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

Background: Candida glabrata (C. glabrata) is an opportunistic fungal pathogen that has emerged as a potential risk for orthopedic prosthetic hardware infection. This case report highlights the clinical significance, management strategies, and evolving trends in the treatment of these complex infections.

Case presentation: A male Vietnam War veteran presented to the emergency department in July 2023 with pain and a large fluid collection over the surgical site on his left hip. The patient had a complex orthopedic history, having undergone total left hip arthroplasty in 1996, in addition to open reduction internal fixation about 9 months prior to presentation. On admission, the patient was afebrile and normotensive, with an elevated erythrocyte sedimentation rate and C-reactive protein. Bedside irrigation and debridement were performed, and synovial fluid analysis revealed an elevated white blood cell count, negative bacterial cultures, and the presence of C. glabrata. The patient started receiving intravenous micafungin 100 mg/day as empiric antifungal therapy. Wound cultures obtained during debridement and implant retention were positive for C. glabrata, Enterococcus faecalis, Staphylococcus epidermidis, and Corynebacterium tuberculostearicum. These findings necessitated a chronic suppressive antibiotic and antifungal regimen, in addition to ongoing local wound care for persistent serosanguinous fluid drainage. The patient opted for a 2-staged revision arthroplasty after shared decision-making with his family and orthopedic surgery team.

Conclusions: This report underscores the importance of a multidisciplinary approach in managing C. glabrata-related prosthetic joint infections, along with early detection and initiation of prompt therapy for positive patient outcomes. In addition, this report emphasizes the need for greater awareness and research into this rare but challenging infectious complication in patients undergoing similar orthopedic procedures.

Background: Electronic health records (EHRs) are critical to modern health care systems, transforming patient data management and health care delivery. Despite their benefits to patient care and safety, EHRs often face challenges in physician satisfaction and efficiency. The Inpatient Dashboard is an online EHR companion tool that streamlines the presentation of clinical information, standardizes inpatient notes, and improves safety measures.

Observations: The Inpatient Dashboard was assessed by a survey of 4 general medicine teams at the Veterans Affairs Ann Arbor Healthcare System from December 2018 to September 2019. The survey focused primarily on satisfaction, perceived safety, efficiency, and workload stress. The 68 respondents represented various medical training levels. They expressed overall satisfaction with the Inpatient Dashboard, with the majority (86%) preferring it over the Computerized Patient Records System (CPRS).

Conclusions: The Inpatient Dashboard exemplifies an innovative, user-centric EHR solution that produced high satisfaction among users at a Veterans Health Administration hospital.

Background: Nurses from Sierra Pacific Network Veterans Health Administration (VHA) facilities assembled a research team to chronicle the impact the COVID-19 pandemic had on VHA nurses within the network. This study sought to include nurses who worked in outpatient areas that were not captured in previous research and nurses who work in inpatient areas.

Methods: After reviewing current literature examining the initial effects of the COVID-19 pandemic on health care workers and possible measurement tools, the team adapted and formatted an electronic survey to measure nurses' experiences related to job satisfaction, burnout, moral distress, depression, and intent to stay in the workplace.

Results: A total of 860 registered and licensed practical/vocational nurses completed the survey in March 2023. Survey results indicated that VHA nurses experienced loss of patients (58%) and colleagues (30%) from COVID-19, overwhelming workload (57%), stress from short staffing (81%), lack of supplies (51%), burnout (50%), and moral injury (30%).

Conclusions: A high percentage of VHA nurses reported they were satisfied with their jobs and the care they provided to veterans despite experiencing personal and professional challenges stemming from COVID-19. We have identified strategies for leaders to support nurses during and after pandemics as well as plan and prepare for future pandemics.

Background: Osteoporosis medications, notably anabolic therapies, necessitate careful oversight due to their high cost and laboratory monitoring requirements, precise dosing in clinics, and strategic sequencing. These challenges were exacerbated by the COVID-19 pandemic. To address this, we created an automated clinic dashboard to aid in population health management at a US Department of Veterans Affairs osteoporosis clinic.

Methods: An automated dashboard was created to host data for patients with ≥ 1 prescription for alendronate, zoledronic acid, abaloparatide, denosumab, or romosozumab when prescriptions, appointments, or laboratory tests were overdue or out of reference range.

Results: As of March 20, 2021, 139 patients were displayed on the dashboard; 29% were female aged 40 to 100 years. The dashboard alerted us to 92 (66%) veterans with unmet care needs. The most common alert was 40 overdue laboratory tests (29%); 37 were for patients receiving bisphosphonates (93%). Of the 23 patients (17%) that had overdue medications, 2 (8%) had not refilled oral bisphosphonates, and 18 (20%) were overdue for intravenous bisphosphonates appointments. Three patients transferred care to another clinic.

Conclusions: A dashboard alerted the osteoporosis team to veterans overdue for visits, laboratory tests, and prescription renewals, thus minimizing therapy gaps and supporting high-quality care and safety. Although the dashboard was developed in response to the COVID-19 pandemic, it remains a useful patient care resource. The dashboard serves as a valuable clinical support tool for osteoporosis care coordination and has the potential for use at other health care systems.

Objectives: The US Department of Veterans Affairs (VA) has been an integral component of resident education in otolaryngology. However, the impact of resident surgical training on patient outcomes and productivity in the VA is unknown. This study sought to determine how resident participation impacted complications, operative time, and productivity in veterans undergoing total laryngectomy.

Methods: Patients who underwent total laryngectomy, with or without neck dissection, were identified in the VA Surgical Quality Improvement Program database between 2001 and 2021. Operative time, work relative value units (wRVU) generated per hour, and postoperative complications were compared for attending physicians with junior residents, attending physicians with senior residents, and attending physicians alone. Patient demographics and preoperative health variables were collected to determine their impact on postoperative outcomes, including complication rate, return to the operating room (OR), and death within 30 days.

Results: This study identified 1857 veterans who underwent a total laryngectomy at a VA facility. Most laryngectomies were performed by an attending physician with a senior resident (64%), followed by attending physician alone (24%), and an attending physician with a junior resident (12%). Resident participation was significantly associated with increased operative time (P = .001) and lower wRVU per hour (P = .002). Resident participation did not significantly affect postoperative complication rate (21.3%; n = 395) or patient return to the OR (14.6%; n = 272). On multivariate analysis, junior resident involvement (P = .001), and weight loss > 10% (P = .007) were significantly associated with longer operative times. There was a statistically significant drop in the rate of resident participation in laryngectomies from 80.6% between 2001 and 2011 to 68.3% between 2012 and 2021 (P < .001).

Conclusions: Resident participation in total laryngectomies increased operative time and reduced wRVU generated per hour but did not impact complication rates or patient return to the OR. The VA remains an integral part of otolaryngology residency training programs, but there has been a decline in resident participation in total laryngectomies.

Background: Treatment options for obesity have previously focused on lifestyle modifications, including diet, exercise, and surgery. More recently, anti-obesity medications (AOMs), such as semaglutide, liraglutide, phentermine/topiramate, bupropion/naltrexone, and orlistat, have been shown to be effective for both weight loss and improving cardiometabolic risk factors. However, no data exist comparing the efficacy of AOMs in differing age groups.

Methods: The primary endpoint for this study was the percent change in body weight from baseline compared to 6 and 12 months after AOM initiation in adults (aged < 65 years) vs older adults (aged ≥ 65 years). Secondary endpoints included changes in low-density lipoprotein (LDL), hemoglobin A_1c (HbA_1c) in patients diagnosed with diabetes or prediabetes at baseline, and blood pressure at 12 months from baseline. Safety endpoints recorded the incidence of adverse events (AEs) and AOM discontinuation.

Results: Between January 1, 2021, and June 30, 2023, a total of 116 adults and 28 older adults at the Veterans Affairs Sioux Falls Health Care System were prescribed an AOM and included in the study. There was no significant difference in percent change in body weight at 6 months (P = .08) or 12 months (P = .26) between adults and older adults. HbA_1c (P = .73) and LDL (P = .95) levels showed no statistically significant difference between age groups, nor did systolic (P = .55) and diastolic (P = .51) blood pressure. More AEs were reported (61% vs 39%), and increased discontinuation of therapy due to AEs (6% vs 0%) was noted in the adult group compared with the older adult group.

Conclusions: AOMs may have similar outcomes for weight loss in patients of all ages and similar metabolic results between adults aged < 65 years and older adults aged ≥ 65 years. Adults may experience more AEs when compared with older adults.

Background: Exercise is an established intervention for the management of arthritis, but it is unclear whether general exercise programs, such as Gerofit clinical exercise program for older veterans, are effective for arthritis.

Methods: This secondary data analysis of previously collected Gerofit data evaluated the effect 3 months of participation had on physical function by self-reported arthritis status (ie, no arthritis, any arthritis, lower body arthritis, or both upper and lower body arthritis). Veterans aged ≥ 65 years from 5 sites were included. Physical function measures included 10-meter walk test for usual gait speed (m/s), 30-second arm curl test, 30-second chair stand test, and 6-minute walk distance test (m). Linear models estimated the change from baseline to 3 months, adjusting for arthritis status, age, and body mass index.

Results: This study included 737 patients. At 3 months, each group improved physical function across all 4 measures with no differences across any arthritis status group. Gerofit exercise was associated with functional gains, regardless of arthritis status.

Conclusions: Participation in 3 months of supervised outpatient exercise programs, such as Gerofit, can improve physical function for older adults, regardless of arthritis status. These programs may increase access to exercise programming that is beneficial for common conditions affecting older adults, such as arthritis.

Background: Idiopathic postprandial syndrome (IPP) presents with hypoglycemic-like symptoms in the absence of biochemical hypoglycemia and remains a diagnosis of exclusion. Its pathophysiology is poorly understood. The diagnosis requires thorough evaluation and the Whipple triad criteria. Treatment typically involves dietary modifications, including reduced carbohydrate intake, increased protein and fiber, and frequent small meals. Continuous glucose monitoring (CGM) may be a useful adjunct in correlating symptoms with glucose trends, but its role is still evolving.

Case presentation: A 41-year-old male veteran presented with chronic postprandial episodes characterized by lightheadedness, nausea, tremulousness, anxiety, and other adrenergic symptoms occurring after carbohydrate-heavy meals. An extensive workup was unremarkable. CGM confirmed normoglycemia during episodes, ruling out true hypoglycemia and supporting a diagnosis of idiopathic postprandial syndrome. He was referred to a nutritionist for guidance on a high-protein, high-fiber, low-carbohydrate diet and subsequently reported symptomatic improvement.

Conclusions: This case highlights the importance of recognizing IPP as a distinct clinical entity, especially due to its nonspecific clinical presentation. Early identification allows for a more accurate diagnosis and targeted treatment through tailored dietary and behavioral strategies, helping to alleviate symptoms.