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

Background: A duodenocaval fistula is seen when a connection exists between the duodenum and the inferior vena cava. It is a rare entity that presents a diagnostic challenge due to its nonspecific presenting symptoms and often is found only during a laparotomy or autopsy.

Case presentation: A 37-year-old man initially presented to the hospital for melena but went into cardiac arrest before undergoing an esophagogastroduodenoscopy. Unfortunately, a duodenocaval fistula was only found during the autopsy.

Conclusions: Duodenocaval fistula is a diagnostic challenge as it may present with nonspecific findings concerning for other etiologies. We want to highlight that although rare, duodenocaval fistula should be considered for patients who present with gastrointestinal bleeding and hypoxic respiratory failure.

Background: The emergency department (ED) at the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) saw a decrease in the number of visits during the early stages of the COVID-19 pandemic. Little is known whether risk mitigation procedures may help reduce the spread of COVID-19 infections for veterans visiting the ED. Therefore, we reviewed patient visits to the ED for diagnoses other than COVID-19 to assess whether these patients had an increased COVID-19 positivity rate within 21 days of the initial visit.

Observations: Risk mitigation procedures instituted by the VAGLAHS ED included a COVID-19 outdoor testing tent, immediate isolation of persons under investigation for COVID-19, disinfection protocols between high-risk patient encounters, dedicated training in donning and doffing personal protective equipment, implementation of 2-physician airway teams for COVID-19 intubations, use of electronic tablets to communicate with COVID-19 patients, and implementation of social distancing initiatives in the waiting room to minimize COVID-19 exposures. The average positivity rate at the VAGLAHS ED during this time frame was 0% to 6.7%, compared with 6.9% to 33.3% within the wider VAGLAHS.

Conclusions: Implementing risk mitigation procedures in the VAGLAHS ED helped minimize exposure and subsequent diagnosis of COVID-19 for veterans who visited the VAGLAHS ED for symptoms not associated with COVID-19 infection. Seeking acute medical care in the ED did not put patients at higher risk of contracting COVID-19.

Background: Evaluations are conducted days or weeks before a scheduled surgical or invasive procedure involving anesthesia to assess patients' preprocedure condition and risk, optimize status, and prepare them for their procedure. The traditional pre-anesthesia evaluation is conducted in person, although telehealth modalities have been used for several years and have accelerated since the advent of the COVID-19 pandemic.

Methods: We surveyed 109 anesthesiology services to understand the barriers and facilitators to the adoption of telephone- and video-based pre-anesthesia evaluation visits within the US Department of Veterans Affairs (VA).

Results: The analysis included 55 responses from 50 facilities. Twenty-two facilities reported using both telephone and video, 11 telephone only, 5 video only, and 12 none of these modalities. For telehealth users, the ability to obtain a history of present illness, the ability to assess for comorbidities, and assess for health habits were rated highest while assessing nutritional status was lowest. Among nonusers of telehealth modalities, barriers to adoption included the inability to perform a physical examination and the inability to obtain vital signs. Respondents not using telephone cited concerns about safety, while respondents not using video also cited lack of information technology and staff support and patient-level barriers.

Conclusions: We found no significant perceived advantages of video over telephone in the ability to conduct routine pre-anesthesia evaluations except for the perceived ability to assess nutritional status. Clinicians with no telehealth experience cited the inability to perform a physical examination and obtain vital signs as the most significant barriers to implementation. Future work should focus on delineating the most appropriate and valuable uses of telehealth for pre-anesthesia evaluation and/or optimization.

Background: Uptake and access to HIV preexposure prophylaxis (PrEP) is key to reducing incident HIV infections. Pharmacists are one of the most accessible health care professionals in the United States and are well suited to address this need.

Observations: We describe a model of care at the Veterans Affairs Greater Los Angeles Healthcare System in which clinical pharmacist practitioners developed and implemented a pharmacy-led PrEP clinic colocated within an infectious disease clinic. Veterans Health Administration clinical pharmacists provide direct patient care under a scope of practice that includes ordering and interpreting laboratory tests and providing PrEP prescriptions. To improve access and patient acceptability, we also used novel telemedicine modes of care to ensure flexible appointment scheduling.

Conclusions: This model can be used by other federal and community-based health care organizations to implement interdisciplinary pharmacist-managed PrEP clinics and expand telehealth modalities to deliver outpatient services.

Background: Telepathology, which includes the use of telecommunication links, helps enable transmission of digital pathology images for primary diagnosis, quality assurance, education, research, or second opinion diagnoses.

Observations: This review covers all aspects of telepathology implementation, including the selection of platforms, budgets and regulations, validation, implementation, education, quality monitoring, and the potential to improve practice. Considering the long-term trends, the lessons of the COVID-19 pandemic, and the potential for future pandemics or other disasters, the validation and implementation of telepathology remains a reasonable choice for laboratories looking to improve their practice.

Conclusions: Though barriers to implementation exist, there are potential benefits, such as the wide spectrum of uses like frozen section, telecytology, primary diagnosis, and second opinions. Telepathology represents an innovation that may transform the future of pathology practice.

Background: We studied the effects of the first year of the COVID-19 pandemic on frailty trends in a subset of older veterans at the Phoenix Veterans Affairs Health Care System.

Methods: We identified 3538 and 6103 veterans aged 70 to 75 years as of February 8, 2019, with a calculated Care Assessment Need (CAN) score of ≥ 75 for 1-year mortality and hospitalization, respectively. After excluding veterans with insufficient 2020 and 2021 data, we compared the difference in 1-year mortality and hospitalization CAN scores from 2019 to 2020 with 2020 to 2021 using a paired t test.

Results: The difference in mean (SD) 1-year mortality CAN scores from 2020 to 2021 was 0.2 (13.4) when compared with the previous year's -4.9 (12.5) (P < .0001), indicating increased frailty. The difference in 1-year hospitalization CAN scores from 2020 to 2021 was -1.5 (12.0) when compared with the previous year's -2.8 (9.9) (P < .0001).

Conclusions: Frailty in our veteran subpopulation as calculated by 1-year mortality CAN scores increased in the first year of the COVID-19 pandemic when compared with a recovering trend the previous year.