficiaries. The mean annual decline of 16.0% and an overall reduction of 48.2% from 2018 to 2022 displayed consistent patterns across subgroups stratified by sex, age, and beneficiary type.

Conclusions: The results of this study do not show an increase in SLE incidence among DoD beneficiaries during the COVID-19 pandemic. These findings suggest that the mitigation strategies implemented within the DoD to reduce COVID-19 transmission may have contributed to this trend. Further research is warranted to monitor SLE incidence over time, with attention to broader environmental changes and shifting patterns of common infections.

Background: Timely de-escalation of antibiotics improves patient outcomes and reduces costs. The BioFire FilmArray Blood Culture Identification (BCID2) panel, a rapid diagnostic technology, enables enhanced antimicrobial stewardship. This study evaluated whether BCID2 use at Veteran Health Indiana (VHI) saved time and money to prescribe optimal antibiotics from blood culture draw pre- and postimplementation.

Methods: This pre-post quasi-experimental study evaluated patients with bacteremia at VHI between March 1, 2022, and October 1, 2023. Patient data were generated using electronic health records and microbiology laboratory data. A random sampling of eligible patients was included if they had a positive bacterial blood culture for which they received ≥ 1 antibiotic while hospitalized.

Results: Median difference in time to organism identification was 37.8 hours in the preintervention group vs 16.9 hours in the postintervention group (P < .001). Other differences in time were not statistically significant. Median difference in time to optimal antibiotics was 58.5 hours in the preintervention group vs 43.4 hours in the postintervention group (P = .11). Median difference in time on antibiotics was 45.2 hours in the preintervention group vs 46.6 hours in the postintervention group (P = .99). Median difference in time on appropriate antibiotics was 2.3 hours in the preintervention group vs 1.9 hours in the postintervention group (P = .79).

Conclusions: BCID2 use resulted in a decrease in median time to optimal antibiotics that was not statistically significant. Additional barriers to optimal antibiotic prescription should be addressed to maximize rapid blood culture identification technologies and enhance antimicrobial stewardship.

Background: Tinea versicolor is a common superficial fungal infection caused by Malassezia species. It typically affects the trunk and proximal upper extremities and is treated with topical or oral antifungal medications. Treatment may be limited by patient preference or logistical constraints, especially in cases of extensive cutaneous involvement, where topical application may be challenging.

Case presentation: An 18-year-old active duty female with extensive tinea versicolor, likely precipitated by military training in hot and humid conditions, presented to the dermatology clinic. Given the patient's inability to consistently apply topical treatments during military activities and the limited efficacy of oral antifungals, the patient underwent in-office treatment with a salicylic acid 30% peel. Two peels were administered 10 days apart. At 3 weeks posttreatment the arm lesions were no longer evident and there was significant improvement of the lesions on her back. Incidental improvement in acne vulgaris was also noted.

Conclusions: This case highlights the potential use of a salicylic acid 30% peel as an effective in-office treatment for tinea versicolor, particularly in patients who face challenges with topical medication adherence. The peel also offers additional benefits for patients with concomitant acne.

Background: The relationship between the gut microbiome and overall human health is increasingly recognized. This review discusses new research that outlines pathways and intermediaries that may mediate the interaction between the gut microbiome and cardiac arrhythmias.

Observations: Gut microbial constituents and their products have been shown to influence human physiology, including the cardiovascular system, cardiac arrhythmia, and other disease processes. The effect of the human gut microbiome on cardiovascular diseases may improve understanding of disease pathophysiologic mechanisms and presents opportunities for therapeutic modification of the gut microbiome to positively affect disease outcomes.

Conclusions: Research into the gut microbiome and its overarching impact on the human body is still in its early stages. Continued investigation of its complex relationships may lead to the development of novel therapies and strategies to enhance patient safety.

Background: Sarcoidosis is a multiorgan granulomatous disorder of unknown etiology. Clinical manifestations vary and depend, in part, on the extent and severity of organ involvement. Clinical practice guidelines recommend 20 to 40 mg prednisone daily as first-line pharmacotherapy for systemic corticosteroid-naïve patients with active sarcoidosis. This study sought to determine whether initial dosages were guideline adherent.

Methods: Records were restrospectively reviewed for patients diagnosed with sarcoidosis who were naïve to systemic corticosteroids and received initial prednisone dosages between 2014 and 2023 at the Jesse Brown Department of Veterans Affairs Medical Center. Patient demographics, medical specialty of the prescriber, and daily starting dosage were tabulated.

Results: Sixty-eight patients were identified; most were Black (n = 52, 76%) and male (n = 62, 91%), with a mean (SD) age of 63 (11) years. Pulmonologists prescribed initial prednisone dosages in the 20 to 40 mg daily range (median, 35 mg). Other specialists, including primary care practitioners, often prescribed 20 mg (median, 17.5 mg; P < .05) initial dosages.

Conclusions: Initial prednisone dosages varied between pulmonologists and nonpulmonologists for systemic corticosteroid-naïve patients with active sarcoidosis. However, this study did not determine reasons for this phenomenon, nor its impact on long-term patient outcomes.

Background: Patients admitted to the hospital from the emergency department are often evaluated with inherent diagnostic biases, particularly when the admitting diagnosis is anchored early. When a patient presents with suspected decompensated cirrhosis, it is important to consider other diagnoses with similar presentations and ensure multiple disease processes are not contributing to the symptoms.

Case presentation: A 64-year-old male without stable housing was admitted for management of newly diagnosed decompensated cirrhosis based on imaging. Additional analysis of laboratory results, imaging, and clinical presentation suggested that the decompensated cirrhosis diagnosis was not proportionate to the severity of the patient's hypoalbuminemia. Additional workup was conducted, and hepatology, nephrology, and infectious disease specialists were consulted. Extensive laboratory workup and a renal biopsy confirmed a diagnosis of compensated cirrhosis and nephrotic syndrome due to early membranoproliferative glomerulonephritis, both secondary to hepatitis C infection.

Conclusions: This case offers important teaching points on nephrotic syndrome and hepatitis C, and highlights the importance of re-evaluating diagnostic assumptions to prevent delays and errors.

Background: System-wide, patient-centered health care transformations and efforts to enhance shared decision-making (SDM) are often separate initiatives. Multiple initiatives can create competing or inefficient demands on clinicians. This is evident within the US Department of Veterans Affairs (VA) Whole Health System of Care and the aligned but distinct effort to implement SDM for lung cancer screening (LCS).

Observations: This article describes a VA-based research team's efforts to identify alignment between whole health and SDM for LCS and to integrate these initiatives into a single model to inform future health care practitioner training. The study identified areas of overlap between the 2 initiatives and created a 3-step model for integrating SDM and whole health for LCS.

Conclusions: Integrating 2 programs previously treated as separate initiatives ensured uptake for both SDM for LCS and whole health. This approach of integrating separate initiatives can be applied more broadly to other VA programs or in any health care system seeking to advance SDM within broader patient-centered care initiatives.