Lakeland Health

Despite high cost and wide prevalence of posttraumatic stress disorder (PTSD) in veteran populations, and Veterans Health Administration (VA)-wide mental health provider training in evidence-based treatments for PTSD, most veterans with PTSD do not receive best practices interventions. This may be because virtually all evidence-based PTSD treatment is offered through specialty clinics, which require multiple steps and referrals to access. One solution is to offer PTSD treatment in VA primary care settings, which are often the first and only contact point for veterans. The present study, Improving Function Through Primary Care Treatment of PTSD (IMPACT), used a randomized controlled design to compare an adaptation of prolonged exposure for PTSD to primary care (PE-PC) versus best practices Primary Care Mental Health Integration (PCMHI) clinic treatment as usual (TAU) in terms of both functioning and psychological symptoms in 120 veterans recruited between April 2019 and September 2021. Participants were mostly males (81.7%) with a mean age of 43.6 years (SD = 12.8), and more than half were non-White veterans (50.8%). Both conditions evinced significant improvement over baseline across functioning, PTSD, and depression measures, with no differences observed between groups. As observed in prior studies, PTSD symptoms continued to improve over time in both conditions, as measured by structured clinical interview. Both PE-PC and best-practices TAU are effective in improving function and reducing PTSD severity and depression severity. Although we did not observe differences between the two treatments, note that this study site and two PCMHI clinics employ primarily cognitive behavioral therapies (e.g., exposure and behavioral activation). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Introduction: Hepatitis B surveillance is crucial. We proposed to describe the seroprevalence of Hepatitis B infection and the associated factors among Ecuadorian Amazonia communities. Outline: A serologic cross-sectional study was carried out in subjects over two years old. We classified seropositivity according to the Centers of Diseases Control criteria and recorded sex, age, temporary migration, sometime Hepatitis B in their life, and previous vaccination. Results: Out of 215 participants, 50.0%, 8.8%, 1.9%, and 1.4% were susceptible, immune due to natural infection, chronic infection, and early acute HBV infection, respectively. Of the 8 people who reported having ever been diagnosed with Hepatitis B, none showed chronic or acute infection and one was positive for immunity due to the vaccine. HBsAg was found in 3.3% (95% IC 0.9-7.0) and was higher among those who migrate 7.7% (p-value 0.04). 16.3% (95% CI 11.6-21.4) was immune due to HBV vaccination. Among the 58 participants who declared having received the vaccine, 20.7% presented post-vaccine immunity. Implications: Participants who should have benefited from the vaccination campaign (susceptible) are those with the lowest immune response due to vaccination. To assessing the burden of viral hepatitis in people living in marginalized areas and guide preventive measures is mandatory.

Introduction: Neuroendocrine tumors (NET) most commonly occur in the small bowel; however, NETs at the ampulla of Vater are rare and more aggressive, irrespective of size. Gangliocytic paragangliomas (GP) are a more benign type of NET that must be properly differentiated from other similar appearing NETs, which may carry a worse prognosis. Case Description/Methods: A 77-year-old man presented with right flank pain and was incidentally found to have a duodenal mass in the periampullary region measuring 11 x 8 mm, with dilation of the common bile duct to 10 mm on computed tomography scan. Laboratory data showed normal liver function tests. Esophagogastroduodenoscopy revealed a subepithelial lesion at the ampulla, and endoscopic ultrasound (EUS) demonstrated a 15 x 12 mm hypoechoic subepithelial lesion arising from the submucosa. A fine needle biopsy was performed and immunohistochemical staining was positive for synaptophysin, chromogranin and pankeratin, consistent with neoplasm with neuroendocrine differentiation. Subsequent DOTATATE PET scan showed uptake in the ampullary region with no uptake anywhere else. The case was discussed in multidisciplinary conference, and the decision was made to proceed with endoscopic papillectomy given concerns for NET. An endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillectomy was performed. A biliary and pancreatic duct stent was placed. The pathology was consistent with gangliocytic paraganglioma, and the patient had no adverse events with removal of stents after four weeks. (Figure) Discussion: Gangliocytic paragangliomas typically arise in the second part of the duodenum, presenting as gastrointestinal bleeding and abdominal pain. Although its distribution varies significantly, GPs in particular embody epithelioid, spindle-shaped, and ganglion-like cell types. While GPs are predominantly benign, rare reports of spread to regional lymph nodes are present. Our report shows that endoscopic papillectomy is safe and effective for both diagnostic and therapeutic purposes in the management of ampullary gangliocytic paragangliomas.Figure 1.: Ampullary lesion prior to (A) and after endoscopic papillectomy (B), with histopathology consistent with ​gangliocytic paraganglioma (C).

BackgroundClostridiodes difficile infections (CDI) are a significant cause of hospital acquired infections, resulting in significant morbidity and mortality. Early detection of CDI has been shown to reduce the spread of CDI within the hospital. As nurses are frequently at the patient’s bedside, we proposed to empower the nursing staff to assess, collect stool samples, and order C. difficile testing.MethodsRates of CDI were measured by our Infection Control Department. Hospital-onset CDI (HO-CDI) was defined as a positive C. difficile PCR assay after 3 days of admission, defined as a stay of at least 3 midnights. Community-onset CDI (CO-CDI) was defined as any case that was diagnosed in the Emergency Department or inpatient ward < 3 days of hospitalization based on stool testing as above. Nursing was instructed and empowered to assess, collect stool specimens, and place an order for C. difficile testing, based on the criteria of ≥3 loose or watery stools over 24 hours. Nursing was also educated to not order a test if patients had received stool softeners, enemas, or laxatives within 24 hours. The protocol was initiated in February 2019.ResultsRates of HO-CDI increased during the intervention period, rising from 2.6 cases/10000 patient days and peaking at 17.7 cases/10000 patient days (average 6.7 vs. 12.1 monthly cases per 10,000 patient days. Rates of CO-CDI did not significantly change (12.4 vs. 11.5 monthly cases per 10000 patient days). Due to concerns of inappropriate testing, which included testing after laxatives, enemas, or sending specimens despite < 3 stools over 24 hours, the protocol was discontinued in June 2019. Although the HO-CDI rate remained elevated over the next month, the rate subsequently decreased over the next several months (12.1 vs. 8.0 cases per 10000 patient days). Overall testing also increased over the study period (148.3 vs. 169.9 cases/per 10000 patient days).Figure 1 - Clostridiodes difficile ratesFigure 2 - CDI testing ratesConclusionA nursing driven protocol resulted in increased HO-CDI and overall CDI rates suggesting that the intervention may have been a factor in increasing the frequency of HO-CDI diagnoses, although the possibility of misdiagnosis of colonization for true CDI cannot be excluded. Further education of nursing staff may be a potential intervention in improving appropriate CDI testing.DisclosuresAll Authors: No reported disclosures

Abstract Exposure of non‐target species pesticide via drift is of concern to the United States Environmental Protection Agency (EPA) as evidenced by required buffer zones and language on labels regarding offsite exposure to endangered species. In 2008, flazasulfuron received a conditional registration that specified a 30‐m nontreated buffer between treated areas and sensitive plants. This buffer would make most intended uses of flazasulfuron in warm‐season turfgrass impossible. Assessment of drift in field conditions is required to replace model‐predicted buffer restrictions. Studies were conducted to assess drift of flazasulfuron and a similar herbicide, trifloxysulfuron sodium, in field conditions using conventional turfgrass spray equipment and maximum boom height and minimum droplet size specified on product labels. Herbicides were applied perpendicular to a 6.4 to 9.7 km h−1 wind over ‘Riviera’ bermudagrass [Cynodon dactylon (L.) Pers.] turf and sentinel corn plants were placed at distances between 0 and 30.5 m downwind. A bioassay based on reduction of corn height growth rate and shoot biomass indicated trifloxysulfuron sodium and flazasulfuron reduced corn growth similarly but the magnitude of these effects were dependent on year. Year dependency was likely associated with differences in corn cultivars between years. Herbicide drift was not detected beyond 4.6 m downwind of any application. Upon reviewing these and other data, EPA approved a label modification for flazasulfuron that reduced the minimum buffer to 7.6 m.

Patient: Female, 72-year-oldFinal Diagnosis: Paraneoplastic leukemoid reactionSymptoms: AnemiaMedication:—Clinical Procedure: —Specialty: OncologyObjective:Rare diseaseBackground:The presence of leukocytosis associated with non-hematological malignancy after ruling out other causes is defined as paraneoplastic leukemoid reaction (PLR). PLR is a rare manifestation of various solid tumors. It is associated with poor prognosis unless receiving effective antineoplastic treatments.Case Report:A 72-year-old female was referred to a hematologist/oncologist for the evaluation of leukocytosis with neutrophilia. Initial workup was unremarkable; however, she had progressively worsening leukocytosis with neutrophilia, associated with severe anemia and dysphagia. Computed tomography (CT) scan revealed wall thickening at the gastroesophageal junction (GEJ) and multiple hypodensities of the liver. Esophagogastroduodenoscopy (EGD) confirmed the diagnosis of GEJ tumor and biopsy returned as adenocarcinoma with human epidermal growth factor receptor 2 (HER2) overexpression. Leukocytosis resolved after the first round of chemotherapy and the patient remains progression-free with the addition of trastuzumab to her chemotherapy regimen.Conclusions:We report a rare case of PLR caused by GEJ adenocarcinoma. This is the first case of PLR in a patient with metastatic GEJ adenocarcinoma with HER2 overexpression in the Caucasian population. It is important to workup leukocytosis promptly, to keep malignancy in the differential diagnosis and to seek early hematology/oncology consultation.