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

Background: Patients undergoing plastic surgery have traditionally been instructed to avoid anticoagulants and antiplatelets during the perioperative period to avoid bleeding that could lead to painful hematomas, skin necrosis, unplanned procedures, and blood transfusions. Many veterans are currently prescribed anticoagulants for prevention of life- and limb-threatening embolic and thrombotic events. In early 2015, the plastic surgery service began to instruct patients undergoing elective hand surgery to stay on their prescription anticoagulant perioperatively. The objective of this study was to determine the postoperative bleeding complication rate, if any, over a 7.5-year period in patients who did not interrupt their prescription anticoagulants.

Methods: Health records at the Malcom Randall Veterans Affairs Medical Center in Gainesville, Florida, were queried for all plastic surgery cases performed from January 1, 2015, through June 30, 2022. Elective hand cases were identified based on the operation description and included carpal tunnel decompression (endo and open), cubital tunnel decompression (in situ), trigger finger release, trapeziectomy, small-joint fusion, neurectomy, elective amputations, and benign neoplasm removals. Patient history and physicals notes were reviewed for mention of a prescription anticoagulant on their medication list and for instructions to not discontinue blood thinner use. The postoperative notes were reviewed for up to 30 days to look for evidence of postoperative bleeding complications.

Results: One hundred seventy-eight patients were identified for maintaining prescription blood thinners during their elective hand surgery. There was 1 major complication (0.6%) when a patient had to return to surgery for emergent control of bleeding. This was an in situ cubital tunnel release on clopidogrel and aspirin. There were 4 minor bleeding complications (2.2%) that were treated in the clinic with compression, wound care, or expedited follow-up for reassurance.

Conclusions: Continuing prescription anticoagulants and antiplatelets during the perioperative period for elective hand surgery is a safe practice with an acceptably low local complication rate.

Background: After the initial thyroid nodule diagnosis, a patient's thyrotropin is often monitored. However, the American Thyroid Association guidelines do not offer recommendations for follow-up thyrotropin testing for patients with thyroid nodules who have no history of conditions or known medications that affect thyroid hormone levels.

Methods: At the Veterans Affairs Dayton Healthcare System in Ohio, we conducted a retrospective chart review from January 2010 to December 2016 of 100 patients diagnosed with ≥ 1 thyroid nodule on imaging studies who had normal blood thyrotropin at the time of nodule diagnosis. The thyrotropin value was studied at and after diagnosis. A 95% CI was determined for the true population rate of patients with an abnormal thyrotropin at their most recent testing. χ² tests for categorical variables and independent sample t tests for continuous variables were used to compare the abnormal and normal most recent thyrotropin groups.

Results: One hundred patients (male [83%], White race [82%]) with normal thyrotropin at nodule diagnosis had thyrotropin monitoring for a mean (SD) of 5.7 (2.5) years. Six of 100 patients (6%; 95% CI, 2.5%-12.7%) developed abnormal thyrotropin levels in a mean (SD) of 6.9 (3.1) years. When comparing the 6 patients with abnormal thyrotropin vs the 94 with normal thyrotropin, there were no significant differences in sex (P = .99), race (P = .55), age at diagnosis (P = .12), initial thyrotropin level (P = .24), most recent thyrotropin level (P = .98), or time from diagnosis to most recent thyrotropin level (P = .23).

Conclusions: This study found no significant change in thyrotropin levels over time in patients with thyroid nodules and no history of medical conditions or medications known to affect thyrotropin levels. Monitoring thyrotropin over time may not be required in these patients. More studies are needed to provide additional data on thyrotropin monitoring for thyroid nodules so that clinicians can make evidence-based decisions.

Background: The Central Texas Veterans Health Care System (CTVHCS) in Temple, a 189-bed teaching hospital, recently opened its Center for Innovation and Learning for simulation-based learning. CTVHCS built a rapid response simulation curriculum to improve preparedness for internal medicine residents, medical students, and physician assistant students that exploits newly developed medical education technology.

Observations: The Center for Innovation and Learning curriculum was created based on the most common rapid response calls received over the previous 3 years. Cardiac, respiratory, and neurological simulations were implemented. Learners approach each scenario as if they were on night service alone without specialist help. Learners must identify tachyarrhythmia, impending respiratory failure, and a patient with encephalopathy requiring transfer.

Conclusions: Sixteen learners were surveyed before the simulation and after addressing each educational objective was completed and showed improvement. Educating trainees on rapid response scenarios by using a simulation curriculum provides many benefits. Trainees reported improvement in addressing cardiac, respiratory, and neurological rapid response scenarios after experiencing the simulation.