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

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Patient With Leukocytosis and Persistent Dry Cough 白细胞增多伴持续性干咳患者

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0407

Mariela M Rivera-Agosto

An 83-year-old man who was a nonsmoker with no history of systemic disease was transferred to the Veterans Affairs Caribbean Healthcare System from an outside hospital due to marked leukocytosis (white blood cell [WBC] count, 22.5 × 10/μL). He reported a 3-month history of persistent dry cough, which required several primary care physician (PCP) evaluations. He was initially treated for an upper respiratory tract infection without adequate response. Instead, his symptoms progressed, and he presented with associated hoarseness and unintentional 26-pound weight loss. The patient’s physical examination was remarkable for left-sided decreased breath sounds. Laboratory tests confirmed leukocytosis (WBC, 20.0 × 10/μL), and his radiographic chest X-ray (Figure 1) showed a left upper lobe mass, confirmed by computed tomography (CT) (Figure 2) in which mediastinal lymphadenopathy also was seen. The abdominal/pelvic CT showed renal and bilateral adrenal lesions suggestive of metastatic disease. A core needle biopsy from the anterior component of the mediastinal mass showed pleomorphic cells with hyperchromatic nuclei, spindle configuration, and mitotic figures (Figure 3). Immunohistochemistry was positive for pancytokeratin, CK7, and vimentin.

{"title":"Patient With Leukocytosis and Persistent Dry Cough","authors":"Mariela M Rivera-Agosto","doi":"10.12788/fp.0407","DOIUrl":"https://doi.org/10.12788/fp.0407","url":null,"abstract":"An 83-year-old man who was a nonsmoker with no history of systemic disease was transferred to the Veterans Affairs Caribbean Healthcare System from an outside hospital due to marked leukocytosis (white blood cell [WBC] count, 22.5 × 10/μL). He reported a 3-month history of persistent dry cough, which required several primary care physician (PCP) evaluations. He was initially treated for an upper respiratory tract infection without adequate response. Instead, his symptoms progressed, and he presented with associated hoarseness and unintentional 26-pound weight loss. The patient’s physical examination was remarkable for left-sided decreased breath sounds. Laboratory tests confirmed leukocytosis (WBC, 20.0 × 10/μL), and his radiographic chest X-ray (Figure 1) showed a left upper lobe mass, confirmed by computed tomography (CT) (Figure 2) in which mediastinal lymphadenopathy also was seen. The abdominal/pelvic CT showed renal and bilateral adrenal lesions suggestive of metastatic disease. A core needle biopsy from the anterior component of the mediastinal mass showed pleomorphic cells with hyperchromatic nuclei, spindle configuration, and mitotic figures (Figure 3). Immunohistochemistry was positive for pancytokeratin, CK7, and vimentin.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135640630","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Idiopathic Granulomatous Lobular Mastitis: A Mimicker of Inflammatory Breast Cancer 特发性肉芽肿性小叶性乳腺炎:炎性乳腺癌的模拟物

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0408

Benjamin F Wilson

Background: Idiopathic granulomatous lobular mastitis (IGLM) is a rare, chronic inflammatory breast disease without a known etiology. Even though the current literature proposes several treatment strategies, there is no universal consensus for long-term management. Case Presentation: A 43-year-old White woman (gravida 5, para 4) presented with a 2-week history of right lower outer quadrant breast tenderness, heaviness, warmth, and redness. Mammography and ultrasound were concerning for inflammatory breast cancer. Biopsies returned as granulomatous mastitis without malignancy. After 8 months of unsuccessful therapy with prednisone and methotrexate, surgeons excised the breast tissue. Cultures and special stains were negative for other organisms. At the 7-month follow-up, no evidence of recurrence was seen. Conclusions: As there remains no consensus behind the etiology or management of IGLM, our case demonstrates a reasonable and successful stepwise treatment beginning with medical therapy before proceeding to surgical cure. Because of possible malignancy risk with chronic IGLM, patients should not delay surgical excision if their condition remains refractory to medical therapy alone.

{"title":"Idiopathic Granulomatous Lobular Mastitis: A Mimicker of Inflammatory Breast Cancer","authors":"Benjamin F Wilson","doi":"10.12788/fp.0408","DOIUrl":"https://doi.org/10.12788/fp.0408","url":null,"abstract":"Background: Idiopathic granulomatous lobular mastitis (IGLM) is a rare, chronic inflammatory breast disease without a known etiology. Even though the current literature proposes several treatment strategies, there is no universal consensus for long-term management. Case Presentation: A 43-year-old White woman (gravida 5, para 4) presented with a 2-week history of right lower outer quadrant breast tenderness, heaviness, warmth, and redness. Mammography and ultrasound were concerning for inflammatory breast cancer. Biopsies returned as granulomatous mastitis without malignancy. After 8 months of unsuccessful therapy with prednisone and methotrexate, surgeons excised the breast tissue. Cultures and special stains were negative for other organisms. At the 7-month follow-up, no evidence of recurrence was seen. Conclusions: As there remains no consensus behind the etiology or management of IGLM, our case demonstrates a reasonable and successful stepwise treatment beginning with medical therapy before proceeding to surgical cure. Because of possible malignancy risk with chronic IGLM, patients should not delay surgical excision if their condition remains refractory to medical therapy alone.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135640738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19–Positive Veterans in the Atlanta VA Health Care System 利用主动监测在亚特兰大VA医疗保健系统中识别covid -19阳性退伍军人中的单克隆抗体候选物

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0411

Kathryn E DeSilva

an orally admin- istered prodrug of N-hydroxycytidine (NHC, EIDD-1931), a nucleoside with broad antiviral activity against a range of RNA viruses. MOV acts by driving viral error catastrophe following its incorporation by the viral RdRp into the viral genome. Given its mechanism of action, MOV activity should not be affected by substitu- tions in the spike protein present in SARS-CoV-2 variants of concern which impact efficacy of therapeutic neutralizing antibodies and vaccine induced immunity. We characterized MOV activity against variants by assessing antiviral activity in vitro and virologic response from the Phase 2/3 clinical trials (MOVe-In, MOVe-Out) for treatment of COVID-19. Methods. MOV activity against several SARS-CoV-2 variants, was evaluated in an in vitro infection assay. Antiviral potency of NHC (IC50) was determined in Vero E6 cells infected with virus at MOI ~0.1 by monitoring CPE. Longitudinal SARS- CoV-2 RNA viral load measures in participants enrolled in MOVe-In and MOVe-Out were analyzed based on SARS-CoV-2 genotype. Sequences of SARS-CoV-2 from study participants were amplified from nasal swabs by PCR and NGS was performed on samples with viral genome RNA of >22,000

{"title":"Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19–Positive Veterans in the Atlanta VA Health Care System","authors":"Kathryn E DeSilva","doi":"10.12788/fp.0411","DOIUrl":"https://doi.org/10.12788/fp.0411","url":null,"abstract":"an orally admin- istered prodrug of N-hydroxycytidine (NHC, EIDD-1931), a nucleoside with broad antiviral activity against a range of RNA viruses. MOV acts by driving viral error catastrophe following its incorporation by the viral RdRp into the viral genome. Given its mechanism of action, MOV activity should not be affected by substitu- tions in the spike protein present in SARS-CoV-2 variants of concern which impact efficacy of therapeutic neutralizing antibodies and vaccine induced immunity. We characterized MOV activity against variants by assessing antiviral activity in vitro and virologic response from the Phase 2/3 clinical trials (MOVe-In, MOVe-Out) for treatment of COVID-19. Methods. MOV activity against several SARS-CoV-2 variants, was evaluated in an in vitro infection assay. Antiviral potency of NHC (IC50) was determined in Vero E6 cells infected with virus at MOI ~0.1 by monitoring CPE. Longitudinal SARS- CoV-2 RNA viral load measures in participants enrolled in MOVe-In and MOVe-Out were analyzed based on SARS-CoV-2 genotype. Sequences of SARS-CoV-2 from study participants were amplified from nasal swabs by PCR and NGS was performed on samples with viral genome RNA of >22,000","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135640739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Supplements Are Not a Synonym for Safe: Suspected Liver Injury From Ashwagandha 补品不是安全的同义词:阿什瓦甘达可能导致肝损伤

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0409

Sondra Vazirani

引用次数: 0

Rifampin for Prosthetic Joint Infections: Lessons Learned Over 20 Years at a VA Medical Center 利福平治疗假体关节感染:在退伍军人医疗中心20多年的经验教训

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0406

Solana Cushing

Background: The Minneapolis Veterans Affairs Health Care System uses debridement and implant retention (DAIR) combined with oral rifampin and a second antibiotic to treat orthopedic implant infections. However, the success rate of this approach in a veteran population is unknown. Methods: We performed a retrospective analysis of patients who underwent DAIR with a rifampin-containing regimen for an orthopedic implant infection over the past 20 years at the Minneapolis Veterans Affairs Health Care System. The primary outcome was treatment success among participants who were treated with curative intent, defined as planned device retention without ongoing antibiotic use. Secondary outcomes were treatment harms and therapy duration. Treatment success was defined as the absence of recurrent infection or further measures to suppress infection within 1 year of completing antimicrobial therapy. Results: A total of 78 patients (88% male) were included (median age, 65.5 years), with 50 treated with curative intent (primary analysis group). Forty-one participants (82%) in the curative intent group experienced treatment success. The success rate was higher among participants whose implant was < 2 months old vs those whose implant was ≥ 2 months old (93% vs 65%, respectively; P = .02). The 28 participants treated without curative intent had more comorbidities, higher rates of chronic infection, and older implants than those treated with curative intent. Conclusions: Veterans with orthopedic implant infections can be successfully treated with DAIR combined with a rifampin-containing antimicrobial regimen. Success is highest for patients with a recent implant. Debridement and implant retention using regimens that include rifampin is an evidence-based strategy for managing patients with infected prosthetic hardware. Here we report that this approach is feasible in a veteran population, especially with recently implanted prosthetic material.

{"title":"Rifampin for Prosthetic Joint Infections: Lessons Learned Over 20 Years at a VA Medical Center","authors":"Solana Cushing","doi":"10.12788/fp.0406","DOIUrl":"https://doi.org/10.12788/fp.0406","url":null,"abstract":"Background: The Minneapolis Veterans Affairs Health Care System uses debridement and implant retention (DAIR) combined with oral rifampin and a second antibiotic to treat orthopedic implant infections. However, the success rate of this approach in a veteran population is unknown. Methods: We performed a retrospective analysis of patients who underwent DAIR with a rifampin-containing regimen for an orthopedic implant infection over the past 20 years at the Minneapolis Veterans Affairs Health Care System. The primary outcome was treatment success among participants who were treated with curative intent, defined as planned device retention without ongoing antibiotic use. Secondary outcomes were treatment harms and therapy duration. Treatment success was defined as the absence of recurrent infection or further measures to suppress infection within 1 year of completing antimicrobial therapy. Results: A total of 78 patients (88% male) were included (median age, 65.5 years), with 50 treated with curative intent (primary analysis group). Forty-one participants (82%) in the curative intent group experienced treatment success. The success rate was higher among participants whose implant was < 2 months old vs those whose implant was ≥ 2 months old (93% vs 65%, respectively; P = .02). The 28 participants treated without curative intent had more comorbidities, higher rates of chronic infection, and older implants than those treated with curative intent. Conclusions: Veterans with orthopedic implant infections can be successfully treated with DAIR combined with a rifampin-containing antimicrobial regimen. Success is highest for patients with a recent implant. Debridement and implant retention using regimens that include rifampin is an evidence-based strategy for managing patients with infected prosthetic hardware. Here we report that this approach is feasible in a veteran population, especially with recently implanted prosthetic material.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135640741","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Salute to Service Dogs 向服务犬致敬

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

Pub Date : 2023-09-01 DOI: 10.12788/fp.0414

Meaghann Weaver

The psychological and moral comfort of a presence at once humble and understanding—this is the greatest benefit that the dog has bestowed upon man.

引用次数: 0

Implementation of an Automated Phone Call Distribution System in an Inpatient Pharmacy Setting. 在住院药房实施自动电话呼叫分配系统。

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

Pub Date : 2023-09-01 Epub Date: 2023-09-15 DOI: 10.1278/fp.0402

Samaneh Ghassemi, Freddy Tadros, Elizabeth Stone, Joelle Farano

Background: Inpatient pharmacies receive numerous phone calls from health care professionals and patients. This uncaptured workload poses potential staffing concerns for pharmacy administrators as unequal distribution or misdirected calls to the pharmacy team can lead to accountability and patient safety concerns. We aimed to implement and evaluate the effectiveness of an automated call distribution (ACD) system in an inpatient pharmacy setting at a US Department of Veterans Affairs hospital.

Observations: A new inpatient pharmacy service phone line extension was implemented at the Edward Hines, Jr. Veterans Affairs Hospital in Illinois. The ACD phone system yielded positive performance metrics, including ≤ 30 seconds mean speed to answer and ≤ 5% abandonment rate in the 12 months after implementation.

Conclusions: The ACD phone system is a promising, new application of available technology implemented in a nontraditional setting. The ACD system provides more actionable information and quality metrics data to pharmacy leadership. The implementation of the ACD system has improved accountability, efficiency, work distribution, and the allocation of resources.

背景：住院药房会接到大量来自医护人员和患者的电话。这种无法捕捉的工作量给药房管理者带来了潜在的人员问题，因为分配不均或药房团队接错电话可能会导致问责和患者安全问题。我们的目标是在美国退伍军人事务部医院的住院药房环境中实施自动呼叫分配（ACD）系统并评估其有效性：在伊利诺伊州的 Edward Hines, Jr.退伍军人事务医院实施了新的住院药房服务电话线路扩展。ACD 电话系统产生了积极的性能指标，包括在实施后的 12 个月内，平均接听速度≤ 30 秒，放弃率≤ 5%：结论：ACD 电话系统是在非传统环境中应用现有技术的一种很有前途的新方法。ACD 系统为药房领导层提供了更多可操作的信息和质量指标数据。ACD 系统的实施改善了问责制、效率、工作分配和资源分配。

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引用次数: 0

Implementing Smoking Cessation Telehealth Technologies Within the VHA: Lessons Learned. 在VHA内实施戒烟远程健康技术：经验教训。

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

Pub Date : 2023-08-01 Epub Date: 2023-08-11 DOI: 10.12788/fp.0393

Sara E Golden, Stephanie Unger, Christopher G Slatore

Background: Health care systems need to reach patients who are smokers and connect them to evidence-based resources that can help them quit. Telehealth, such as an interactive voice response (IVR) system, may be one solution, but there is no roadmap to develop or implement an IVR system within the US Department of Veterans Affairs (VA).

Observations: We describe the development and implemention of IVR at the VA Portland Health Care System in Oregon to proactively reach veterans who use tobacco and connect them with cessation resources. We coordinated with local departments to verify the necessary processes and strategies that are important. We recommend several questions to ask the IVR vendor and be prepared to answer before contract finalization. The Patient Engagement, Tracking, and Long-term Support (PETALS) initiative may be an excellent place to start for VA IVR-related questions and can be used for IVR initiation within the VA, but other vendors will be needed for nonresearch purposes. Finally, we describe the process timeline and steps to help potential users.

Conclusions: IVR systems, once they are developed and implemented, can be efficient, low-cost, resource-nonintensive solutions that can effectively connect patients with needed health care services. Developing an IVR system within the VA was challenging for our research team. We experienced a large learning curve during implementation and hope that our experience and lessons will help VA personnel in the future.

背景：医疗保健系统需要接触吸烟者，并将他们与能够帮助他们戒烟的循证资源联系起来。远程健康，例如交互式语音响应（IVR）系统，可以是一种解决方案，但美国退伍军人事务部（VA）内部没有制定或实施IVR系统的路线图。观察结果：我们描述了俄勒冈州退伍军人事务部波特兰医疗保健系统制定和实施IVR的情况，以主动接触使用烟草的退伍军人，并将他们与戒烟资源联系起来。我们与当地部门进行了协调，以验证必要的重要流程和策略。我们建议IVR供应商提出几个问题，并准备在合同敲定前回答。患者参与、跟踪和长期支持（PETALS）计划可能是VA IVR相关问题的一个很好的起点，可以用于VA内部的IVR启动，但非搜索目的需要其他供应商。最后，我们描述了帮助潜在用户的流程时间表和步骤。结论：IVR系统一旦开发和实施，就可以成为高效、低成本、无资源影响的解决方案，有效地将患者与所需的医疗保健服务联系起来。在VA内开发IVR系统对我们的研究团队来说是一项挑战。在实施过程中，我们经历了一个巨大的学习曲线，希望我们的经验和教训将在未来帮助退伍军人事务部人员。

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引用次数: 0

Spider Bite Wound Care and Review of Traditional and Advanced Treatment Options. 蜘蛛咬伤伤口护理和传统和高级治疗方案的回顾。

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

Pub Date : 2023-08-01 Epub Date: 2023-08-13 DOI: 10.12788/fp.0400

David B Brown, Mohamed Tazi Chibi, Raymond V Searles, Nadia Hassani

Background: Approaches to chronic wound care are worlds apart: In developing nations, the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves); whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). The cost for wound care plays a significant role in total health care costs, and that cost is expected to rise dramatically.

Case presentation: A healthy, 60-year-old man presented after being bitten by a spider 6 days earlier. He was treated and prescribed clindamycin 300 mg 4 times daily for 14 days. Despite treatment, the wound continued to enlarge, and the patient showed symptoms of septicemia. The patient was admitted to the hospital and remained for 3 days. On discharge the patient was given a prescription for doxycycline 100 mg twice a day for 10 days and instructed to use iodoform gauze to pack the wound during daily dressing changes. However, the gauze was ineffective. The patient's dressing was switched to an antibacterial foam dressing impregnated with gentian violet and methylene blue.

Conclusions: There is a disparity in available wound care product availability. Modern products may yield faster healing times with fewer adverse effects than traditional products. Products used by local healers can produce satisfactory results when more modern products are unavailable and at a fraction of the cost.

背景：慢性伤口护理的方法截然不同：在发展中国家，慢性伤口的护理通常涉及当地产品的传统管理（如蜂蜜、煮土豆皮、芦荟凝胶、香蕉叶）；而在发达国家，有更昂贵、技术更先进的产品（如伤口真空吸尘器、盐水伤口室、高压氧治疗、抗菌泡沫）。伤口护理成本在医疗保健总成本中起着重要作用，预计该成本将大幅上升。病例介绍：一名健康的60岁男子在6天前被蜘蛛咬伤后出现。他接受了治疗，并开了克林霉素300mg，每天4次，持续14天。尽管进行了治疗，但伤口仍在继续扩大，患者出现败血症症状。病人被送入医院，住院3天。出院时，给患者开了100 mg多西环素的处方，每天两次，持续10天，并指示患者在每天换药时使用碘仿纱布包裹伤口。然而，纱布效果不佳。病人的敷料换成了浸有龙胆紫和亚甲基蓝的抗菌泡沫敷料。结论：可用的伤口护理产品的可用性存在差异。与传统产品相比，现代产品可以产生更快的愈合时间和更少的不良反应。当无法获得更现代的产品时，当地治疗师使用的产品可以产生令人满意的效果，而且成本很低。

{"title":"Spider Bite Wound Care and Review of Traditional and Advanced Treatment Options.","authors":"David B Brown, Mohamed Tazi Chibi, Raymond V Searles, Nadia Hassani","doi":"10.12788/fp.0400","DOIUrl":"10.12788/fp.0400","url":null,"abstract":"Background: Approaches to chronic wound care are worlds apart: In developing nations, the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves); whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). The cost for wound care plays a significant role in total health care costs, and that cost is expected to rise dramatically.Case presentation: A healthy, 60-year-old man presented after being bitten by a spider 6 days earlier. He was treated and prescribed clindamycin 300 mg 4 times daily for 14 days. Despite treatment, the wound continued to enlarge, and the patient showed symptoms of septicemia. The patient was admitted to the hospital and remained for 3 days. On discharge the patient was given a prescription for doxycycline 100 mg twice a day for 10 days and instructed to use iodoform gauze to pack the wound during daily dressing changes. However, the gauze was ineffective. The patient's dressing was switched to an antibacterial foam dressing impregnated with gentian violet and methylene blue.Conclusions: There is a disparity in available wound care product availability. Modern products may yield faster healing times with fewer adverse effects than traditional products. Products used by local healers can produce satisfactory results when more modern products are unavailable and at a fraction of the cost.","PeriodicalId":94009,"journal":{"name":"Federal practitioner : for the health care professionals of the VA, DoD, and PHS","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10589002/pdf/fp-40-08-248.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49695361","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

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Moral Injury: The Spirit's Unseen Wound. 道德伤害：精神的无形创伤。

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

Pub Date : 2023-08-01 Epub Date: 2023-08-16 DOI: 10.12788/fp.0405

Cynthia Geppert

引用次数: 0

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