Wound Healing Society 2023 update on guidelines for arterial ulcers.

The Wound Healing Society guidelines for the treatment of arterial insufficiency ulcers were originally published in 2006, with the last update in 2014. 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 9 years, additional 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 2014 guidelines. Members included vascular surgeons, internists, plastic surgeons, anaesthesiologists, emergency medicine physicians and dermatologists, 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.

Battlefield Acupuncture as a Treatment for Pain.

This study evaluated both randomized and nonrandomized trials of battlefield acupuncture for the treatment of both acute and chronic pain. Studies published between May 2016 and November 2019 were found through PubMed, the Cochrane Library, or Scopus, concerned with the treatment of pain using auricular acupuncture in accordance with battlefield acupuncture protocol. Search terms were battlefield acupuncture AND pain or auricular acupuncture AND pain. Case reports, literature reviews, meta-analyses, and expert opinions were not included. Bias risk was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We found 12 studies with a combined sample size of 12,326. All five of the included nonrandomized trials reported positive outcomes, while five of seven of the included randomized trials reached statistical significance in their primary outcome. Six of the randomized trials were considered to have a high risk of bias resulting from the lack of blinding. The one randomized trial with moderate bias risk was a positive study. No severe adverse events were reported. Clinicians may consider battlefield acupuncture as a safe treatment for pain while the evidence base grows; however, we conclude that widespread adoption of battlefield acupuncture will require further high-quality studies drawing from diverse settings and patient populations. In addition, future studies should attempt to achieve blinding.

Patient Feedback on the Effectiveness of Auricular Acupuncture on Pain in Routine Clinical Care: The Experience of 11,406 Veterans.

OBJECTIVES: Veterans Health Administration (VHA) launched a national initiative to train providers in a specific, protocolized auricular acupuncture treatment (also called Battlefield Acupuncture or BFA) as a nonpharmacological approach to pain management. This evaluation assessed the real-world effectiveness of BFA on immediate pain relief and identified subgroups of patients for whom BFA is most effective. RESEARCH DESIGN: In a cross-sectional cohort study, electronic medical record data for 11,406 Veterans treated with BFA at 57 VHA medical centers between October 2016 and September 2018 was analyzed. The multivariate analysis incorporated data on pain history, change in pain level on an 11-point scale, complications, and demographic information. METHODS: A total of 11,406 Veterans were treated with BFA at 57 VHA medical centers between October 2016 and September 2018 and had effectiveness data recorded in their electronic medical record. RESULTS: More than 3 quarters experienced immediate decreases in pain following administration of BFA, with nearly 60% reported experiencing a minimal clinically important difference in pain intensity. The average decrease in pain intensity was -2.5 points (SD=2.2) at the initial BFA treatment, and -2.2 points (SD=2.0) at subsequent treatments. BFA was effective across a wide range of Veterans with many having preexisting chronic pain, or physical, or psychological comorbid conditions. Veterans with opioid use in the year before BFA experienced less improvement, with pain intensity scores improving more among Veterans who had not recently used opioids. CONCLUSION: VHA's rapid expansion of training providers to offer BFA as a nonpharmacological approach to pain management has benefited many Veterans.

Group Battlefield Acupuncture in Primary Care for Veterans with Pain.

OBJECTIVE: To obtain preliminary data on the short- and intermediate-term effects of battlefield acupuncture (BFA) on self-reported pain intensity in a relatively large cohort of veterans to assess whether a more comprehensive clinical trial evaluation is warranted. METHODS: The treatment, in an outpatient group setting, consisted of up to five auricular semipermanent needles inserted into each ear at prespecified points. Efficacy of treatment was measured by self-reported pain, using the Defense and Veterans Pain Rating Scale, just before treatment and at posttreatment days 0, 1, 7, and 30. RESULTS: A total of 112 patients attended the group clinics. The mean pretreatment pain score was 6.8, with an immediate postprocedure decrease of 2.4 points. The proportion of patients reporting decreased pain was 88.4%, 80.7%, 52.4%, and 51% at posttreatment days 0, 1, 7, and 30, respectively. CONCLUSIONS: The short- and intermediate-term beneficial effect of BFA on chronic pain is clinically meaningful. The large proportion of patients reporting decreased pain even 30 days after treatment suggests that the long-term effect of BFA merits further investigation.

Bedside Rounds Valued But Not Preferred: Perceptions of Internal Medicine Residents and Attending Physicians in a Diverse Academic Training Program.

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.

Battlefield Acupuncture: Is It Ready for Widespread Dissemination?

The use of prescription opioids for chronic pain has increased markedly within the past few decades; thus, death rates associated with opioid overdoses have increased dramatically. Nonopioid pharmacologic therapies also are associated with adverse effects. Other pain-abatement modalities such as acupuncture may be useful in the treatment of several painful conditions. Battlefield acupuncture is being promulgated as a potential low-risk, nonpharmacological therapy for pain. In this narrative review we examine the published literature to support battlefield acupuncture. We conclude that the amount and quality of published research presently do not justify wide adoption of this practice by those strictly adherent to evidence-based medicine.

The "Hand-in" Project: Jump-starting Communication Between Inpatient and Outpatient Providers.

OBJECTIVES: Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. METHODS: This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. RESULTS: Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. CONCLUSIONS: A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

Number of Consults and Response Times to ED: Effects on Patient Flow and Outcomes.

OBJECTIVES: 'he number of consults and response times to our Emergency Department (ED) were tracked to understand the effects on patient flow and outcomes. STUDY DESIGN: We conducted a prospective observational study using convenience samples. METHODS: There were 992 requests for physician consultations or logistical services (bed manager, transport, or room cleaning) logged during ED shifts from January through July, 2014 at the VA CT Healthcare System West Haven Campus (VACHS). Services were paged every 15 minutes until a response was received; the total response time was then recorded. One-hundred-eighty-six requests were triggered by one author's cohort of 392 patients, for which age, disposition, and outcomes were also tracked. RESULTS: The median response times were one to six minutes depending on the service requested; outli- ers exceeded an hour. A patient's ED stay duration increased with the number of services paged. The number of services paged was associated with mortality despite adjusting for age, ED waiting time, ED total time, and disposition (odds ratio = 3.14, P = .02) although comorbidity scores were not tracked. CONCLUSIONS: Response time to ED pages varies widely. The number of services paged correlated with ED length of stay and possibly inpatient mortality.

Singing the "Minocycline Blues".

A variety of medical conditions and medications can lead to cutaneous dyschromia. We report a case of minocycline dyschromia that had been mistakenly attributed to chronic actinic purpura.

Advanced, neglected basal cell carcinoma.

Although basal cell carcinoma (BCC) rarely metastasizes and has a cure rate >95% when diagnosed early in its course, BCC causes significant morbidity and presents an enormous burden to the healthcare system worldwide. Patients who present late in the course of their disease are particularly challenging in that their treatment can be more complicated and less likely to be effective than had they presented earlier. Given the high prevalence of this malignancy and the morbidity associated with a late presentation, healthcare professionals should be familiar with the consequences of neglected BCCs, as well as their management after presentation. Knowledge of patient risk characteristics may allow earlier engagement and diagnosis of patients, before more significant morbidity occurs.

Gynecomastia: etiologies, clinical presentations, diagnosis, and management.

Gynecomastia is a common finding that is present in up to 57% of men. It is caused by proliferation of the mammary glands, which leads to the development of dense subareolar tissue. The condition results from both physiologic (eg, hypogonadism, altered estrogen-to-androgen ratio) and nonphysiologic (eg, drugs, herbal products) causes. Most cases are benign and resolve spontaneously. Treatment is usually unnecessary, although there are specific signs and symptoms that warrant further workup. Psychosocial effects also are of concern, particularly among adolescents. Knowledge of the possible causes of gynecomastia and a thoughtful approach to the patient presenting with this condition can lead to improved outcomes and patient satisfaction. This concise review of the common presentation, etiologies, diagnosis, and treatment of gynecomastia should aid healthcare professionals who may encounter these patients in their practices.

A longitudinal, collaborative, practice-based learning and improvement model to improve post-discharge heart failure outcomes.

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.

Robot-assisted therapy for long-term upper-limb impairment after stroke.

BACKGROUND: Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS: In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS: At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS: In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Elderly adults and skin disorders: common problems for nondermatologists.

Diseases of elderly adults are becoming increasingly important as life expectancy gradually rises worldwide. To promote healthy aging, it is important to understand the skin changes associated with aging. This review focuses on the special considerations for some of the more common dermatological disorders in elderly adults and examines presentation, contributing factors, and association with systemic diseases.

Cessation of group battlefield acupuncture visits due to COVID-19: a pilot study.

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.

An economic analysis of robot-assisted therapy for long-term upper-limb impairment after stroke.

BACKGROUND AND PURPOSE: Stroke is a leading cause of disability. Rehabilitation robotics have been developed to aid in recovery after a stroke. This study determined the additional cost of robot-assisted therapy and tested its cost-effectiveness. METHODS: We estimated the intervention costs and tracked participants' healthcare costs. We collected quality of life using the Stroke Impact Scale and the Health Utilities Index. We analyzed the cost data at 36 weeks postrandomization using multivariate regression models controlling for site, presence of a prior stroke, and Veterans Affairs costs in the year before randomization. RESULTS: A total of 127 participants were randomized to usual care plus robot therapy (n=49), usual care plus intensive comparison therapy (n=50), or usual care alone (n=28). The average cost of delivering robot therapy and intensive comparison therapy was $5152 and $7382, respectively (P<0.001), and both were significantly more expensive than usual care alone (no additional intervention costs). At 36 weeks postrandomization, the total costs were comparable for the 3 groups ($17 831 for robot therapy, $19 746 for intensive comparison therapy, and $19 098 for usual care). Changes in quality of life were modest and not statistically different. CONCLUSIONS: The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. However, uncertainty remains about the cost-effectiveness of robotic-assisted rehabilitation compared with traditional rehabilitation. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00372411.

Psoriasis and vascular disease-risk factors and outcomes: a systematic review of the literature.

BACKGROUND: Psoriasis afflicts 2-3% of the world's population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality. PURPOSE: To determine which CVD risk factors are associated with psoriasis independent of confounders, whether psoriasis is associated with CVD independent of CVD risk factors, and whether there is increased mortality among patients with psoriasis. DATA SOURCES: MEDLINE, Embase, and Cochrane Collaborations from inception through October 2009. We reviewed bibliographies of retrieved articles for additional references. STUDY SELECTION: Cross-sectional, cohort-based, case-control, and randomized controlled trials which involved patients with psoriasis. DATA EXTRACTION: Two investigators independently reviewed studies and resolved any discrepancies by consensus. DATA SYNTHESIS: Of the 2,303 articles identified by literature search, 90 studies met inclusion criteria for this review; 15 were cohort-based studies, 45 were case-control, and 30 were cross-sectional. LIMITATIONS: The quality of evidence was limited by study heterogeneity and lack of large scale prospective studies with long-term follow-up. CONCLUSIONS: Patients with psoriasis demonstrate a higher prevalence of cardiovascular risk factors and appear to be at increased risk for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. This increase in vascular disease may be independent of shared risk factors and may contribute to the increase in all-cause mortality. Future research should aim to more confidently distinguish between a true causal relationship or merely an association resulting from multiple shared risk factors. Physicians should screen for and aggressively treat modifiable risk factors for CVD in patients with psoriasis.