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

Background: The Veterans Health Administration (VHA) provides health care in rural communities through the Telerehabilitation Enterprise-Wide Initiative (TR-EWI) and other community care (CC) programs. Telehealth may allow clinicians to overcome challenges associated with CC, but there is a lack of understanding of the use of CC for rehabilitation services.

Methods: This study explores CC physical therapy (PT) referral use and cost trends for 7 Veterans Integrated Services Networks (VISNs) with TR-EWI sites, using US Department of Veterans Affairs Corporate Data Warehouse and VHA Support Service Center referral data, as well as cost data from the VHA Community Care Referral Dashboard. We used descriptive statistics to analyze data. This study also qualitatively analyzed provisional diagnosis data to ascertain which PT diagnosis groups were most frequently referred to CC.

Results: There were 344,406 PT referrals to CC from fiscal year (FY) 2019 to FY 2022. Referrals decreased from FY 2019 to FY 2020 but increased from FY 2020 to FY 2022, most notably in VISNs 19 and 22; VISN 8 consistently had high PT referrals over time. More referrals were made for veterans living in urban communities (56.2%) than rural communities (39.8%) and for those aged 60 to 69 years (20.7%) and aged 70 to 79 years (26.9%). There were 200,204 PT referrals with cost data from FY 2020 to FY 2022, totaling about $221 million in selected VISNs. Referral costs nearly doubled from FY 2020 to FY 2021, but only slightly increased from FY 2021 to FY 2022.

Conclusions: This study highlights the variations in PT referrals and costs across VISNs and eligibility reasons for CC referral. Cost trends underscore the financial commitment to provide PT to veterans. Understanding the factors driving cost is necessary for the VHA to optimally provide and manage the rehabilitation resources needed to serve veterans through traditional in-person care, telehealth, and CC while ensuring timely, high-quality care.

Background: Lyme disease is a bacterial infection caused by the spirochete Borrelia burgdorferi sensu lato complex transmitted by the Ixodes tick genus. There is uncertainty regarding proper diagnostic testing for suspected cases. Ocular manifestations have been documented in all stages of Lyme disease, but are more prevalent in early disseminated disease.

Observations: This review article provides guidelines for the appropriate diagnostic testing to obtain when encountering ocular manifestations of suspected Lyme disease.

Conclusions: To ensure timely diagnosis and treatment, eye care clinicians should be familiar with the appropriate diagnostic testing for patients suspected to have ocular manifestations of Lyme disease. If testing confirms Lyme disease, refer the patient to an infectious disease specialist for antimicrobial treatment and additional management.

Background: Arachnoid granulations are extensions of the subarachnoid space, an important component of the complex circulation of brain cerebrospinal fluid. While these structures primarily transmit cerebrospinal fluid into the dural venous sinuses, they also may serve as a conduit for brain tissue herniation. Such occurrences have been referred to in the literature as brain herniations into arachnoid granulations (BHAGs), which are considered incidental and asymptomatic but can be associated with nonspecific neurologic symptoms such as headache, tinnitus, vertigo, and seizure. BHAGs can be visualized more readily due to improved cross-sectional magnetic resonance imaging (MRI) with increased spatial and contrast resolution.

Case presentation: We present 5 cases where brain herniations were detected in patients undergoing MRI for various neurologic symptoms. All patients experienced chronic symptoms, including headaches and seizures. Two cases included BHAG in locations that were associated with the patients' symptoms.

Conclusions: BHAGs are increasingly recognized due to improved spatial resolution in MRIs. While there is still no definitive evidence that these lesions are responsible for various neurologic symptoms, some of these abnormalities may hold clinical significance, such as the visual symptoms seen in 2 of the cases described. BHAG can be associated with gliosis of adjacent brain tissue, which may be a mechanism for symptom development.

Background: Obesity is a chronic disease associated with several metabolic comorbidities. Weight loss interventions, such as bariatric surgery and endoscopic procedures like endoscopic sleeve gastroplasty (ESG), are known to improve obesity-related health conditions. However, there is limited data on the impact of endoscopic procedures on psychiatric disorders. Our report aims to describe the clinical course of a veteran with psychiatric comorbidities that prevented him from proceeding with bariatric surgery, and ultimately underwent an ESG.

Case presentation: A 59-year-old male veteran with severe obesity had limited exercise capability and poor quality of life due to a large ventral hernia. The patient's dietary, lifestyle modification, and medication-assisted weight loss attempts were unsuccessful. A planned weight loss surgery was canceled due to anxiety and a panic attack. He underwent ESG with a successful total body weight loss of 16.7% at 12 months. Subsequent improvement in metabolic and psychiatric comorbidities ultimately enabled the patient to undergo ventral hernia repair, which significantly improved his quality of life.

Conclusions: This report demonstrates that ESG may be an option for weight loss in patients with psychiatric comorbidities and can lead to significant clinical improvement in multiple obesity-associated comorbidities. This case further highlights the value of endoscopic procedures as alternatives to bariatric surgery in select cases when lifestyle changes and medications have not been effective, and surgery may not be a viable option.

Background: Aspirin is a commonly prescribed antiplatelet agent for primary and secondary prevention of cardiovascular events. Guidelines recommend avoiding aspirin for primary prevention in most patients aged ≥ 70 years, but there is limited data on the most effective way to deprescribe aspirin in outpatient settings.

Methods: This prospective quality improvement study used the US Department of Veterans Affairs (VA) VIONE medication safety dashboard to identify eligible patients at a Durham VA Health Care System (DVAHCS) community-based outpatient clinic. Patients were aged ≥ 70 years without known atherosclerotic cardiovascular disease and an active aspirin prescription as of September 1, 2022. Two pharmacists gave a deprescribing presentation to primary care practitioners (PCPs) 90 days later. The primary objective was to compare the efficiency of pharmacist direct deprescribing of aspirin with PCP deprescribing for primary prevention over a 12-week period following the education session. Secondary objectives assessed the number of aspirin orders discontinued, the effect of the education on aspirin deprescribing for primary prevention, and pharmacist time to complete the intervention.

Results: Two aspirin orders were deprescribed per hour of pharmacist time compared with 67 aspirin orders per hour for PCPs. In the 12 weeks following the PCP education session, 230 aspirin orders were discontinued, 97 by pharmacists and 133 by PCPs. Among the 868 patients identified, 224 met inclusion criteria for the pharmacist direct deprescribing intervention, and all patients were eligible through the PCP education method. Pharmacists spent about 48 hours on the pharmacist intervention and 1 hour on the PCP education intervention.

Conclusions: PCP education was more efficient for deprescribing aspirin compared with direct deprescribing by pharmacists based on the number of aspirin orders discontinued by time spent.

Background: Neurological disorders are a leading cause of disability and death worldwide. Their burden on the health care system has substantially increased in the past 25 years, due to more effective treatments and longer life expectancies. The Veterans Health Administration has seen increases in neurology referrals and patients with neurologic disorders.

Observations: Collaborative efforts among primary care, geriatrics, neurology, psychiatry, physical medicine and rehabilitation, social work, and other disciplines are needed to properly care for veterans with neurologic disorders. Neurology education is an important tool for clinicians to better care for veterans with neurologic disorders. The use of technology and online resources have improved education dissemination. This article describes how an annual neurology education program has expanded its reach and availability over 4 years.

Conclusions: A small, in-person neurology symposium evolved into an annual virtual conference that included more clinicians from outside the specialty. Increased participation and survey data suggest the seminar improved neurologic knowledge in non-neurologist clinical personnel and increased their comfort level during initial evaluations of neurologic disorders in veterans.

Background: Integrative medicine or complementary and alternative medicine (IM/CAM) is widely utilized by patients despite the limited training available across health care education. There is a gap between patient interest and the need for guidance amid a lack of preparation among clinicians in IM/CAM. To address this, the Baltimore Geriatric Research Education and Clinical Center created a US Department of Veterans Affairs-based whole health rotation that incorporates core IM/CAM competencies for family medicine and preventive medicine residents.

Observations: A structured 2-week IM/CAM curriculum was developed by medical school faculty in cooperation with a range of health care professionals. Assessments, including surveys and a case analysis, measured overall program satisfaction, perception of IM/CAM modalities, IM/CAM knowledge, confidence in pain care, self-care perception, self-care practice, and burnout symptom frequency. Residents participating in the IM/CAM rotation reported positive experiences overall, gained knowledge for their own personal benefit, and acquired resources and skills they felt confident discussing with their patients. They also reported a slight decrease in feelings of burnout and perceived stress.

Conclusions: IM/CAM education, delivered as a standardized family medicine rotation, enhances resident capacity to make informed decisions and counsel patients on IM/CAM options, while also providing strategies for maintaining optimal health and well-being.

Background: Posthoc analyses have found an increased bleeding risk in oral anticoagulation with concomitant nonsteroidal anti-inflammatory drug (NSAID) use. However, this research was primarily conducted in mixed populations prescribed both direct oral anticoagulants (DOACs) and warfarin. Research evaluating bleeding risk with NSAID use among DOACs alone is limited. This study evaluates bleeding rates in patients taking rivaroxaban and apixaban with and without NSAID use and investigates the potential impact of NSAID selectivity or proton pump inhibitor (PPI) coprescribing.

Methods: This single-center retrospective cohort study compared bleeding rates between rivaroxaban or apixaban among NSAID and non-NSAID users. The primary endpoint was a composite of any bleeding event per International Society on Thrombosis and Haemostatis criteria. The secondary endpoint was bleeding rates for NSAID users based on NSAID choice and PPI coprescribing.

Results: The study included 681 patients on rivaroxaban and 3225 patients on apixaban. Seventy-two patients on rivaroxaban (10.6%) and 300 patients on apixaban (9.3%) were NSAID users. There was no statistically significant difference between rivaroxaban and apixaban among NSAID users (hazard ratio 1.04; 95% CI, 0.98-1.12) or non-NSAID users (hazard ratio 1.15; 95% CI, 0.80-1.66). There was no clinically significant difference observed for NSAID selectivity or PPI coprescribing for NSAID users.

Conclusions: Bleeding rates were not significantly different between patients taking rivaroxaban and patients taking apixaban, regardless of NSAID use. A population health management tool may provide a safe approach for coprescribing NSAIDs with DOACs. Additional prospective studies are needed to quantify the comparative bleeding risk with concomitant NSAID use among DOACs alone.

Background: The US Department of Veterans Affairs (VA) launched the VA Video Connect (VVC) video conferencing platform to connect veterans with VA clinicians in 2018. We assessed practices, concerns, and perceptions toward VVC encounters among physicians within the VA New Mexico Healthcare System (VANMHCS).

Methods: Medicine Service Physicians of VANMHCS who had previously completed ≥ 1 VVC encounter were invited to semistructured interviews. Questions were constructed to assess the following domains: overarching views of video telehealth, perceptions of the VVC application, and barriers to the broad implementation of video telehealth. Interviews were assessed using a qualitative, open-coding approach. Themes were constructed both deductively, through direct responses to interview questions, and inductively, by identifying emerging patterns in the data.

Results: Of the 64 physicians invited to participate, 13 (20%) were interviewed. Of those interviewed, 9 (69%) were female, 10 (77%) were specialists, 8 (62%) had been practicing for ≥ 10 years, and 7 (54%) completed ≥ 5 VVC visits. Interviews ranged from 10 to 25 minutes. Five themes were observed: (1) VVC software and internet connection issues affected implementation; (2) patient technological literacy affected both veteran and physician comfort with VVC; (3) integration of supportive measures is desired; (4) clinical video telehealth (CVT) services may increasingly enhance access to care; and (5) in-person encounters provided unique advantages over CVT.

Conclusions: Physicians believe VVC could lead to improved access to care for veterans facing geographical challenges. Efforts should focus on improving VVC user interface and addressing technological issues, educating veterans/physicians on the use of CVT, and integrating supportive measures for successful VVC encounters.

Background: Sulfamethoxazole-trimethoprim is an antibiotic that can cause rare and potentially life-threatening adverse effects. This case describes an immunocompetent patient who developed acute agranulocytosis complicated with aseptic meningitis after being prescribed sulfamethoxazole-trimethoprim.

Case presentation: A healthy 39-year-old male veteran presented to the emergency department with worsening left testicular pain and increased urinary urgency and frequency. The patient was diagnosed with left epididymo-orchitis and prescribed oral sulfamethoxazole-trimethoprim 800-160 mg every 12 hours for 30 days. Two weeks later, the patient returned to the emergency department with fever, headache, chills, and generalized body aches that led to hospitalization. It was discovered that he had not finished the full course of antibiotics due to symptoms resolution and had restarted the medication to finish the course of therapy. The patient was diagnosed with agranulocytosis and aseptic meningitis secondary to sulfamethoxazole-trimethoprim.

Conclusions: This case highlights the rare potential for acute agranulocytosis in combination with aseptic meningitis following the use of sulfamethoxazole-trimethoprim in an immunocompetent patient.