St. Cloud VA Health Care System

IMPORTANCE: Although research on quality of life and dermatologic conditions is well represented in the literature, information on teledermatology's effect on quality of life is virtually absent. OBJECTIVE: To determine the effect of store and forward teledermatology on quality of life. DESIGN: Two-site, parallel-group, superiority randomized controlled trial. SETTING: Dermatology clinics and affiliated sites of primary care at 2 US Department of Veterans Affairs medical facilities. PARTICIPANTS: Patients being referred to a dermatology clinic were randomly assigned, stratified by site, to teledermatology or the conventional consultation process. Among the 392 patients who met the inclusion criteria and were randomized, 326 completed the allocated intervention and were included in the analysis. INTERVENTIONS: Store and forward teledermatology (digital images and a standardized history) or conventional text-based consultation processes were used to manage the dermatology consultations. Patients were followed up for 9 months. MAIN OUTCOME MEASURES: The primary end point was change in Skindex-16 scores, a skin-specific quality-of-life instrument, between baseline and 9 months. A secondary end point was change in Skindex-16 scores between baseline and 3 months. RESULTS: Patients in both randomization groups demonstrated a clinically significant improvement in Skindex-16 scores between baseline and 9 months with no significant difference by randomization group (P = .66, composite score). No significant difference in Skindex-16 scores by randomization group between baseline and 3 months was found (P = .39, composite score). CONCLUSIONS: Compared with the conventional consultation process, store and forward teledermatology did not result in a statistically significant difference in skin-related quality of life at 3 or 9 months after referral. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00488293.

Background Oncology pharmacists are capable of providing medication therapy management (MTM) because of their level of training, practice experiences, and responsibilities. Very little data exist about their current practice, including changing roles in the multidisciplinary team, overall impact, and effects in the education of patients and healthcare professionals. Methods A 70-item survey about oncology pharmacists' activities in oral chemotherapy programs, MTM, and collaborative practice agreements (CPAs) was deployed using a web survey tool (Qualtrics, Provo, UT, USA), targeting pharmacist members of American College of Clinical Pharmacy (ACCP) Hematology/Oncology Practice and Research Network (PRN). The objective of this study was to determine oncology pharmacists' activities in areas of oral chemotherapy programs, MTM, and CPAs. A cross-sectional survey was distributed to the ACCP Hematology/Oncology PRN membership. Investigational Review Board approval was obtained. Results Of the 795 members who were sent the survey, 81 members (10%) responded; 33 respondents (47%) are involved with an oral chemotherapy program; with 42% measuring outcomes of programs. Only six pharmacists (19%) have published or presented their data. A total of 28 (35%) respondents provide MTM services, with almost half (43%) of these MTM services being dictated by CPAs. A small fraction of these pharmacists (21.4%) reported conducting quality assurance evaluations of their MTM services and three pharmacists (10.7%) reported publishing their results. Those pharmacists practicing under CPAs ( n = 28) were surveyed as to activities included in their CPA. The most common activities included adjusting medication, ordering, interpreting, and monitoring lab tests, developing therapeutic plans and educating patients. Reimbursement for providing these services was uncommon: MTM (4%), oral chemotherapy program (6%), and CPA services (11%). Reported obstacles to reimbursement included lack of understanding, administrative assistance, or time with setting up reimbursement models within the institution. Conclusion Many oncology pharmacists are participating in oral chemotherapy programs, MTM, and/or CPAs and perceived barriers were identified. Increased efforts should be directed toward prospectively reporting and assessing the impact these services have on patient care.

We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral (P = 0.88) or between baseline and the first dermatology clinic visit (P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course (P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.

The objective of this study was to conduct a confirmatory factor analysis (CFA) of the Posttraumatic Growth Inventory (PTGI) to determine if the factor structure is the same for a veteran sample with posttraumatic stress disorder (PTSD; N = 221) as compared to previous studies that have used more heterogeneous samples of subjects. Analyses were conducted in order to examine the best model fit between three broad dimensional factors, a five-factor structure, or a factor structure consisting of one higher-order “general” factor with five “lower-order” factors. Results of the CFA revealed adequate fits for the five-factor and five-factor higher-order models. The findings of this study support the use of the PTGI total and factor scores when interpreting results in veteran samples with PTSD.

BACKGROUND: The causes of elevated B-Type natriuretic peptide (BNP) levels are multifactorial. Renal dysfunction has been shown to affect BNP levels in some studies and the diagnostic value of BNP levels in the presence of chronic kidney disease has been questioned. Prior studies have involved small patient populations with variable outcomes noted. This study evaluated the association of BNP levels with an estimated glomerular filtration rate (eGFR) and presence or absence of congestive heart failure (CHF). METHODS: A retrospective, cross-sectional study in which medical records were electronically screened, identified patients with a BNP level and serum creatinine measurement on the same day between December 2002 and March 2006. RESULTS: Of 1739 eligible patients, 537 were positive for CHF and 1202 were negative for CHF by our criteria. There was a clear trend for BNP to be higher with the advancement of CHF, as determined by New York Heart Association (NYHA) classification (P<0.001). Median BNP levels increased from 65 pg/mL in patients without CHF to 496 pg/mL in patients with NYHA class IV CHF (P <0.001), and there was a strong inverse association with eGFR (P <0.001). CONCLUSION: BNP levels show a strong inverse association with eGFR in both CHF and non-CHF patients. Currently best practice at most institutions involves use of BNP cutoff diagnostic levels not adjusted for eGFR. The data presented underlines that eGFR is a significant confounder of BNP measurement especially when renal status is compromised and interpretation of clinical significance in the presence of elevated BNP measures should take renal status into consideration.

INTRODUCTION: Information continuity is critical to person-centered care when patients receive care from multiple healthcare systems. Patients can access their electronic health record data through patient portals to facilitate information exchange. This pilot was developed to improve care continuity for rural Veterans by (1) promoting the use of the Department of Veterans Affairs (VA) patient portal to share health information with non-VA providers, and (2) evaluating the impact of health information sharing at a community appointment. MATERIALS AND METHODS: Veterans from nine VA healthcare systems were trained to access and share their VA Continuity of Care Document (CCD) with their non-VA providers. Patients and non-VA providers completed surveys on their experiences. RESULTS: Participants (n = 620) were primarily older, white, and Vietnam era Veterans. After training, 78% reported the CCD would help them be more involved in their healthcare and 86% planned to share it regularly with non-VA providers. Veterans (n = 256) then attended 277 community appointments. Provider responses from these appointments (n = 133) indicated they were confident in the accuracy of the information (97%) and wanted to continue to receive the CCD (96%). Ninety percent of providers reported the CCD improved their ability to have an accurate medication list and helped them make medication treatment decisions. Fifty percent reported they did not order a laboratory test or another procedure because of information available in the CCD. CONCLUSIONS: This pilot demonstrates feasibility and value of patient access to a CCD to facilitate information sharing between VA and non-VA providers. Outreach and targeted education are needed to promote consumer-mediated health information exchange.

OBJECTIVE: The Beck Depression Inventory-II (BDI-II) is widely used as a screening instrument for depressive symptomatology in clinical settings. The factor structure has been researched in a variety of settings with results ranging from a single factor to a five-factor structure. The purpose of this study was to examine several identified factor structures when applied to a mixed polytrauma sample. METHOD: A sample of 310 veterans was used for this study. All subjects were administered the BDI-II screening measure as part of an evaluation in an outpatient polytrauma clinic. Confirmatory factor analysis was used to determine the best model. RESULTS: Confirmatory factor analysis revealed that a three-factor model provided a best fit. A model previously identified for individuals in residential treatment for substance abuse provided a best fit for this sample. CONCLUSIONS: The BDI-II may provide additional information for clinicians when examining the three-factor model with veterans in polytrauma settings.

The purpose of this article is to review the literature regarding job satisfaction and how it relates to an individual's characteristics. Nurses experience a complex interplay among stressors and mediating variables. How these variables and stressors interact differently among individuals is described.

SIGNIFICANCE: This case illustrates a novel screening protocol for linezolid-induced toxic optic neuropathy. PURPOSE: To present a case report and analysis of linezolid-induced optic neuropathies in adult patients to develop screening recommendations. CASE REPORT: A case report of optic neuropathy from extended use of linezolid illustrates its potential effects on vision. We conduct a retrospective analysis of 39 reported cases to derive a recommended screening protocol for linezolid-induced toxic optic neuropathy in adult patients. Of 39 reported adult cases, 32 presented with optic neuropathy within 90 to 365 days of treatment. Within this subset, the duration of linezolid dosage to first symptoms is 235 ± 71 days. Seven outliers either experienced optic neuropathy within the first 28 days or between 600 and 1125 days. Of the 33 cases that quantified visual recovery, 30 reported final binocular visual acuity equivalent to 20/40 or better when the medication was discontinued from 0 to 268 days after symptom onset. Recovery potential was reported over a period of 2 weeks to approximately 6 months after cessation. To evaluate the effect of cumulative dose, the data were separated into patients taking 600 mg twice daily and those at 600 mg once daily. At the higher dosage, a mean of 180 ± 96 days with a mean cumulative dosage of 216 ± 115 g was noted at first symptom, whereas at lower dosage, a mean of 201 ± 102 days was noted with a mean cumulative dose of 138 ± 69 g. CONCLUSIONS: We recommend screening adult patients within 1 month after initiating linezolid, followed by a subsequent evaluation every 30 to 60 days beginning 3 months from initiation. Substantial visual recovery is reported when linezolid is discontinued. Toxicity appears to be correlated to duration of treatment, rather than cumulative dose.

Background Clinical care team members in Department of Veterans' Affairs (VA) facilities nationwide are working to integrate the use of Secure Messaging (SM) into care delivery and identify innovative uses. Identifying best practices for proactive use of SM is a key factor in its successful implementation and sustained use by VA clinical care team members and veterans. Objectives A collaborative project solicited input from VA clinical care teams about their local practices using SM to provide access to proactive patient-centered care for veterans and enhance workflow. Methods This project implemented a single-item cross-sectional qualitative electronic survey via internal e-mail to local coordinators in all 23 Veterans Integrated Service Networks (VISNs). Content analysis was used to manage descriptive data responses. Descriptive statistics described sample characteristics. Results VA clinical care team members across 15 of 23 VISNs responded to the questionnaire. Content analysis of 171 responses produced two global domains: (1) benefits of SM and (2) SM best practices. Benefits of SM use emphasize enhanced and efficient communication and increased access to care. Care team members incorporate SM into their daily clinical practices, using it to provide services before, during, and after clinical encounters as a best practice. SM users suggest improvements in veteran care, clinical team workflow, and efficient use of health resources. Clinical team members invested in the successful implementation of SM integrate SM into their daily practices to provide meaningful and useful veteran-centered care and improve workflow. Conclusion VA clinical care team members can use SM proactively to create an integrated SM culture. With adequate knowledge and motivation to proactively use this technology, all clinical team members within the VA system can replicate best practices shared by other clinical care teams to generate meaningful and useful interactions with SM to enrich veterans' health care experience.

BACKGROUND: The purpose of this study was to explore the use of the oral decontamination solution chlorhexidine (CHX) to reduce ventilator-associated pneumonia (VAP) in a long-term ventilator care setting over time. Most of the research in this area has been conducted in acute and intensive care settings. METHODS: This study was a retrospective medical record review conducted in a long-term care facility with a dedicated ventilator unit. Veterans records (N = 12) were accessed for this study. The study covered 50 months, with a 43-month time period during which CHX was administered. RESULTS: While the sample size was small, many of the veterans on ventilators used CHX for years without an incident of VAP. CONCLUSIONS: These findings support using CHX to significantly reduce the number of days of intravenous antibiotics used to treat VAP with little side effects.

RATIONALE: Psilocybin is a potentially paradigm-shifting depression intervention. We conducted a systematic review and meta-analysis of psilocybin-for-depression randomized controlled trials (RCTs). OBJECTIVES: Systematically assess harm reporting, risk of bias, action mechanism specification, and incremental therapeutic effect sizes in the psilocybin-for-depression RCT literature. METHODS: Assessed databases included PsycINFO, CINAHL, Embase, Medline, Web of Science, and Scopus. Search terms "Psilocybin" or "Psychedelic" were paired with "Depression", and "Randomized Controlled Trial" or "RCT". RESULTS: We identified k = 9 RCTs (k = 10 subgroups) involving n = 602 participants (56% psilocybin). Five studies had low/very low harm quality reporting, opposed to two with high. Most studies demonstrated a high risk of bias. Therapeutic mechanisms of action (MoAs) were discussed in varying detail but rarely assessed in original publications. Psilocybin was moderately superior to controls at reducing depression (g = 0.62; 95% CI = 0.27, 0.98). Effects were heterogenous (τ = .47). Smaller studies evidenced stronger effects that favored psilocybin (Egger's b0 = 3.63, p = .014). Almost all studies documented financial conflicts of interests. CONCLUSION: Psilocybin demonstrates significant depression reduction relative to controls. However, researchers, clinicians, and stakeholders should consider several contextual factors. Effects were moderate and attenuated in larger and better-controlled studies. Harms reporting and risk of bias was high, though partly driven by unique challenges of psilocybin research. MoAs were variably specified but rarely assessed; suggesting it is unclear how depression is reduced. We advise researchers conduct RCTs with active control conditions, larger samples, and include MoA assessments. Independent RCTs from researchers without financial conflicts of interest are needed.

Public libraries have conducted collection diversity audits, but this is the first known report of a diversity audit in the hospital library community. A two-part questionnaire was sent to hospital librarians to determine their use of diversity audits in collection management and to provide a tool for a preliminary assessment of their collections' diversity. Results of the questionnaire indicate that developing diversity within hospital library collections is important to these respondents. These librarians also support diversity in their library personnel, open access, researching critical gaps, and programming.

PURPOSE: To compare the management of prediabetes between a family practice clinic and internal medicine/endocrinology practice. METHODS: A randomized, retrospective evaluation of the medical history in 168 eligible patients with a diagnosis of prediabetes or abnormal blood glucose (BG) at a family practice clinic (n = 78) and an internal medicine/endocrinology practice (n = 90). RESULTS: The internal medicine/endocrinology practice provided more counseling regarding lifestyle modifications (91.1% vs 76.9%, P = .039), specific physical activity recommendations (26.7% vs 7.7%, P = .003), and recommended more patients receive 150 minutes/week of moderate exercise (8.9% vs 1.3%, P = .038). The family practice clinic provided more written dietary information (16.9% vs 13.3%, P = .044) and specific weight loss goals (20.5% vs 6.7%, P = .015). The internal medicine/endocrinology practice initiated pharmacological therapy in more patients (51.1% vs 3.8%, P< .001) and had a significant decrease in fasting BG from baseline compared to the family practice clinic (-9.0 vs -5.6 mg/dL, P< .001). CONCLUSION: Providers are likely to initiate nonpharmacological therapy but may not provide specific education recommended by the American Diabetes Association. The integration of a multidisciplinary team to provide guideline-based nonpharmacologic counseling may be beneficial in improving outcomes in the management of prediabetes.

The Beck Anxiety Inventory (BAI) is commonly used as a screening instrument for symptoms of anxiety in clinical settings. The factor structure has been researched in a variety of different clinical settings with results ranging from a 2- to 5-factor structure. The purpose of this study was to explore the factor structure of this instrument in a polytrauma veteran sample. A sample of 304 veterans was used for this study. All subjects were administered the BAI screening measure as part of an evaluation in an outpatient polytrauma clinic. Exploratory factor analysis was conducted for half of the sample, followed by confirmatory factor analysis for the remaining sample to determine the best model. Factor analyses revealed that a 5-factor model provided a best fit. It is interesting to note that previously identified models of the BAI with other types of samples did not provide the best fit for this polytrauma sample. The BAI may provide additional information for clinicians when examining the 5-factor model with veterans in polytrauma settings. The factor structure of the BAI includes 1 factor (i.e., personal safety) that may be unique for veterans who have served in combat zones.

Journal Article Effects of dark chocolate on blood pressure in patients with hypertension Get access Stacy L. Haber, Pharm.D., Stacy L. Haber, Pharm.D. Associate Professor Midwestern University College of Pharmacy—Glendale 19555 North 59th Avenue Glendale, AZ 85308 shaber@midwestern.edu Search for other works by this author on: Oxford Academic Google Scholar Karen Gallus, Pharm.D. Karen Gallus, Pharm.D. Clinical Pharmacist St. Cloud Veterans Affairs Health Care System St. Cloud, MN Search for other works by this author on: Oxford Academic Google Scholar American Journal of Health-System Pharmacy, Volume 69, Issue 15, 1 August 2012, Pages 1287–1293, https://doi.org/10.2146/ajhp110498 Published: 01 August 2012

Coping with stressors related to the coronavirus disease (COVID) pandemic has caused major mental health challenges. Text message interventions are identified as helpful for promoting health behavior self-management. Drawing from cognitive-behavioral theory (CBT), U.S. Veterans Health Administration staff developed a 20-week automated text messaging protocol called "Coping During COVID" to support veterans' self-care during the pandemic. This project evaluated attitudes about and perceived helpfulness of the protocol among 651 veterans. A cross-sectional evaluation quantitatively assessed COVID-related stressors as well as reported use, acceptability, attitudes, and perceived helpfulness of the protocol via a self-administered online questionnaire. Open-ended questions assessed perceived helpfulness/unhelpfulness of the protocol. Of the 651 veterans (22% of those enrolled in the protocol) who responded to the survey, 73.1% were male and 88.5% were 50 years or over. Ninety percent found the protocol messages helpful and about half endorsed various additional benefits, including feeling better, being more educated about coping behaviors, and being better able to focus on positive thoughts. Qualitative feedback was overwhelmingly positive. For example, veterans stated that the protocol "was like having a personal coach giving hints and tips to cope with the boredom every day," that it "gave me reminders of skills I was not using. It helped me focus on the positives," and brought relief from "many hopeless and sad thoughts … the messages from Annie have been a Godsend to me." Overall results suggested that the Coping During COVID text messaging protocol successfully supported the majority of respondents' self-care efforts during the COVID pandemic. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

OBJECTIVE: The purpose of the study was to determine if there was a significant difference between veterans who received treatment voluntarily versus involuntarily in regard to length of sobriety. METHOD: A sample of 120 veterans being treated for alcohol use disorder in a residential rehabilitation treatment program was used for this study. Veterans who were admitted under recommendation by court order (n = 60) were matched with veterans who were admitted without recommendation of court order (n = 60). Success of the program was determined by the number of days of sobriety postdischarge. RESULTS: The study revealed that there was no significant difference between types of motivation for residential treatment (i.e., voluntary vs. involuntary treatment) and length of sobriety for veterans with alcohol use disorder posttreatment. CONCLUSIONS: Findings revealed that there was no significant relationship when comparing types of motivation for treatment in a residential treatment program for veterans in regard to length of sobriety posttreatment. Therefore, a veteran's motivation for treatment may not necessarily be an accurate indicator of treatment outcomes (i.e., length of sobriety posttreatment) for residential treatment settings.

Cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) therapy were compared for veterans in a posttraumatic stress disorder (PTSD) residential program (N = 51) who received individual EMDR and group CPT, individual CPT and group CPT, or trauma group exposure (TGE) therapy. Analyses revealed an overall significant difference on posttest measures of the PTSD Checklist for individual EMDR/group CPT and individual CPT/group CPT when compared to TGE, with no significant difference found between EMDR and CPT. Depression scores were significantly decreased between pre- and posttest for patients who received individual EMDR/group CPT. Results support EMDR and CPT as clinically effective and complementary treatments in residential PTSD treatment programs.

As clinicians, we are well aware of the importance of drug supply, price, availability, and access in propagating and maintaining illicit drug use, abuse, and addiction. However, we tend to be silent on these topics, leaving them to elected and appointed government leaders. The author proposes that our remaining silent is analogous to an infectious disease expert remaining silent on water supply and sewage in the midst of a cholera epidemic. It is not only unseemly for us to remain silent, it is unprofessional at best and unethical at worst. Governmental means of addressing the social genesis of addiction and illicit drug supply falls under the general rubric of statecraft. Our elected leaders, our appointed governmental leaders, and our publicly supported workers (e.g., police, courts, schools, health care workers, social agencies) can and do exert influences either favoring or counteracting illicit drug supply, use, abuse, and addiction. Public officials can and do learn the exercise of statecraft in addressing a large range of social needs, such as housing, transportation, security, a safe food supply, and so forth. They can and should develop knowledge, skills, and experience in the exercise of statecraft vis-a-vis drugs. This article reviews the relevant literature on this topic. In addition, the author reflects on his observations on "addiction statecraft" in several countries over the past three decades. He underscores the need to consider elements such as community deterioration, corruption of police and other officials, and social anti-drug strategies that have worked as well as those that have not worked. Public leaders must also take stands regarding intervention and treatment programs that are not widely popular, such as those involving methadone. The author argues that we speak out authoritatively on "addiction statecraft." In undertaking such social roles, we must take care to speak out of our own collective wisdom and experience, rather than out of personal bias or personal agendas.