John J. Pershing VA Medical Center

(1953). Perceptual Organization and Development as Reflected in the Structure of Rorschach Test Responses. Journal of Projective Techniques: Vol. 17, No. 2, pp. 162-170.

BACKGROUND: We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). DESIGN: Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). SETTING: The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. PARTICIPANTS: The study included inpatient providers at participating sites who prescribe antibiotics. INTERVENTION: During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. METHODS: The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. RESULTS: = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. CONCLUSIONS: The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.

Potential bias in ophthalmic pharmaceutical clinical trials Paul VarnerJohn J Pershing Veterans’ Administration Medical Center, Poplar Bluff, Missouri, USAAbstract: To make clinicians aware of potential sources of error in ophthalmic pharmaceutical clinical trials that can lead to erroneous interpretation of results, a critical review of the study design of various pharmaceutical ophthalmic clinical trials was completed. Discrepancies as a result of study shortcomings may explain observed differences between reported ophthalmic trial data and observed clinical results.Keywords: evidence-based medicine, validity, bias, gold standard

The consumers who utilize the Veterans Health Administration healthcare system are older, and most are learning to live with chronic diseases. Their desires and needs have driven changes within the Veterans Health Administration. Through patient satisfaction initiatives and other feedback sources, consumers have made it clear that they do not want to wait for their care, they want a say in what care is provided to them, and they want to remain as independent as possible. Two interdisciplinary processes/models of healthcare are being implemented on the national level to address these issues: advanced clinic access and care coordination. These programs have a synergistic relationship and are integrated with patient self-management initiatives. Positive outcomes of these programs also meet the needs of our staff. As these new processes and programs are implemented nationwide, skills of both patients and nursing staff who provide their care need to be enhanced to meet the challenges of providing nursing care now and into the 21st century. Veterans Health Administration Office of Nursing Services Strategic Planning Work Group is defining and implementing processes/programs to ensure nurses have the knowledge, information, and skills to meet these patient care demands at all levels within the organization.

In keeping with the national emphasis on patient safety, and in keeping with the concept that quality healthcare is not episodic but spans the entire continuum of care, with the patient's home being the "preferred site of care," the Home Operations Utilizing Safety Education Program was developed. This program uses patient assessment, education, and other interventions that adjust the home environment to complement the patient's needs. The assessment and education serve as a link between in-patient, ambulatory care, and the patient's home in a cost-effective and efficient manner for reducing preventable injuries in a predominantly rural setting. The unique aspects of this program include patient follow-up in the home after initial face-to-face interviews/assessments and interventions via a hand-held camera phone. This program was developed as part of our plan to further enhance safety as a cultural norm within our Medical Center.

To determine if routine dilated fundus examination (DFE) should be performed sooner than at 10-year intervals in asymptomatic patients. Records for all patients consecutively evaluated in a one-year time frame were systematically reviewed. Of those patients who received initial DFE and were living 10 years later, records for sequential DFE were again evaluated to determine presence of clinically-significant, peripheral retinal findings. Databases were also searched in order to determine the number of patients during the same 10-year time period who developed vision or life-threatening peripheral retinal findings. The two groups were cross-matched to determine effectiveness of routine DFE. Only 10 of 592 patients were deemed to have “clinically-significant” peripheral retinal findings—none of whom developed untoward outcomes. Of the 29 new retinal detachments and four intraocular tumors discovered during ten years of clinical follow-up, nearly 90% were symptomatic at the time of discovery. Three detachments and one tumor were detected as incidental findings in asymptomatic patients. No further treatment was recommended for the three detachments and the patient with the tumor survives, although with profound loss of vision in the involved eye. In the absence of symptoms, routine DFE seems to have a very low yield for discovery of serious ocular events and appears to be ineffective in altering the course of incidental findings. Routine DFE is not indicated for older, asymptomatic patients—even at decade intervals. The findings of this study should be prospectively confirmed in population-based studies. Determinar si el examen rutinario del fondo de ojo debe realizarse con más frecuencia que a intervalos de 10 años en pacientes asintomáticos. Se revisaron sistemáticamente las historias de todos los pacientes consecutivamente evaluados durante un periodo de un año. Se volvieron a evaluar las historias de aquellos pacientes cuyo fondo había sido inicialmente examinado, y que seguían con vida 10 años después, para determinar la presencia de hallazgos con significación clínica relativa a la retina periférica. Se realizó también una búsqueda en las bases de datos para determinar el número de pacientes, durante el mismo periodo de 10 años, que había desarrollado casos en la retina periférica, con riesgo de vida o visión. Se cruzaron los dos grupos para determinar la efectividad del examen rutinario del fondo de ojo. Únicamente 10 de entre 592 pacientes mostraron casos en la retina periférica “clínicamente significativos”, de los que ninguno evolucionó inadecuadamente. De los 29 nuevos desprendimientos de retina y cuatro tumores intraoculares descubiertos durante los diez años de seguimiento clínico casi el 90% fueron asintomáticos en el momento de su descubrimiento. Se detectaron tres desprendimientos y un tumor como casos incidentales en pacientes asintomáticos. No se recomendó ningún tratamiento adicional para los tres desprendimientos, y el paciente con el tumor sigue vivo, aunque con una profunda pérdida de visión en el ojo afectado. En ausencia de síntomas, el rendimiento del examen rutinario del fondo de ojo es muy bajo a la hora de descubrir eventos oculares serios, revelándose poco eficaz para alterar el curso de los hallazgos incidentales. Dicho examen no está indicado en pacientes de edad y asintomáticos, incluso a intervalos de 10 años. Los hallazgos de este estudio deberán confirmarse prospectivamente mediante estudios basados en población.

ASHP and the ASHP Research and Education Foundation developed the Pharmacy Practice Model Initiative (PPMI) in 2010.1,2 The primary goal of PPMI was advancement of the health and well-being of patients by supporting practice models that encourage pharmacists as direct patient care providers. In 2015, the PPMI became the Practice Advancement Initiative (PAI) based on recommendations from the ASHP Ambulatory Care Summit. This move aimed to include a broader range of pharmacist services and healthcare settings than the previous initiative. The primary goals of the PAI focus on care team integration, pharmacy technician roles, pharmacist training and credentialing, automation and technology, and pharmacists taking the lead in medication use for patients.2,3 The PAI is vital for the growth of the pharmacy profession and to promote pharmacy as an integral provider in healthcare. The PAI Hospital Self-Assessment (HSA), a 106-question survey, was designed to identify gaps in hospital pharmacy practices across the nation.4 The HSA also provides the opportunity to generate reports comparing gathered data on each respective hospital and provide comparisons with similar hospitals within a specific state and nationwide.4,5

Viewing the Substance Abuse and Mental Health Services Administration's recovery principles through an antiracist lens has guided the authors' vision of recovery-oriented systems for all. In this brief letter, they present some considerations arising from their application of recovery principles to areas affected by racial bias. They are also identifying best practices for incorporating micro and macro antiracism efforts into recovery-oriented health care. These are important steps in promoting recovery-oriented care, but there is much more to do. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A 48-year-old Caucasian man with an established diagnosis of pathological ankylosing spondylitis with cervical spinal fusion and a lengthy history of acute, recurrent, anterior uveitis presented with decreased vision in both eyes. Biomicroscopic examination revealed bilateral inflammatory pupillary membranes associated with anterior uveitis to be the source of the visual compromise. Aggressive topical anti-inflammatory and mydriatic therapy did not break the pupillary membranes and the patient ultimately underwent surgical resection of the membranes in both eyes. Vision returned to normal in one eye and was only slightly reduced in the fellow eye after a prolonged post-operative period involving multiple ophthalmic surgical procedures. This is the first reported case of bilateral, simultaneous uveitis-associated pupillary membranes.

The Department of Veterans Health Administration Office of Nursing Service has embarked on a multiyear transformational process, an example of which is the development of an organization-wide nursing handbook. The development of this handbook offered the opportunity to improve collaboration, redefine expectations and behavior, as well as prepare for the future of Nursing within the Veterans Health Administration. The lessons learned from this process have revolved around the themes of leadership skills for managing high-level change often in a virtual environment; constant collaboration; that the practice of nursing will continue to evolve on the basis of new evidence, technology, customer expectations, and resources; and that the process to accomplish this goal is powerful.

Abstract: Isolated unilateral disk edema is a familiar clinical presentation with myriad associations. Related, non-consensus terminology is a barrier to understanding a common pathogenesis. Mechanisms for the development of disk edema are reviewed, and a new framework for clinical differentiation of medical associations is presented. Keywords: disk edema, axoplasmic flow, clinical multiplier, optic neuritis, ischemic optic neuropathy, papilledema

Shuffling a deck of cards is normally used for randomization. An imperfect shuffle would not produce the desired randomization, since there would be residual correlation with the original order. On the other hand, from the classical card magic literature it is known that eight successive perfect riffle shuffles returns the deck to the original order. The question addressed here is whether this observation is in fact unusual and surprising. Although a general closed‐form analytical solution does not appear to be possible, a simple program could be written to determine deck sizes and numbers of shuffles for which eventual reordering occurs. This computational approach correctly predicts the original observation of eight shuffles for a deck of 52 cards; in fact if the trivial solutions of integral multiples of eight shuffles are discarded, eight shuffles appears to be the unique solution for a 52 card deck.

The use of digital stories in the English language learning classroom is not a new practice. Experienced teachers value the project-based nature of developing stories overtime with their students for the meaningful practice it gives learners in terms of pronunciation, vocabulary development, narrative development, author decision making, and the consideration of a real audience for one’s work. However, there is a dearth of empirical studies that measure student progress based on the individual doing multiple stories. Typically learners do only one story as a culminating class project and researchers show development over drafts (e.g., Kajder, 2004; Skinner & Hagood, 2008; Vinogradova, Linville, & Bickel, 2011). While revision was an important component of the project the current researchers describe because the project was carried over a 7-month period and learners made 3 digital stories (each story having multiple revisions), the researchers present not only the extent to which learners develop over one digital story, but over several-thus presenting a more nuanced description of computer assisted language learning. In addition to showing examples of student development overtime and over multiple stories, the researchers will present a system of selfand peer-evaluation that was developed for, by and with the language learners of this project. Researchers will present how a shared assessment project contributed to the sustainability of a more authentic community of practice in this middle school class of 19 beginner English language learners. The audience of this presentation will be provided with ways they can assess digital stories using a system of selfevaluation, peer and teacher formative feedback. Practical considerations of sequencing and combining different tools (e.g., KeyNote, PowerPoint, VoiceThread, GoogleDocs) will be discussed. While this work was done in a language learner context, ways in which digital stories might develop native speaker’s language and cognitive development across subjects will be addressed.

Abstract: Retinal cholesterol emboli (RCE) are occasionally found on ophthalmic examination. Originally, all RCE were thought to be related to impending cardiovascular morbidity and mortality, but it is now apparent that accompanying symptoms can be used to help better stratify cardiovascular event risk for these patients. Regardless of associated visual symptoms, all patients with RCE but unknown medical status, merit referral to primary care providers for further assessment of cardiovascular health status. Symptomatic patients with known cardiovascular diseases require carotid duplex ultrasonography to determine degree of arteriolar occlusion with possible referral to vascular surgeons for invasive correction of carotid artery occlusive disease. Asymptomatic patients with known cardiovascular profiles may benefit from the addition of only 81 mg aspirin if not otherwise contraindicated. Screening carotid studies should not be considered for these patients. Carotid auscultation in the eye clinic setting is unwarranted for either set of patients. Keywords: retina, embolus, hollenhorst plaque

Abstract The Inertia of Fear and the Scientific Worldview , by Valentin F. Turchin, Columbia University Press, New York, 1981, 300 pp.

INTRODUCTION: Mental health services are an area of high need in many health care systems in the United States. With a limited number of psychiatric providers and a projected increase in the deficit of psychiatrists, a call for increased mental health services is apparent. The inclusion of mental health clinical pharmacy specialists (MH-CPS) as part of interdisciplinary care teams has enabled the William S. Middleton Memorial Veterans Hospital & Clinics as well as numerous other Veterans Affairs sites to improve access to mental health providers when pharmacists serve as an integral part of the mental health team. Our objectives were to (1) evaluate impressions of nonpharmacist mental health providers of MH-CPS and (2) assess for areas of improvement in MH-CPS services. METHODS: A survey was formulated, using 5-point Likert scale criteria, to evaluate impressions of MH-CPS from other mental health providers. Questions were designed to address impressions of clinical skills, knowledge, team contribution, and comfort with MH-CPS providers. These were distributed and completed in December 2018 by members of mental health treatment teams at the William S. Middleton Memorial Veterans Hospital & Clinics. RESULTS: Overall, mental health team members rated satisfaction with MH-CPS highly across all evaluated criteria. DISCUSSION: Per review of these results, MH-CPS are a valued and respected part of the mental health team.

Amaurosis fugax is a common term fraught with different interpretations. Disparities inunderstanding appear to be related to professional training. A new framework to facilitateinterdisciplinary communication and clinical research is presented.

Abstract Background Remote Infectious Disease (ID) physicians can provide stewardship support through telehealth. Using the RE-AIM framework, we assessed the implementation of telehealth-supported prospective-audit-and-feedback (tele-PAF) across 3 rural Veterans Administration medical centers (VAMC). Methods All 3 invited sites agreed to participate and lacked ID support for stewardship at baseline. During 2021, an ID physician met virtually 3 times/week with the stewardship pharmacist champion at each participating VAMC to review patients on antibiotics in acute-care (mean daily census 3/site) and nursing-homes (NHs; mean census 71/site); real-time feedback on antibiotic use was given to clinicians. The primary outcome of effectiveness was monthly antibiotic days of therapy (DOT) per 1,000 days-present aggregated across all sites; the secondary outcome was days of antibiotic spectrum coverage (DASC) per 1,000 days-present. An interrupted time-series analysis was performed to asses these outcomes during the 1-year intervention period vs. the 2-year prior baseline. Semi-structured interviews with 20 clinicians and pharmacists were conducted to assess implementation. Results RE-AIM elements are summarized in Table 1. Tele-PAF reviewed 502 unique patients and made 681 recommendations to 23 clinicians; 77% of recommendations were accepted. The most common recommendations were to stop antibiotics (28%) and change duration (20%). After the start of tele-PAF, antibiotic DOT and DASC immediately decreased in acute-care (-20%, p=0.01; -22%, p< 0.01) and NHs (-28%, p=0.03; -37%, p< 0.01). Both metrics began to rise again in acute-care (DOT: +2.5%/month, p=0.02; DASC: +2.7%/month, p=0.02) but were stable in NHs (Figure 1). Clinicians generally appreciated feedback, found it compatible with their workflow and responded favorably to collaborative discussions. Barriers included difficulty establishing rapport with some providers. Conclusion The implementation of tele-PAF was associated with sustained reductions in antibiotic use across 3 NHs but not in the studied small acute-care units. Overall, clinicians perceived the intervention as acceptable and appropriate. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use. Disclosures Daniel J. Livorsi, MD, Merck & Co.: Grant/Research Support.

This case report of a 78 year-old man demonstrates a case of bilateral optic neuropathy that does not completely fit the modern definition of Primary Open-Angle Glaucoma. In this case, visual field testing does not substantiate a diagnosis of glaucoma, and retrograde optic neuropathy seems to be a more likely source for the optic nerve presentation. Clinicians are reminded that incomplete clinical pictures merit further scrutiny. Este caso clínico de un hombre de 78 años presenta una neuropatía óptica bilateral que no se ajusta completamente a la definición actual de glaucoma primario de ángulo abierto. En este caso, las pruebas del campo visual no corroboran un diagnóstico de glaucoma y aparentemente el origen más probable de esta presentación del nervio óptico sea la neuropatía óptica retrógrada. Se recuerda a los médicos que las imágenes clínicas incompletas merecen un examen más exhaustivo.

How frequently should asymptomatic patients be dilated?20-year results ¿Con qué frecuencia debería dilatarse a los pacientes asintomáticos?Resultados de 20 años