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

Background: Recent research suggests veterans are more likely to experience personality disorders (PDs) relative to the general population. However, due to longstanding stigma surrounding these conditions, research into the clinical and psychosocial needs of veterans with PDs has been greatly limited.

Methods: Data from a sample of 104,198 veterans receiving community-based, state-funded mental health services in 2022 was used for this study. The dataset included demographic, comorbid clinical needs, and psychosocial outcome patterns among veterans with and without documented PD diagnoses.

Results: Among veterans in this sample, 2% had a diagnosed PD, with diagnoses most common among veterans who were White (risk ratio [RR], 1.11), non-Hispanic (RR, 1.03), aged ≥ 45 years (RR, 1.16-1.40), underemployed (RR, 2.00), nontraditionally housed (RR, 1.42), and also diagnosed with trauma-related (RR, 1.33), bipolar (RR, 1.56), and/or psychotic (RR, 1.15) disorders. Veterans receiving treatment in a state psychiatric hospital (RR, 3.05), community mental health facility (RR, 1.06), or judicial system setting (RR, 6.33) were also more likely to have a diagnosed PD.

Conclusions: This study of a national sample of veterans receiving community-based, state-funded mental health care attests to the necessity for transdiagnostic treatment planning and care coordination for veterans with PDs.

Background: Hypertrophic cardiomyopathy is a relatively common inherited disorder that may be asymptomatic. It is a common cause of sudden cardiac death and can lead to catastrophic cardiovascular collapse in the operating room if previously undiagnosed. This case report discusses the implications of unsuspected hypertrophic cardiomyopathy for anesthesia management.

Case presentation: A veteran aged 55 years presented to the preadmission testing clinic prior to undergoing outpatient surveillance colonoscopy under anesthesia. His initial medical history was unremarkable. On physical examination, a murmur with benign characteristics was detected. However, further evaluation with echocardiography, revealed severe hypertrophic obstructive cardiomyopathy. The patient was ultimately referred for septal myectomy consideration.

Conclusions: Hypertrophic cardiomyopathy is a relatively common disorder that often remains undiagnosed. This condition has critical implications for preoperative evaluation, as patients with this disorder may develop sudden, unexpected, and refractory hypotension upon induction of anesthesia.

Background: In rare cases, statin therapy for the reduction of lipid levels may cause muscle-related adverse effects leading to autoimmune myopathy. Statin-induced necrotizing autoimmune myopathy (SINAM) is typically accompanied by symmetrical proximal muscle weakness and elevated creatine phosphokinase (CPK). Glucocorticoids are the first-line treatment, but therapy may escalate to include methotrexate and/or intravenous immune globulin therapy (IVIG).

Case presentation: A male aged 59 years with confirmed atorvastatin adherence for 1 year presented with a 4-month history of fatigue, neuropathy, and progressive proximal muscle weakness. Laboratory tests revealed elevated CPK as high as 12,990 mcg/L. The anti-3-hydroxy-3-methlyglutaryl coenzyme A reductase (anti-HMGCR) antibody test was positive, and the patient started immunosuppressive therapy with IVIG therapy monotherapy (2 g/kg) over 3 days. Gluocorticoid therapy was not used due to difficult to control type 2 diabetes. After hospital discharge, the patient continued monthly IVIG treatment. Following 7 total rounds (6 rounds postadmission) of IVIG, the patient reported an improvement in activity, increased strength in his daily activities, and his CPK level continued decreasing to 680 mcg/L.

Conclusions: Patients presenting with proximal muscle weakness and elevated CPK, even after statin discontinuation, should be considered for a full workup for potential SINAM. The detection of anti-HMGCR antibodies or presence of necrosis on muscle biopsy are necessary for a formal diagnosis. This case displayed success with IVIG monotherapy, although previous research suggests the best chance of muscle symptom improvement is with a combination of a glucocorticoid, methotrexate, and IVIG.

Background: US Department of Veterans Affairs (VA) podiatrists advance clinical practices and ensure expert foot and ankle care for veterans. Quantifying the research expertise of VA podiatrists will enhance the confidence of the veteran population regarding the care they receive from highly knowledgeable and research-active clinicians, and provide podiatrists insight into their professional development.

Methods: This cross-sectional analysis aimed to describe the expertise of VA podiatrists; those with a history of peer-reviewed publications were analyzed. Sex, region of practice, salary, academic appointment, number of publications, and h-index were recorded. Descriptive statistics were reported, and associations between variables were assessed. The threshold for statistical significance was set at P ≤ .05.

Results: Of 819 podiatrists, 157 met the selection criteria for final analysis, with most being male and located primarily on the West Coast. Significant differences were found in the median number of publications and the Hirsch index among academic ranks, but no relationship was observed between salary and these metrics. No statistically significant difference was noted in average salary among different academic appointments, although compensation did vary.

Conclusions: A substantial proportion of VA podiatrists have published their research, providing advanced foot and ankle care to veterans. These findings underscore the expertise available to veterans and highlight its role in enhancing clinical practices and professional growth among VA podiatrists.

Background: Pulmonary embolism is a common cause of morbidity and mortality in the United States. A nonspecific clinical presentation makes it challenging to diagnose, and management varies significantly depending on a risk-benefit assessment, the patient's current clinical status, and institutional practices.

Case presentation: Multidisciplinary appraisal led to differing use of tissue plasminogen activator (tPA) infusion for 2 patients at intermediate-risk for pulmonary embolism. Both cases demonstrated favorable outcomes and improved right ventricular function after treatment. One patient underwent systemic tPA infusion and demonstrated resolution of pulmonary hypertension and symptoms after 24 hours. A second patient received localized tPA infusion for 24 hours and had a marked decrease in clot burden and pulmonary artery pressure gradient.

Conclusions: These cases illustrate the variety and complexity of management of patients with intermediate-risk pulmonary embolism and highlight the role institutional pulmonary embolism response teams may have in these scenarios.

Background: Veterans comprise about 8% of the incarcerated US population. Legal system involvement may result in exposure to events that violate moral expectations (ie, moral injury). Currently, there are no validated measures for assessing legal-related moral injury.

Methods: The goal of this study was to conduct a psychometric evaluation of an adapted version of the Moral Injury Events Scale (MIES) to assess moral injury among legal-involved individuals. This study collected demographic and clinical data via a semistructured survey. Veterans then completed the original and adapted versions of the MIES, the PTSD Checklist for DSM-5, and Personal Health Questionnaire-9.

Results: One hundred veterans with a history of incarceration completed the MIES and an adapted version for legal-involved persons (MIES-LIP). More than 90% of participants reported potentially morally injurious experiences in the legal context. While confirmatory factor analysis did not support the proposed factor structure of the MIES-LIP, an exploratory factor analysis supported a 2-factor solution characterized by self- and other-directed moral injury.

Conclusions: The MIES-LIP demonstrated strong psychometric properties, including good reliability and convergent validity, suggesting that legal-related moral injury is a salient and distinct phenomenon affecting legal-involved veterans. Future studies should consider the MIES-LIP as a tailored tool for legal-involved veterans.

Background: The Veterans Health Administration is the largest integrated health care system in the United States, and becoming an enterprise-wide high reliability organization (HRO). In extremely complex and risk-prone environments, HROs provide safe, high-quality patient care without causing harm or adverse events. Integral to this work is psychological safety-the belief that team members can comfortably speak up when they have questions, voice concerns (especially regarding safety), take risks, and suggest ways of doing things differently. These actions are taken without undue fear of negative consequences, such as humiliation or criticism. Although progress has been made, much still needs to be done to promote psychological safety in all health care systems-especially HROs.

Observations: In its journey to become an enterprise-wide HRO, the Veterans Health Administration has implemented initiatives to develop and foster psychological safety as a means to promote patient safety and improve outcomes. In this article, we describe strategies that can be implemented to promote psychological safety.

Conclusions: Psychological safety is critical to providing safe, quality health care within an HRO. However, achieving and cultivating psychological safety in this setting requires time and patience and must be actively promoted and supported. It also requires thoughtful and purposeful attention to strategies that promote a culture where individuals feel safe to speak up when they have safety concerns.

Background: The US Department of Veterans Affairs (VA) has made concerted efforts to improve community collaboration, which can help address stressors that contribute to suicide risk in veterans. However, not all veterans have access to VA care, and some may require services outside the VA purview. One strategy to further connect veterans to services to reduce suicide risk is community asset mapping (CAM). CAM, also known as asset mapping or environmental scanning, involves identifying and gathering contact information about local community resources so that these resources can be shared and utilized.

Observations: This article describes the CAM process to address risk factors and related social determinants of health that may contribute to suicide risk. VA suicide prevention CAM includes creating a list of points of contact for community referrals, such as veteran service organizations, vet centers, Community Veterans Engagement Boards, state suicide prevention coordinators, and community mental health organizations. CAM allows for the centralization of resources so veterans and referring practitioners can better access these resources and use them to mitigate the factors that put veterans at risk of suicide.

Conclusions: Continued efforts to build and strengthen partnerships between VA and local communities are essential to prevent suicide among veterans who are served both within and outside of the VA system.

Background: Burnout and disengagement are common among primary care practitioners (PCPs), particularly those who provide women's health care at the Veterans Health Administration. The shift to virtual care forced by the COVID-19 pandemic exacerbated this issue, which may also impact clinician attrition, the patient-clinician relationship, and ultimately, patient health.

Observations: Physicians who participate in the medical humanities have more empathy and experience less burnout. To improve satisfaction and engagement among PCPs who care for women veterans, this large-scale, virtual, interprofessional narrative medicine event was implemented to gain a deeper appreciation of the impact of deployments on women veterans, describe the social and emotional challenges faced by women veterans postdeployment, and identify strategies to support veterans during reintegration. This novel use of medical media resulted in high attendance (> 800 participants) and engagement (> 1700 unique chat messages, with > 80 spontaneous replies). Findings suggest a potential shift in clinician appreciation and a positive impact on the patient-clinician relationship.

Conclusions: Medical humanities interventions are feasible on a large-scale virtual implementation. This curriculum demonstrates the successful utilization of women veterans' stories for demonstrating a positive clinician impact as evidenced by the extensive participation, engagement, and participant satisfaction.