Background:Colorectal cancer screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic. Fecal immunochemical testing is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer. The VACHS implemented a program that mailed fecal immunochemical testing kits to patients to improve colorectal cancer screening rates. Observations:This article describes the components of the VACHS patient aligned care team-based mailed fecal immunochemical testing program. Fecal immunochemical testing utilization, completion, and colorectal cancer screening rates at VACHS substantially increased after the implementation of this project. Conclusions:Through a proactive, population-based colorectal cancer screening program centered on mailed fecal immunochemical testing kits outside of a traditional patient visit, VACHS substantially increased the utilization of fecal immunochemical testing kits as well as colorectal cancer screening rates.

“Bismarck” I excitedly blurt, several decibels louder than necessary, while energetically pressing my thumb against the imaginary buzzer I grip tightly in my right hand (Fargo not even once entering my brain when asked to identify the capital of North Dakota). I allow myself the latitude of not putting the answer in the form of a question, in order to afford myself every advantage competing against the actual Jeopardy! contestants, who have probably been training for months, if not years, and selected from thousands of other brilliant applicants. I furtively look out of the corner of my eye to ensure my wife actually saw me respond well before the actual contestants. For the past several months, we had been watching Jeopardy! together almost nightly, even recording the episodes we are forced to miss when we have to attend to other obligations, though none of those seem as important as being on our nightly date with Ken Jennings at the famed Alex Trebek stage at Sony Pictures Studios. How did I get here? While having intermittently watched Jeopardy! since the Art Fleming days and throughout the entire glorious tenure of Alex Trebek, you may be wondering why my present relationship with Jeopardy! is of such paramount importance to me. You see, I am losing a little on my fastball, my medical fastball, and it both galls and terrifies me. After a less than mediocre medical school career (let's face it, half of medical students are below average), I entered my residency hell-bent on bettering myself and the care afforded actual patients. I voraciously read and savored medical textbooks, journals, Medical Knowledge Self-Assessment Program volumes, and anything else I could get my hands on. I attended every lecture, grand rounds, or conference with rapt attention. I quixotically thought it possible to eventually know almost all of medicine, if one were willing to toil hard enough. I maintained these good habits after completion of a rather arduous training, one only allowable in the bygone Mesozoic era, and this came in handy as I later embarked on an academic general medicine career. Later, when working with trainees, I would never accept a straightforward presentation without the orator generating a broad differential diagnosis. I would probe their knowledge of each condition, hoping to later inject a couple of “factoids” that I hoped they would not only consume, but devour. I am old enough to say that the majority of my inpatient attending time was before the era of duty hour mandates, and that while I would be a major violator today, I rather humbly admit that I was a popular attending. Selfishly, generating lengthy differentials and thinking about medical trivia kept this information fresh in my mind, ready for release at a second's notice should it actually be needed. However, time inexorably marches on, and before you know it, the tummy gets soft, wrinkles suddenly appear, if you are lucky enough to have hair, it turns gray, and whether you intended so or not, you become the Chief of Medicine at the VA. Instead of participating in education, my job has morphed so that I now spend the overwhelming majority of my days responding to multiple e-mail complaints about the overnight temperature in the resident call rooms, the flood in the computed tomography scan rooms, unclosed windows before the impending frigid temperatures, and disinfectant wipes being flushed down toilets, and trying to find non-existent office space for the new gastroenterologist and hospitalist hires. Perhaps most frustrating is dealing with the human resources morass, that too often seems like World War 1 trench warfare: lasting years, filled with peril, occasional explosions, but without an inch of progress being made. Over the past few years, I have developed a relationship with my keyboard and Microsoft Outlook that not only makes my wife jealous, but simultaneously leads me to contemplate priorities—both my own and those of others. Those few times I either intentionally or accidentally get sucked into the wonderful realm of clinical medical education, I find myself no longer able to readily come up with the names of the exact organisms comprising the HACEK group in culture-negative endocarditis, the exact testing algorithm to confirm antiphospholipid syndrome, more than 7 or 8 causes of hypercalcemia, or the latest diagnostic criteria for systemic lupus erythematosus. These are things that used to be on the tip of my tongue, standing ready to impress. I find myself more reticent to speak, more unsure of myself, during those rare occasions I am able to attend resident morning report, fearful that I will use outdated names such as Rochalimaea henselae and Pneumocystis carinii pneumonia. Nobody from the bartonella or jirovecii camps consulted me prior to the name changes. Had they, I would have objected. At my age, it is difficult to learn something, perhaps more challenging to un-learn it. Trainees and staff no longer come to me seeking my medical opinion about specific complex patients or clinical conundrums; instead, they seek me out when they have questions relating to how to get things done, or more frequently, to inform me of often unsolvable problems, both real and imagined, that they want addressed immediately. I know some may interpret this as my own version of complaining. It isn't. It is a true privilege to serve learners, VA staff, and Veterans, and there is no place I would rather be. However, I find myself more reliant on Ken Jennings to allay the fears that being in one's early 60s precipitates the fear of impending cognitive decline. I find myself shouting “Lake Superior!” when the prompt is to name the largest Great Lake. In contrast, earlier that day I couldn't remember what else caused aquatically acquired infections other than Mycobacterium marinum, Vibrio, Erysipilothrix, and Aeromonas. I used to know more. One question later, my confidence grows as I correctly scream “Ben Franklin!” when asked who invented the flexible catheter and bifocals. I glance again at my wife, who now unintentionally embarrasses me by acknowledging that I am clearly looking at her for affirmation. However, my newly found confidence is shattered when the bespeckled librarian from Nebraska, correctly comes up with and beating me in the category of “Starts and ends with the same vowel” (the clue was “red corpuscle,” and she proffered “erythrocyte” before I could). Crap, I can't even get the medical Jeopardy! questions anymore.

BACKGROUND:Prior to the COVID-19 pandemic, battlefield acupuncture (BFA) was offered to veterans with chronic pain in multidisciplinary group visits.OBJECTIVE:We aimed to assess the impact of cessation of BFA due to COVID-19 and to determine the utility of different aspects of the group visits for chronic pain management.METHODS:Participants who had attended at least three BFA group visits completed questionnaires assessing the impact of treatment interruption on pain, overall function and desire to resume treatment.RESULTS:Thirty-nine veterans were surveyed; 49% responded to the questionnaire. Ninety percent (17/19) agreed that BFA was an important part of pain management and that their pain had worsened after treatment interruption. Seventy-four percent (14/19) responded that they were taking more pain medications since BFA had ended. Ninety-five percent (18/19) responded that BFA improved daily function; 79% (15/19) agreed that BFA improved their sleep. Ninety-five percent (18/19) were interested in resuming BFA. Camaraderie was mentioned as the most helpful aspect of the group by 8/19 (42%) of participants. Participation of health psychology and nutrition were each mentioned as a most helpful aspect of the group by 5/19 (26%) of participants.CONCLUSION:Our results suggest that participants may have believed that BFA, camaraderie, and input from nutrition and health psychology services were important contributors to their pain control. The results also suggest that veterans may have suffered worsening pain, used more pain medications, and had worsening quality of sleep and daily function during the COVID-related clinic disruption, and that they were interested in resumption of the program.

Medical AcupunctureVol. 34, No. 3 Letter to EditorFree AccessRe: “Self-Administration of Auricular Acupuncture in Rural Veterans with Chronic Pain: A Pilot Project” by James et al.Daniel G. Federman, David F. Drake, and Juli L. OlsonDaniel G. FedermanAddress correspondence to: Daniel G. Federman, MD, Department of Medicine, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516-2770, USA E-mail Address: daniel.federman@va.govDepartment of Medicine, VA Connecticut Healthcare System, West Haven, CT, USA.Search for more papers by this author, David F. DrakeCentral Virginia VA Healthcare System, Richmond, VA, USA.Search for more papers by this author, and Juli L. OlsonDepartment of Physical Medicine and Rehabilitation, VA Central Iowa Healthcare System, Des Moines, IA, USA.Search for more papers by this authorPublished Online:16 Jun 2022https://doi.org/10.1089/acu.2021.0078AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Dear Editor:It is with great interest that we read the pilot study by James et al.1 wherein the authors report that they were successful in teaching a selected group of veterans how to self-administer battlefield acupuncture (BFA) after they attended a 2-hour class, and were given 240 gold-plated auricular semi-permanent needles and followed for 6 months.Although studies have shown that BFA is generally safe and a very effective tool in the treatment of pain,2–4 as those charged with oversight of BFA and battlefield auricular acupressure within the Department of Veterans Affairs, we cannot presently endorse the self-administration of BFA. Acupuncture needles are medical equipment not intended for patient self-use. Although this novel application of BFA showed potential benefit in a rural veteran population, the risks would need to be examined on a larger scale.We also believe that correctly placing needles within “the zone” is difficult, and in this selected group of individuals, 17% dropped out. Asking a caregiver to help in this task would equate to practicing acupuncture without a license. Furthermore, although the risk of infection is low, we feel that safer alternatives exist. The self-administration of nonpiercing seeds or magnets as a form of battlefield acupressure can be promoted after adequate patient education. Yeh et al. showed auricular acupressure to be superior to auricular acupuncture for pain relief.5 We acknowledge that the clinical benefits of battlefield acupressure have not been well studied and that there is a more robust compilation of published benefits of BFA. However, we strongly believe in primum non nocere, first do no harm.References1. James BL, Welch III J, Williamson C. Self-administration of auricular acupuncture in rural veterans with chronic pain: A pilot project. Med Acupunct. 2021;33(5):349–352. Link, Google Scholar2. Taylor SL, Giannitrapani KF, Ackland PE, et al. The implementation and effectiveness of battlefield auricular acupuncture for pain. Pain Med. 2021;22(8):1721–1726. Crossref, Medline, Google Scholar3. Salamone FJ, Federman DG. Battlefield acupuncture as a treatment for pain: A systematic review. South Med J. 2021;114:239–245. Crossref, Medline, Google Scholar4. Zeliadt SB, Thomas ER, Olson J, et al. Patient feedback on the effectiveness of auricular acupuncture on pain in routine clinical care: the experience of 11,406 veterans. Med Care. 2020;58 Suppl 2 9S(2 9 Suppl):S101–S107. Crossref, Medline, Google Scholar5. Yeh CH, Chiang YC, Hoffman SL, et al. Efficacy of auricular therapy for pain management: A systematic review and meta-analysis. Evid Based Complement Alternat Med. 2014;2014:934670. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited byResponse to Federman et al. re: “Self-Administration of Auricular Acupuncture in Rural Veterans with Chronic Pain: A Pilot Project” Benjamin Kligler12 December 2022 | Medical Acupuncture, Vol. 34, No. 6 Volume 34Issue 3Jun 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:Daniel G. Federman, David F. Drake, and Juli L. Olson.Re: “Self-Administration of Auricular Acupuncture in Rural Veterans with Chronic Pain: A Pilot Project” by James et al..Medical Acupuncture.Jun 2022.210-210.http://doi.org/10.1089/acu.2021.0078Published in Volume: 34 Issue 3: June 16, 2022Online Ahead of Print:January 7, 2022PDF download

The 2019-2020 pandemic Coronavirus Disease 2019 (COVID-19) has inundated hospital systems globally, as they prepare to accommodate surge of patients requiring advanced levels of care. Pandemic preparedness has not been this urgently and widely needed in the last several decades. According to epidemiologic predictions, the peak of this pandemic has still not been reached, and hospitals everywhere need to ensure readiness to care for more patients than they usually do, and safety for healthcare workers who strive to save lives. We share our hospital-wide rapid preparedness and response to COVID-19 to help provide information to other healthcare systems globally.

Background: Battlefield acupuncture (BFA) is an easy-to-learn type of auricular acupuncture that is being used increasingly and that has been shown to be effective for short-term reduction of pain. Many patients return for repeated applications of the semipermanent needles and ask if permanent earrings inserted in these points would lead to longer-lasting reduction in their pain. Case: A patient sought to have permanent earrings placed at his BFA auricular points. This 47-year-old man was referred for BFA for his chronic pain. He had several underlying health conditions. The BFA gave this patient good pain relief, but he had difficulty traveling to the VA center; this was why he wished to have the permanent earrings. Results: This patient had earrings implanted on his own where he thought the correct BFA points were. Hence, he developed a serious infection and inflammation that were difficult to treat. Conclusions: The patient tried to have permanent earrings, but they produced very deleterious effects. No recommendation for such implantations can be made at this time.

Sarcoidosis is an idiopathic inflammatory disease characterized by granuloma formation in various tissues, most commonly the lungs, lymphatics, skin and eyes. Involvement of the breast in sarcoidosis is rare, and can be defined into three subsets, including granulomas localized to the breast, referred to as breast sarcoidosis. Breast sarcoidosis may present with systemic findings such as erythema nodosum, arthritis, and uveitis, and unlike typical sarcoidosis, commonly manifests during pregnancy. In this report, we present a rare case of breast sarcoidosis presenting in a pregnant female with associated erythema nodosum, arthralgias and ocular complaints.

Purpose of Review Chronic wounds are increasing in prevalence and are often associated with significant pain, which can have a major impact on quality of life. Safe and effective pain management can be challenging, an unfortunate reality that is highlighted by the ongoing opioid crisis. This review aims to provide an evidence-based framework for pharmacologic and non-pharmacologic pain management in patients with chronic wounds. Recent Findings As reflected in the new CDC guidelines, no study has shown that long-term opioid use mitigates chronic pain. Non-pharmacologic therapies, including virtual reality and acupuncture, have shown efficacy and are promising adjuvant therapies for pain management. Summary Non-opioid pharmacotherapies and non-pharmacologic therapies are preferable to opioids for chronic pain related to non-healing wounds. The experience of pain is a subjective and complex biopsychosocial process that necessitates a rational, personalized, and often multimodal approach to management.

Objective: Battlefield Acupuncture (BFA) is an auricular needling protocol for pain. More than 1300 Veterans Health Administration (VHA) clinicians have been trained in BFA delivery. However, little is known about how well BFA has been implemented at the VHA. The aim of this research was to identify the challenges providers experience in implementing BFA and to look for any successful strategies used to overcome these challenges. Materials and Methods: Semistructured telephone interviews were conducted from June 2017 to January 2018, using an interview guide informed by the integrated Promoting Action on Research Implementation in Health Services framework to address several implementation domains: knowledge and attitudes about BFA; professional roles and training in BFA; organization of BFA delivery and resources to provide BFA; and implementation challenges and strategies to address challenges. The interviews were analyzed, using a grounded theory-informed approach. This research was conducted at 20 VHA facilities and involved 23 VHA BFA providers nationwide. Results: Nine main implementation themes were identified: (1) providers organizing BFA delivery in various ways; (2) insufficient time to provide BFA to meet patient demand; (3) beliefs and knowledge about BFA; (4) lack of BFA indication guidelines or effectiveness data; (5) self-efficacy; (6) time delay between training and practice; (7) limited access to resources; (8) key role of leadership and administrative buy-in, and (9) written consent an unwarranted documentation burden. Providers offered some possible strategies to address these issues. Conclusions: System- and provider-level challenges can impede BFA implementation. However, several providers discovered strategies to address some challenges that can be used within and outside the VHA, which, in turn, might improve access to this potentially promising pain-management intervention.

Headaches commonly compel patients to seek medical attention. Migraine, tension headache, cluster headaches, rebound headaches from overuse of medication, headaches that occur as an adverse reaction to medication, and those associated with infection are typically included in the differential diagnosis, but sometimes, a rarer entity is encountered. This was true for a 44-year-old farmer from rural Honduras.

Objective: The Department of Veterans Affairs trained primary-care providers to deliver Battlefield Acupuncture (BFA), a subset of auricular acupuncture, to patients. However, little is known about BFA effectiveness in group or individual sessions or repeated administrations versus singular use. The aim of this study was to examine the use and effectiveness of BFA for back pain and four pain-comorbid conditions in group and individual sessions at a large Veterans Affairs (VA) medical center. Materials and Methods: This cross-sectional study was conducted at the West Haven VA Medical Center, in West Haven CT. Between October 2016 and December 2017, 284 veterans with pain received BFA. The BFA was administered in group clinics or in individual encounters. The Defense and Veterans Pain Rating Scale was used to assess self-reported pain immediately before and after each BFA administration. Results: Over the study period, an average of 57 (range: 50-66) new patients per month received BFA. Of 753 total patient encounters, an immediate decrease in self-reported pain occurred in 616 (82.0%) patients, no change occurred in 73 (9.7%) patients, and an increase occurred in 62 (8.3%) patients. Decreases in pain were common in the group and individual settings, even in patients with originally high pain scores, and the effectiveness remained with repeated uses. Conclusions: BFA can be effective for immediate relief of pain-whether the BFA is administered in a group or individual setting-for the overwhelming majority of veterans and, as such, holds promise as a nonpharmacologic pain-management intervention.

A survey of primary care providers at a VA hospital helped to understand respondents' barriers to and benefits of using a personal health inventory with patients.

The use of prescription opioids in the treatment of pain has increased notably over recent decades.1 With this increase, dramatic unintended consequences have arisen. Rates of death from prescribed opioids increased fourfold between 2000 and 2014.2 Integrative care has been suggested as a potentially safer alternative to opioids in the treatment of chronic non-cancer pain and acupuncture has been shown to be an effective treatment for chronic pain.3 Battlefield acupuncture (BFA), an easily learnt subset of auricular acupuncture, has been proposed to treat a variety of painful disorders in active military members and veterans.4 Patients undergo insertion of five auricular semi-permanent (ASP) needles to the following traditional ear acupuncture points bilaterally: Cingulate Gyrus , Thalamus , Omega 2 , Point Zero and Shenmen (figure 1). While other investigators have evaluated models for integrating medical acupuncture into practice,5 to our knowledge, there has been no evaluation of how to incorporate BFA efficiently into a busy primary care (PC) practice. Since shared medical appointments (SMA) have been shown to be helpful in chronic disease management and may decrease healthcare utilisation, we developed …

Objectives Bedside rounds/rounding (BDR) is an important tool for patient-centered care and trainee education. This study aimed at understanding the attitudes toward BDR among residents and attending physicians. Methods A survey was conducted using the Qualtrics survey tool. Responses were measured using a five-point Likert scale. Results The survey was sent to 301 attending physicians and 195 residents. Attending physicians conducted BDR 19% of the time. The preferred mode of rounding for residents was hallway and/or conference room rounding (67%). The major barriers to BDR were concern for causing confusion in or alarm to patients (attending physicians 49%, residents 77%) and prolongation of rounds (attending physicians 47%, residents 72%). The major advantages to BDR were increased likelihood of using patient-friendly language (attending physicians 84%, residents 69%) and the potential to improve trainees’ oral presentations and physical examination skills (attending physicians 71%, residents 54%). Attending physicians reported having adequate skills to conduct BDR (95%) and potential opportunity to be better teachers with this mode of rounding (69%). Residents reported having some previous experience with BDR (46%) and agreed that BDR is an important skill for residents (62%). Only 34% of residents agreed that BDR allowed them to learn more about patient care compared with other modes of rounding, however. Conclusions Our study showed that our participants perceive BDR positively. Endorsed benefits include the ability to use patient-friendly language, the potential to improve trainees’ clinical skills, and an opportunity to become better teachers. The reported major barriers to BDR were potential concern for patient confusion and prolongation of rounds. Despite some prior exposure reported by residents and adequate attending skills, the frequency and preference for BDR remains low and the residents remain uncertain about the educational value of BDR. The evaluation of other factors that contribute to the low frequency of BDR needs further consideration. Furthermore, each residency program may differ in the patterns of perception toward BDR and these should be formally assessed before implementing this patient-centered mode of rounding.

Screening for lung cancer with low-dose computed tomography (LDCT) has been shown to reduce mortality and has been recommended by the U.S. Preventive Services Task Force for adults 55 to 80years of age with a 30 pack-year smoking history who are either current smokers or those that quit within 15years. However, the overwhelming majority of abnormalities detected are not from malignancy. We report a case of pulmonary Langerhans' cell histiocytosis, here-to-fore thought of as extremely uncommon, and make readers aware that this may be increasingly found as LDCT is more widely adopted.

The Wound Healing Society guidelines for the treatment of arterial insufficiency ulcers were originally published in 2006. These guidelines provided recommendations, along with their respective levels of evidence on seven categories: diagnosis, surgery, infection control, wound bed preparation, dressings, adjuvant therapy, and long-term maintenance. Over the last 7 years, a great deal of literature regarding these aspects of arterial ulcer management has been published. An advisory panel comprised of academicians, clinicians, and researchers was chosen to update the 2006 guidelines. Members included vascular surgeons, internists, plastic surgeons, anesthesiologists, emergency medicine physicians, and registered nurses, all with expertise in wound healing. The goal of this article is to evaluate relevant new findings, upon which an updated version of the guidelines will be based.

IMPORTANCE Abdominal aortic aneurysms are associated with chronic inflammation within the aortic wall, and previous studies have suggested that chronic inflammation may be a consequence of a dysregulated and persistent autoimmune response. Persistent aortic remodeling after aneurysm repair could place the patient at risk for endoleak or sac rupture.OBJECTIVE To determine whether patients with systemic inflammatory disease and large aneurysms have persistent aortic remodeling after endovascular aneurysm repair (EVAR).DESIGN, SETTING, AND PARTICIPANTS The records of all patients who underwent EVAR between July 2002 and June 2011 at the Veterans Affairs Connecticut Healthcare System were included in this retrospective review. Patients were considered to have a systemic inflammatory disease when confirmed by a referring specialist. Post-EVAR surveillance was performed by yearly imaging.INTERVENTION Endovascular aneurysm repair.MAIN OUTCOMES AND MEASURES Significant endoleak, defined as endoleak and sac diameter increase of 0.5 cm or greater.RESULTS A total of 51 of 79 patients (65%) had a systemic inflammatory disease. These patients had similar comorbid conditions compared with patients without inflammation but significantly greater numbers of major postoperative complications after EVAR (23.5% vs 3.6%; P = .02) and overall postoperative complications after EVAR (27.5% vs 7.1%; P = .03). Patients with a history of systemic inflammatory disease developed more endoleaks (45.1% vs 17.9%; P = .02) and late sac expansion (51.0% vs 21.4%; P = .01) and required more interventions (21.6% vs 3.6%; P = .03) during long-term follow-up. Systemic inflammatory disease was significantly associated with significant endoleak (odds ratio, 5.18; 95% CI, 1.56-17.16; P = .007).CONCLUSIONS AND RELEVANCE Patients with systemic inflammatory disease are at high risk for postoperative complications, type II endoleak, sac expansion, and additional interventions after EVAR. Additional strategies for improving the efficacy of EVAR in these patients may be warranted.

From *Albert Einstein College of Medicine, Bronx, NY; †Department of Internal Medicine, Yale University School of Medicine, New Haven, CT. The authors declare no conflict of interest. Correspondence: Benjamin T. Galen, MD, Albert Einstein College of Medicine and Montefiore Medical Center, Division of Hospital Medicine, 1825 Eastchester Road, Suite 2-76,? Bronx, NY 10461. E-mail: [email protected].

BACKGROUND:Practice-based learning and improvement is one of the Accreditation Council of Graduate Medical Education's core competencies fortrainees. Residencyprograms have grappled with how to accomplish this goal.AIM:We describe our institution's unique, longitudinal post-graduate year process and project.SETTING:West Haven, VA Medical Center.PARTICIPANTS:Yale University School of Medicine junior residents on ambulatory electives and faculty preceptor.PROGRAM DESCRIPTION:Longitudinal program aimed to decrease re-admissions for hospitalized patients with congestive heart failure.DISCUSSION:We feel that our longitudinal project is a novel innovation worthy of further study.