Boise VA Medical Center

As life expectancy increases, the older adult population is expected to grow significantly. As a result, gout cases continue to escalate in both incidence and prevalence. Gout is a chronic inflammatory condition that disproportionately affects older adults, certain racial and ethnic groups, and underserved populations. Risk factors for gout include renal impairment, genetics, select medications, obesity, and lifestyle factors. It is also associated with numerous comorbidities, such as cardiovascular disease, metabolic syndromes, chronic kidney disease (CKD), depression, and anxiety. This article examines the prevalence, pathophysiology, and risk factors of gout in the aging population. It highlights the unique challenges of managing gout in older adults, including polypharmacy, declining renal function, and the presence of other chronic conditions. The roles of diet, medication use, and lifestyle in the development and exacerbation of gout are discussed, with special attention to the complexities these factors introduce in geriatric care. The goal of this review is to equip clinicians with the knowledge needed to provide optimal care for older adults living with gout, as the need for this service continues to rise.

Background/Objectives: Advanced wound healing biologics for diabetic foot ulcer (DFU) are typically withheld from persons who are at high risk for amputation. However, a prospective, single-center cohort study evaluated the use of an advanced biologic, dehydrated amniotic (DAMA) tissue as early treatment for DFUs in patients with a high risk for amputation, demonstrating benefit for a small sample. This is the report of the five-year follow-up of those high-risk participants. Methods: This chart review provides a 5-year follow-up of 18 of 20 participants in the original study. The data were collected by medical record review. Specific data points included mortality, re-ulceration and additional ulceration, amputation (minor and major), end-stage renal disease with dialysis dependence, hospitalization, and limb-threatening ischemia. Results: The 5-year mortality rate from the time of wound healing was 50% (9/18 deceased). Four of the eighteen participants (22.2%) underwent major amputation within 5 years of study completion. Two had amputations of the study limb and two had amputations of the contralateral limb. Fifty percent (2/4) of those who had amputations died within 5 years after the major amputation. Over fifty percent (55.5% or 10 out of 18) of the participants experienced the re-ulceration of the original study ulcer and 94% (17 out of 18) developed a new site ulceration. A total of 25% of the hospitalizations over the 5 years were related to DFU (infection, osteomyelitis, and sepsis). Conclusions: This small-sample 5-year follow-up shows that early treatment with dehydrated amniotic (DAMA) tissue in patients with diabetic foot ulcers of moderate-to-high amputation risk results in similar outcomes as noted in the current research on patients with low risk for amputation. In fact, this paper may suggest that advanced biologics can safely be used for early treatment in moderate-to-high amputation risk without increasing mortality and amputation over 5 years.

CYP2C9 and CYP2C19 are major CYP450 enzymes that heavily influence the hepatic metabolism and bioactivation of many medications, including over-the-counter and narrow therapeutic index drugs. Compared to the wild-type alleles, genetic variants in either gene could potentially alter the pharmacokinetics of widely used medications, affect the desired therapeutic outcomes of a drug therapy, or increase the risk of undesired adverse events. The frequency of genetic polymorphisms associated with CYP450 enzymes can widely differ across and between racial and ethnic groups. This narrative review highlights the differences in CYP2C9 and CYP2C19 allele frequencies among European and Asian population subgroups, using published literature. Identifying the substantial differences across European and Asian populations, as well as within Asian subgroups, indicates the need to further scrutinize general population data. Clinical scientists and healthcare providers should advocate for more inclusive clinical pharmacogenomic data and racially and ethnically diverse pharmacogenomic databases. Clinical trials of limited racial and geographical diversity may not necessarily have strong external generalizability for all populations. Furthermore, clinical trials that designate an all-inclusive Asian population consisting of multiple ethnicities may not be adequate due to the perceived genetic differences among Asian subgroups. Gravitating towards a more comprehensive approach to utilizing pharmacogenomic data necessitates granular population-level genetic information which can be leveraged to improve how drug therapies are prescribed, achieve health equity, and advance the future of precision medicine.

ABSTRACT Increased clinical demands and newer means of self-directed learning (SDL) necessitate an understanding of how medical residents are supporting their learning. To examine the patterns of SDL engagement among internal medicine residents, their attitudes and behaviors with various resources, and evaluate the relationship between the clinical learning environment (CLE) and the time residents allocate to SDL and types of resources. This cross-sectional study used a systematic questionnaire informed by previous qualitative research on SDL among internal medicine residents. Internal medicine (IM) residents from 10 residency programs across the United States participated, providing a diverse representation of geographical and institutional contexts. Residents were asked to estimate weekly hours spent on SDL during their last clinical rotation, on which resources, and then to rank the usefulness of each resource. The survey also measured several variables, including attitudes and behaviors after using the resource they perceived to be the most useful, and the influence of training level, residency program type, clinical rotation, and number of hours worked clinically per week on reported time spent on SDL and types of resources. The response rate was 69.5% (783/1,126). Residents dedicated a mean of 18.2 (SD 18.6) hours per week (median of 10.5 hours per week) to SDL. Community-based programs reported more hours of SDL. There was no difference in hours spent on SDL based on the last clinical rotation, number of hours worked clinically, or PGY level. Senior residents favored digital resources, like podcasts, and were less likely to use traditional resources, like textbooks than interns. Our findings underscore the substantial time residents devote to SDL. In light of these results, educators and healthcare systems will need to work together to better support residents in optimizing the complex clinical learning environment.

Background The "X+Y" residency scheduling model includes "X" weeks of uninterrupted inpatient or subspecialty rotations, followed by "Y" week(s) of uninterrupted outpatient rotations. The optimal ratio of X to Y is unclear. Objective Determine the impact of moving from a 6+2 to a 3+1 schedule on patient access to care, perceived quality of care, and resident/faculty satisfaction. Methods Our residency program switched from a 6+2 to a 3+1 scheduling model in July 2018. We measured access to care before and after the change using the "third next available" (TNA) metric. In June 2019, we administered a voluntary, anonymous, 20-item survey to residents, staff, and faculty who worked in resident clinic in both the 6+2 and 3+1 years. Results Patient access to appointments with their resident physician, as measured by TNA, improved significantly after the schedule change (mean 34.1 days in 6+2, mean 26.5 days in 3+1, P<.0001). Fifteen of 17 (88%) eligible residents and 13 of 24 (54%) faculty/staff filled out the voluntary anonymous survey. Surveyed residents and faculty/staff had concordant perception that the schedule change led to improvement in patient continuity, quality of care, and ability of residents to follow up on diagnostic tests and have regular interaction with clinic attendings. However, residents did not report a change in satisfaction with continuity clinic. Conclusions Changing from a 6+2 to a 3+1 schedule was associated with improvement in patient access to care. Residents and faculty/staff perceived that this schedule change improved several aspects of patient care.

Health care administrative overhead is greater in the US than some other nations but has not been assessed in the Veterans Health Administration (VHA). To compare administrative staffing patterns in the VHA and private (non-VHA) sectors. This cross-sectional study was conducted using US employment data from 2019, prior to pandemic-related disruptions in health care staffing, and was carried out between January 14 and August 10, 2023. A nationally representative sample of federal and nonfederal personnel in hospitals and ambulatory care settings from the American Community Survey (ACS), all employees reported in VHA personnel records, and personnel in health insurance carriers and brokers tabulated by the Bureau of Labor Statistics (BLS) were analyzed. VHA vs private sector health care employment, including 397 occupations grouped into 18 categories. The proportion of staff working in administrative occupations. Among 3 239 553 persons surveyed in the ACS, 122 315 individuals (weighted population, 12 501 185 individuals) were civilians working in hospitals or ambulatory care; of the weighted population, 12 156 988 individuals (mean age, 42.6 years [95% CI, 42.5-42.7 years]; 76.2% [95% CI, 75.9%-76.5%] females) were private sector personnel and 344 197 individuals (mean age, 46.2 years [95% CI, 45.7-46.7 years]; 63.8% [95% CI, 61.8%-65.8%] females) were federal employees. In clinical settings, administrative occupations accounted for 23.4% (95% CI, 23.1%-23.8%) of private sector vs 19.8% (95% CI, 18.1%-21.4%) of VHA personnel. After including 1 000 800 employees at private sector health insurers and brokers and 13 956 VHA Central Office personnel with administrative occupations, administration accounted for 3 851 374 of 13 157 788 private sector employees (29.3%) vs 77 500 of 343 721 VHA employees (22.5%). Physicians represented approximately 7% of personnel in the VHA (7.2% [95% CI, 6.1%-8.2%]) and private sector (6.5% [95% CI, 6.3%-6.7%]), while the VHA deployed more registered nurses (23.7% [95% CI, 21.6%-25.8%] vs 21.2% [95% CI, 20.9%-21.5%]) and social service personnel (6.3% [95% CI, 5.4%-7.1%] vs 4.9% [95% CI, 4.7%-5.0%]) than the private sector. In this study, administrative occupations accounted for a smaller share of personnel in the VHA compared with private sector care, a difference possibly attributable to the VHA's simpler financing system. These findings suggest that if staffing patterns in the private sector mirrored those of the VHA, nearly 900 000 fewer administrative staff might be needed.

Objective: Tele-neuropsychology (teleNP) has the potential to deliver assessment to people who face limited access to culturally and linguistically appropriate services, health disparities, and negative social determinants of health (SDOH). We reviewed to what extent teleNP has been examined in racially and ethnically diverse samples within the U.S. and U.S. territories and describe validity, feasibility, barriers, and facilitators. Method: A scoping review was conducted to examine factors relevant to teleNP with racially/ethnically diverse samples, using Google Scholar and PubMed®. Key words referenced “tele-neuropsychology,” racial/ethnic populations within the U.S. and territories, and relevant constructs (e.g. “validity,” “feasibility”). Studies included in the final analysis were empirical, addressed teleNP, and included racially/ethnically diverse individuals within the U.S. The search resulted in 10,312 articles total, with 9,670 following removal of duplicates. We excluded 9,600 following abstract review, and an additional 54 articles following full-text review. Thus, 16 studies were included in the final analysis. Results: Results showed the greatest number of studies supporting feasibility and utility of teleNP with older LatinX/Hispanic adults. Limited reliability and validity data suggested that, for the most part, teleNP and face-to-face neuropsychological evaluations were broadly equivalent, and no studies contraindicated use of teleNP in culturally diverse populations. Conclusions: This review provides preliminary support, particularly in terms of teleNP feasibility, with culturally diverse individuals. Current research is hampered by low inclusion of culturally diverse individuals and limited studies, and while support is nascent, these findings should be balanced with promotion of healthcare equity/access.

To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system. Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period. Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded. Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary. We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity. We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78-0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59-0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73-1.09). Return visits (OR, 1.00; 95% CI, 0.94-1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92-1.59) were not different before and after implementation within facilities that performed intensive implementation. Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity-dependent manner. No impact on ARI-related clinical outcomes was observed.