Characteristics of Veterans With Depression Who Use the Veterans Choice Program of the Veterans Health Administration.

OBJECTIVE: The Veterans Choice Program (VCP) of the Veterans Health Administration (VHA) allowed eligible veterans to use their benefits with participating providers outside the VHA. The authors aimed to identify characteristics of veterans with depression who used or did not use mental health care through the VCP. METHODS: In this cross-sectional study, the authors analyzed secondary data from the national VHA Corporate Data Warehouse. VHA administrative data were linked with VCP claims to examine characteristics of VCP-eligible veterans with depression. The study sample included 595,943 unique veterans who were enrolled in the VHA before 2013, were eligible for the VCP in 2016, were alive in 2018, and had an assessed Patient Health Questionnaire-9 (PHQ-9) score or depressive disorder diagnosis documented in the VHA between 2016 and 2018. RESULTS: Veterans who used the VCP had lower medical comorbidity scores and lived in less socioeconomically disadvantaged counties, compared with veterans who received only VHA care. VCP veterans were also more likely to have a PHQ-9 score assessment and to have higher mean depression scores. Mean counts of annual mental health visits per 1,000 veterans were markedly higher for direct VHA care than for care provided via the VCP. As a percentage of the total counts of visits per 1,000 veterans across the VCP and VHA, residential programs and outpatient procedures were the services that were most frequently delivered through the VCP. CONCLUSIONS: Between 2016 and 2018, the VCP was used primarily to augment mental health care provided by the VHA, rather than to fill a gap in care.

Perspectives on Training and Working in the VHA: Implications for Primary Care Physician Recruitment and Retention.

PURPOSE: The primary care physician shortage in the United States presents significant challenges for health systems seeking to maintain a sufficient primary care workforce. Perspectives on training or working in primary care in the Veterans Health Administration (VHA) may yield insights into strategic recruitment to make the VHA and other health systems more attractive to primary care physicians. The authors sought to understand the experiences of resident and staff physicians with limited tenure within VHA primary care to identify factors to guide health systems in improving recruitment and retention. METHOD: This qualitative exploratory study was conducted from June 2018 to October 2019 with 24 internal medicine residents and 30 staff physicians in VHA primary care. Heterogeneity was ensured by sampling for geographical region, rurality, and gender within each cohort. The authors conducted semistructured interviews to ascertain perspectives on training and employment preferences at VHA and non-VHA sites. Combined content analysis was used to generate findings. RESULTS: The authors identified 4 key themes, centered around shared values and the VHA's mission-driven culture: the VHA "community" was perceived as unique and a major contributor to job satisfaction; facility-level leadership support was important to perceptions of workplace culture around harassment; the VHA primary care delivery model allowed residents and staff physicians to get patients needed care but did not always live up to its potential; and VHA employment was better than expected, but the process of getting hired was a challenge. CONCLUSIONS: Mission and workplace culture may serve important roles in the desirability of health systems for prospective physicians and the job satisfaction of physicians who work in these systems. Physician recruitment efforts based on these attributes may yield the most success in maintaining a sufficient physician workforce.

Text messaging to support a perinatal collaborative care model for depression: A multi-methods inquiry.

OBJECTIVE: Mental health care integrated into obstetric settings improves access to perinatal depression treatments. Digital interactions such as text messaging between patient and provider can further improve access. We describe the use of text messaging within a perinatal Collaborative Care (CC) program, and explore the association of text messaging content with perinatal depression outcomes. METHODS: We analyzed data from an open treatment trial of perinatal CC in a rural obstetric clinic. Twenty five women with Patient Health Questionnaire-9 score of ≥10 enrolled in CC, and used text messaging to communicate with their Care Manager(CM). We used surveys and focus groups to assessacceptability of text messaging with surveys and focus groups. We calculated the number of text messages exchanged, and analyzed content to understand usage patterns. We explored association between text messaging content and depression outcomes. RESULTS: CMs initiated 85.4% messages, and patients responded to 86.9% messages. CMs used text messaging for appointment reminders, and patients used it to obtain obstetric and parenting information. CMs had concerns about the likelihood of boundary violations. Patients appreciated the asynchronous nature of text messaging. CONCLUSION: Text messaging is feasible and acceptable within a perinatal CC program. We need further research into the effectiveness of text messaging content, and response protocols.

Delivering perinatal depression care in a rural obstetric setting: a mixed methods study of feasibility, acceptability and effectiveness.

OBJECTIVES: Universal screening for depression during pregnancy and postpartum is recommended, yet mental health treatment and follow-up rates among screen-positive women in rural settings are low. We studied the feasibility, acceptability and effectiveness of perinatal depression treatment integrated into a rural obstetric setting. METHODS: We conducted an open treatment study of a screening and intervention program modified from the Depression Attention for Women Now (DAWN) Collaborative Care model in a rural obstetric clinic. Depression screen-positive pregnant and postpartum women received problem-solving therapy (PST) with or without antidepressants. A care manager coordinated communication between patient, obstetrician and psychiatric consultant. We measured change in the Patient Health Questionnaire 9 (PHQ-9) score. We used surveys and focus groups to measure patient and provider satisfaction and analyzed focus groups using qualitative analysis. RESULTS: The intervention was well accepted by providers and patients, based on survey and focus group data. Feasibility was also evidenced by recruitment (87.1%) and retention (92.6%) rates and depression outcomes (64% with >50% improvement in PHQ 9) which were comparable to clinical trials in similar urban populations. Conclusions for practice: DAWN Collaborative Care modified for treatment of perinatal depression in a rural obstetric setting is feasible and acceptable. Behavioral health services integrated into rural obstetric settings could improve care for perinatal depression.

Latest innovations for tattoo and permanent makeup removal.

The goal of this article is to reveal the latest techniques and advances in laser removal of both amateur and professional tattoos, as well as cosmetic tattoos and permanent makeup. Each pose different challenges to the removing physician, but the goal is always the same: removal without sequelae. The authors' technique is detailed, and discussion of basic principles of light reflection, ink properties, effects of laser energy and heat, and outcomes and complications of tattoo removal are presented.

Blast-induced tinnitus and hearing loss in rats: behavioral and imaging assays.

Abstract The current study used a rat model to investigate the underlying mechanisms of blast-induced tinnitus, hearing loss, and associated traumatic brain injury (TBI). Seven rats were used to evaluate behavioral evidence of tinnitus and hearing loss, and TBI using magnetic resonance imaging following a single 10-msec blast at 14 psi or 194 dB sound pressure level (SPL). The results demonstrated that the blast exposure induced early onset of tinnitus and central hearing impairment at a broad frequency range. The induced tinnitus and central hearing impairment tended to shift towards high frequencies over time. Hearing threshold measured with auditory brainstem responses also showed an immediate elevation followed by recovery on day 14, coinciding with behaviorally-measured results. Diffusion tensor magnetic resonance imaging results demonstrated significant damage and compensatory plastic changes to certain auditory brain regions, with the majority of changes occurring in the inferior colliculus and medial geniculate body. No significant microstructural changes found in the corpus callosum indicates that the currently adopted blast exposure mainly exerts effects through the auditory pathways rather than through direct impact onto the brain parenchyma. The results showed that this animal model is appropriate for investigation of the mechanisms underlying blast-induced tinnitus, hearing loss, and related TBI. Continued investigation along these lines will help identify pathology with injury/recovery patterns, aiding development of effective treatment strategies.

Cartilage grafts in dorsal nasal augmentation of traumatic saddle nose deformity: a long-term follow-up.

OBJECTIVES/HYPOTHESIS: To document the long-term advantages and disadvantages of cartilage grafts used to correct traumatic saddle nose deformity. Additionally, to demonstrate functional improvement and cosmetic satisfaction with the use of this graft. STUDY DESIGN: Retrospective chart review and prospective follow-up telephone survey of 20 patients after dorsal augmentation of saddle nose deformity secondary to trauma. METHODS: This is a single-surgeon, single-institution investigation within an academic tertiary care medical center. All patients presented for correction of saddle nose deformity after trauma, and cartilage grafts were used for augmentation of the dorsum. Minimum postoperative follow-up period of 1 year was required. A modified and expanded Nasal Obstructive Symptoms Evaluation survey, which included questions pertaining to the appearance of their nose, was used to assess both functional and cosmetic changes after surgery. RESULTS: Only 1 of the 20 patients was dissatisfied with the overall outcome. Three (15%) were extremely satisfied, 12 (60%) were very satisfied, three (15%) were somewhat satisfied, and one (5%) was indifferent. In terms of function, four (20%) experienced excellent relief in nasal obstruction, five (25%) moderate relief, four (20%) mild relief, and seven (35%) noted no difference. Regarding cosmesis, two (10%) noted excellent improvement, three (15%) moderate improvement, nine (45%) mild improvement, and five (25%) noted no significant change. One (5%) patient reported worsening due to tip edema. Mean follow-up time was 6.8 years. CONCLUSIONS: Autogenous cartilage grafts are useful in the correction of mild to moderate traumatic saddle nose deformity. The graft is readily available, preserves long-term structural stability, and achieves functional and cosmetic satisfaction in most patients.

Conservative management of iatrogenic esophageal perforation in head and neck cancer patients with esophageal stricture.

OBJECTIVE: Evaluate the efficacy of conservative management of iatrogenic esophageal perforation following dilatation of a stricture secondary to the treatment of head and neck cancer. STUDY DESIGN: Case series with chart review. SUBJECTS AND METHODS: Retrospective chart review of 24 patients with esophageal perforation treated at the Detroit Medical Center from 1999 to 2008. Of these, eight head and neck cancer patients had esophageal stricture and underwent dilatation with subsequent esophageal perforation. RESULTS: Six patients were managed conservatively; two were managed surgically. All eight patients had radiation, six had chemotherapy, and five had surgery as part of their oncologic treatment. Stricture site was at the cricopharyngeus or neopharynx. Perforation size was estimated at 3 to 7 mm in conservative patients and approximately 10 mm in surgical patients. All patients survived to be discharged from the hospital and diet was tube feeds. CONCLUSION: In head and neck cancer patients with post-treatment esophageal stricture, iatrogenic cervical esophageal perforations can often be safely managed conservatively. The criteria are: prompt diagnosis within one hour, small perforation (3-7 mm), penetrating type of perforation with circumferential mucosal contact, proximal or cervical esophageal location, and stabilization and improvement of clinical signs and symptoms for 24 hours after initial ICU management.

Craniocervical necrotizing fasciitis with and without thoracic extension: management strategies and outcome.

OBJECTIVE: First objective was to review cases of craniocervical necrotizing fasciitis (CCNF) at Wayne State University/Detroit Medical Center (Detroit, MI) for the last 18 years. Second was to analyze patients with and without thoracic extension for contributing factors. METHODS: Retrospective review of 660 patients with necrotizing fasciitis treated at WSU/DMC from January 1989 to January 2007 was conducted. Data regarding source/extent of infection, presenting signs/symptoms, computed tomography, microbiology, antibiotics, comorbidities, number/type of operations, hyperbaric oxygen (HBO) therapy, hospital duration, complications, and overall outcome were compared/analyzed between patients with and without thoracic extension. RESULTS: Twenty patients with CCNF for the past 18 years met the inclusion criteria. Ten patients had thoracic extension, and 10 patients did not have. Individuals in the thoracic extension group were likely to be older, had increased comorbidity, required more surgical debridement, experienced increased postoperative complications, and had lower overall survival. Three patients with thoracic extension underwent HBO therapy and 66% survived. CONCLUSION: This is the largest single institutional review of CCNF comparing patients with and without thoracic extension. Patients with thoracic extension have a poorer outcome as follows: 60% (6/10) survival vs 100% (10/10) for those without thoracic extension (P < .05). The CCNF patients without thoracic extension treated at our institution all survived after prompt medical and surgical intervention. Overall survival of CCNF patients without thoracic extension may be attributed to rigorous wound care, broad spectrum intravenous antibiotics, aggressive surgical debridement, and vigilant care in surgical intensive care unit. The HBO therapy should be included if the patient can tolerate it.