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.

Whole Health Options and Pain Education (wHOPE): A Pragmatic Trial Comparing Whole Health Team vs Primary Care Group Education to Promote Nonpharmacological Strategies to Improve Pain, Functioning, and Quality of Life in Veterans-Rationale, Methods, and Implementation.

BACKGROUND: The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. wHOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. DESIGN: wHOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis. SUMMARY: This trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel.

Nonablative 1927 nm fractional resurfacing for the treatment of facial photopigmentation.

BACKGROUND: Long-term exposure to sunlight, including ultraviolet A and B, produces signs associated with photoaging and photodamage, including laxity and discoloration of the skin. Initial laser treatment for dyspigmentation included the use of ablative lasers, followed by Q-switched lasers and more recently fractional lasers. OBJECTIVE: We investigated the safety and efficacy of a fractionated 1927nm non-ablative thulium laser for the treatment of photo-induced pigmentation. METHODS: Prospective multi-center study of subjects with clinically identifiable photopigmentation. The study protocol was approved by BioMed Institutional Review Board (San Diego, CA). Subjects received two treatments with a non-ablative 1927nm fractionated thulium laser (Fraxel Dual 1550/1927 Laser System, Solta, Hayward CA), energy level of 10mJ, coverage of 40% and 4-6 passes. Subject pain, erythema and edema were recorded immediately after treatment. Two dimensional photography was obtained before each treatment and at one and three month follow up visits. Independent blinded physician assessment was performed evaluating overall improvement in appearance as well as pigment specific improvement. RESULTS: Forty men and women, ages 30 to 80 years, Fitzpatrick skin types I-IV, with photo-induced facial pigmentation were enrolled and treated, and 39 completed the three month follow up visit. Mean pain sensation for subjects during laser treatments was reported to be 4.3 on a 10-point scale. Mean scores for erythema, edema, and skin roughness throughout all treatments indicated moderate erythema, mild edema and mild skin roughness. Assessment of overall improvement was graded as moderate to very significant in 82% of subjects at one month and in 69% of subjects at three months after the second treatment. Assessment of lentigines and ephelides demonstrated moderate to very significant improvement in approximately 68% of subjects at the one month and in 51% of subjects at three months after the second treatment. Independent blinded physician assessment of randomized photography also demonstrated a durable response at three month follow up visit. Treatment was well tolerated and no serious adverse events related to treatment were observed or reported. Study limitations included a limited number of male subjects, lack of Fitzpatrick skin types V and VI, and decrease in improvement at 3 months post-treatment. CONCLUSIONS: Two treatments with a 1927nm non-ablative fractionated thulium laser produced moderate to marked improvement in overall appearance and pigmentation with high patient satisfaction. The response to treatment was maintained at one and three months follow up.

Enhancing data practices for Whole Health: Strategies for a transformative future.

We explored the challenges and solutions for managing data within the Whole Health System (WHS), which operates as a Learning Health System and a patient-centered healthcare approach that combines conventional and complementary approaches. Addressing these challenges is critical for enhancing patient care and improving outcomes within WHS. The proposed solutions include prioritizing interoperability for seamless data exchange, incorporating patient-centered comparative clinical effectiveness research and real-world data to personalize treatment plans and validate integrative approaches, and leveraging advanced data analytics tools to incorporate patient-reported outcomes, objective metrics, robust data platforms. Implementing these measures will enable WHS to fulfill its mission as a holistic and patient-centered healthcare model, promoting greater collaboration among providers, boosting the well-being of patients and providers, and improving patient outcomes.

Protected Time for Self-Care for Veterans Health Administration (VA) Employees.

OBJECTIVES: Employee Whole Health (EWH) empowers VA employees to take charge of their well-being by integrating self-care into their workday, but employees lack time to participate. METHODS: Employees at three VA medical centers participated in a 12-month feasibility cohort study to protect 60 minutes of time per week for self-care. Questionnaire data was collected at three time points; qualitative data at two time points. Pilot offerings included education and complementary and integrative health modalities for well-being. RESULTS: Employees enrolled spring 2021 (n = 312). Complete-case regression analyses indicated significant improvements in wellness culture, resiliency, self-efficacy, perceived stress, and flourishing at twelve months. Multiple imputation analyses confirmed improvements except for self-efficacy. Qualitative findings supported quantitative findings. CONCLUSIONS: Providing protected time for self-care was feasible and supported improvements in well-being. However, high workload was identified as an ongoing barrier to participation.

The Impact of Involvement in Whole Health System for Veterans or Participating in It for Oneself on Job Attitudes in VA Employees.

OBJECTIVE: The aim of the study is to examine how involvement in the Whole Health System of care, clinically and personally (through employee-focused activities), would affect employee satisfaction, engagement, burnout, and turnover intent in the Veterans Health Administration. METHODS: Multivariate logistic regression analysis of cross-sectional survey from Veterans Health Administration employees was used to determine the influence of Whole Health System involvement and Employee Whole Health participation on job attitudes. RESULTS: Whole Health System involvement was associated higher job satisfaction, higher levels of engagement, lower burnout, and lower turnover intent. A similar pattern of results was identified when looking specifically at Employee Whole Health participation and associated job attitudes. CONCLUSIONS: Employees who are either directly involved in delivering Whole Health services to veterans or who have participated in Whole Health programming for their own benefit may experience a meaningful positive impact on their well-being and how they experience the workplace.

Common complementary and alternative therapies with potential use in dermatologic surgery: risks and benefits.

BACKGROUND: Ambulatory surgery patients often use complementary and alternative medicine (CAM) therapies. CAM therapies may create beneficial and detrimental perioperative conditions. OBJECTIVE: We sought to improve knowledge of CAM effects in dermatologic surgery, allowing dermatologists to potentially capitalize on therapeutic actions and to mitigate complications. METHODS: PubMed literature search of CAM therapies in dermatologic and surgical settings was performed. Common CAM therapies with possible effects on dermatologic surgery were selected. Beneficial and detri-mental effects were reviewed. RESULTS: A myriad of products may be used perioperatively by the patient. Therapies appearing to have some evidence for potential benefit include bromelain, honey, propolis, arnica, vitamin C and bioflavonoids, chamomile, aloe vera gel, grape seed extract, zinc, turmeric, calendula, chlorella, lavender oil, and gotu kola. Potential complications vary according to product and include platelet inhibition, contact dermatitis and, in rare cases, systemic toxicity. LIMITATIONS: This review focuses on CAM having significant published studies evaluating efficacy for wound healing, anti-inflammatory, antipurpuric, or perioperative-related use. Most published studies have been small and often have design flaws. The scope of CAM is large and not all therapies are discussed. CONCLUSION: Selected CAM therapies have been reported to promote wound healing, reduce edema or purpura, and provide anti-inflammatory effects. Because of high rates of CAM use, surgeons should familiarize themselves with common uses, potential benefits, and complications. Further study of effects in the dermatologic surgery setting may improve the patient-doctor relationship and enhance outcomes.

1927-nm fractional resurfacing of facial actinic keratoses: a promising new therapeutic option.

BACKGROUND: Actinic keratoses (AK) are precancerous epidermal proliferations commonly present on chronically sun-damaged skin. These lesions are among the most often treated dermatologic conditions. OBJECTIVE: We sought to investigate the 6-month safety, tolerance, and efficacy of nonablative 1927-nm fractional resurfacing of facial AK. METHODS: This was a prospective clinical trial of 24 individuals with facial photodamage and AK receiving up to 4 treatments with the fractionated 1927-nm nonablative thulium laser. RESULTS: At 6 months, an 86.6% reduction in absolute number of lesions was noted by independent physician assessment. In addition, at this same time point, patients reported marked or noticeable improvement in overall photodamage. LIMITATIONS: This prospective study does not provide safety, tolerance, and efficacy data beyond 6 months of follow-up, nor does it identify the precise mechanism of action involved in AK clearance after 1927-nm resurfacing. CONCLUSION: The clinical and histologic findings, as well as the reported patient satisfaction and safety, suggest that the treatment of AK and photodamage with a fractionated 1927-nm nonablative thulium laser is a promising new therapeutic option.

Topical perfluorodecalin resolves immediate whitening reactions and allows rapid effective multiple pass treatment of tattoos.

BACKGROUND AND OBJECTIVE: Laser tattoo removal using multiple passes per session, with each pass delivered after spontaneous resolution of whitening, improves tattoo fading in a 60-minute treatment time. Our objective was to evaluate the safety and efficacy of topical perfluorodecalin (PFD) in facilitating rapid effective multiple-pass tattoo removal. STUDY DESIGN: In a randomized, controlled study using Q-switched ruby or Nd:YAG laser, 22 previously treated tattoos were treated with 3 passes using PFD to resolve whitening after each pass ("R0 method"). In previously untreated symmetric tattoos, seven were treated over half of the tattoo with the R20 method, and the opposite half with 4 passes using PFD (R0 method); two were treated over half with a single pass and the opposite half with 4 passes using PFD (R0 method); and six treated over half with a single pass followed by PFD and the opposite half with a single pass alone. Blinded dermatologists rated tattoo fading at 1-3 months. Optical coherence tomography (OCT) imaging of whitening was performed in two tattoos. RESULTS: Topical PFD clinically resolved immediate whitening reactions within a mean 5 seconds (range 3-10 seconds). Tattoos treated with the R0 method demonstrated excellent fading in an average total treatment time of 5 minutes. Tattoo areas treated with the R0 method demonstrated equal fading compared to the R20 method, and improved fading compared to a single pass method. OCT imaging of whitening demonstrated epidermal and dermal hyper-reflective "bubbles" that dissipated until absent at 9-10 minutes after PFD application, and at 20 minutes without intervention. CONCLUSIONS: Multiple-pass tattoo removal using PFD to deliver rapid sequential passes (R0 method) appears equally effective as the R20 method, in a total treatment time averaging 5 minutes, and more effective than single pass treatment. OCT-visualized whitening-associated "bubbles," upon treatment with PFD, resolve twice as rapidly as spontaneous resolution.

Retrospective study of the treatment of infantile hemangiomas using a combination of propranolol and pulsed dye laser.

BACKGROUND: Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone. OBJECTIVES: To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone. MATERIALS AND METHODS: Retrospective review of facial-segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near-complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near-complete clearance; total days of propranolol; and total propranolol dose were recorded. RESULTS: Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near-complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near-complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs. 401.25 mg/kg for propranolol; p < .001). CONCLUSION: Facial-segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near-complete clearance.

Treatment of port-wine stains with a short pulse width 532-nm Nd:YAG laser.

BACKGROUND AND OBJECTIVE: Pulsed dye laser treatment often results in port-wine stain (PWS) improvement; however, results vary. A frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser that allows for shorter pulse widths along with large spot sizes and high fluences has been developed for the treatment of cutaneous vascular lesions. STUDY DESIGN: A prospective, controlled study was performed in 5 adults with PWS using a frequency-doubled Nd:YAG laser (Excel V; Cutera Inc, Brisbane, CA) in 4 quadrants, using spot sizes of 6 to 10 mm, fluences of 4.8 to 9 J/cm2, and pulse durations of 3 to 6 ms. An adjacent control area was not treated. Each was assessed immediately posttreatment for purpura and edema and at 1 month for PWS color, size, texture, and thickness. Skin biopsies obtained immediately after and at 1 month posttreatment were evaluated. RESULTS: All treatment quadrants displayed purpura. At 1-month follow-up, all treatment quadrants showed at least 1 grade of color improvement, from a minimum of 1% to 25% to a maximum of 51% to 75% improvement (12/20 quadrants with 1%-25% improvement, 3/20 with 26%-50%, 5/20 with 51%-75%, and 0/20 with 76%-100%). Histologic evaluation of treatment quadrants revealed vascular changes ranging 0.35 to 4 mm in depth. Immediately posttreatment, thrombi and extravasated red blood cells were observed in treatment quadrants. Histology at 1 month revealed decreased number and diameter of vessels in treatment quadrants (superficial vessels decreased by mean 1.1 vessels per section [13%], and diameter by 3.0 µm [47%], midlevel vessels decreased in number by 2.3 [20%], diameter by 2.42 µm [25%], and deep vessels decreased in number by 1.5 [83%], and diameter by 7.44 µm [88%]). CONCLUSIONS: A single treatment with a short pulse width, frequency-doubled Nd:YAG laser resulted in safe and effective improvement of PWS, with up to 75% improvement in color observed at 1 month. Histologic evaluation demonstrated vascular injury at depths of 0.35 to 4 mm with a reduction in vessel number and size at multiple dermal levels.

Connecting the Dots: The Interplay Between Stroke and the Gut-Brain Axis.

This article discusses the interplay between the gut-brain axis and stroke, a multifaceted neurological disorder that affects millions of people worldwide. The gut-brain axis is a bidirectional communication network linking the central nervous system (CNS) to the gastrointestinal tract (GIT), including the enteric nervous system (ENS), vagus nerve, and gut microbiota. Dysbiosis in the gut microbiota, alterations in the ENS and vagus nerve, and gut motility changes have been linked to increased inflammation and oxidative stress, which are contributing factors in the development and progression of stroke. Research on animals has shown that modifying the gut microbiota can impact the results of a stroke. Germ-free mice displayed improved neurological function and decreased infarct volumes, indicating a positive effect. Furthermore, studies in stroke patients have shown alterations in the gut microbiota composition, indicating that targeting dysbiosis could be a potential therapeutic strategy for stroke. The review suggests that targeting the gut-brain axis may represent a potential therapeutic approach to reduce the morbidity and mortality associated with stroke.

Phase II Study of Ramucirumab in Advanced Biliary Tract Cancer Previously Treated By Gemcitabine-Based Chemotherapy.

PURPOSE: VEGF receptor-2 (VEGFR-2)-mediated angiogenesis contributes to pathogenesis of biliary tract cancers (BTC). We investigated ramucirumab, a mAb targeting VEGFR-2 for treatment of advanced, chemorefractory BTC. PATIENTS AND METHODS: This is a phase II, single-arm trial for advanced, unresectable, pre-treated patients with BTC with ECOG 0/1, adequate liver, renal, and marrow functions. Ramucirumab was administered at 8 mg/kg, 2 weekly with restaging performed 8 weekly. Primary endpoint was progression-free survival (PFS). Secondary endpoints were overall response rate (ORR), disease control rate (DCR), overall survival (OS), and toxicity. Exploratory endpoints included correlation of tumor mutational status with PFS and OS. RESULTS: 61 patients were enrolled: the median age was 58.5 years; 59 with stage IV disease; 62%, intrahepatic cholangiocarcinoma; 22%, gallbladder cancer; and 16%, extrahepatic cholangiocarcinoma. All received prior chemotherapy: 52% had 1 prior, and rest ≥2 prior lines. Median treatment duration was 10.1 weeks (range, 2.1-86). Median PFS was 3.2 months [95% confidence interval (CI), 2.1-4.8]; median OS, 9.5 months (95% CI, 5.8-13.6). One (1.7%) patient achieved partial response; 26 (43.3%), stable disease; and 25 (41.7%), disease progression; DCR, 45%. Median 6-month PFS and OS rates were 32% (95% CI, 0.22-0.46) and 58% (95% CI, 0.47-0.72). The majority of toxicities were grade 1 or 2; grade 3 proteinuria (1, 2%), hypertension (13, 22%), and pulmonary embolism (1, 2%), and grade 4 gastrointestinal bleeding (1, 2%) occurred. CONCLUSIONS: Ramucirumab was well tolerated and resulted in PFS similar to that achieved with other chemotherapy regimens used historically for chemorefractory BTC.

Combined treatment targeting HIF-1α and Stat3 is a potent strategy for prostate cancer therapy.

BACKGROUND: The Stat3 pathway and the hypoxia-sensing pathway are both up-regulated in prostate cancer. Stat3 is a specific regulator of pro-carcinogenic inflammation and represents a promising therapeutic target. Hypoxia-inducible factor-1 (HIF-1)α, which mediates the cellular response to hypoxia, has been demonstrated to be over-expressed in many human cancers and is associated with poor prognosis and treatment failure in clinic. To develop a potent strategy to increase therapeutic efficacy and reduce drug resistance in prostate cancer therapy, we combined two anti-cancer agents: T40214 (a p-Stat3 inhibitor) and JG244 (a HIF-1α inhibitor) together to treat nude mice bearing human prostate tumor (DU145) and immunocompetent mice (C57BL/6) bearing murine prostate tumor (TRAMP-C2). METHODS: We employed in vitro and in vivo assays, including Western blots, cell cycle analysis, immunohistochemistry, TUNEL and xenograft models to determine the drug efficacy and mechanism of combination treatment of T40214 and JG244. RESULTS: We found that compared to treatment by T40214 or JG244 alone, the combination treatment using T40214 and JG244 together significantly suppressed growth of human or murine prostate tumors. Also, compared with apoptotic cells induced by T40214 or JG244 alone, the combined treatment greatly increased apoptosis in DU145 (P < 0.006) and TRAMP-C2 tumors (P < 0.008). CONCLUSIONS: Our results suggested that combination treatment including a HIF-1α/2α inhibitor not only has therapeutic efficacy in targeting HIF-1α/2α, but also could reduce the hypoxia-induced drug resistance to other therapies (e.g., T40214) and enhance drug efficacy. This approach could make prostate cancer treatments more effective.

G-rich oligonucleotides inhibit HIF-1alpha and HIF-2alpha and block tumor growth.

Hypoxia-inducible factor-1 (HIF-1) plays crucial roles in tumor promotion by upregulating its target genes, which are involved in energy metabolism, angiogenesis, cell survival, invasion, metastasis, and drug resistance. The HIF-1alpha subunit, which is regulated by O2-dependent hydroxylation, ubiquitination, and degradation, has been identified as an important molecular target for cancer therapy. We have rationally designed G-rich oligodeoxynucleotides (ODNs) as inhibitors of HIF-1alpha for human cancer therapy. The lead compounds, JG243 and JG244, which form an intramolecular parallel G-quartet structure, selectively target HIF-1alpha and decreased levels of both HIF-1alpha and HIF-2alpha (IC50 < 2 micromol/l) and also inhibited the expression of HIF-1-regulated proteins [vascular endothelial growth factor (VEGF), Bcl-2, and Bcl-XL], but did not disrupt the expression of p300, Stat3, or p53. JG-ODNs induced proteasomal degradation of HIF-1alpha and HIF-2alpha that was dependent on the hydroxylase activity of prolyl-4-hydroxylase-2. JG243 and JG244 dramatically suppressed the growth of prostate, breast, and pancreatic tumor xenografts. Western blots from tumor tissues showed that JG-ODNs significantly decreased HIF-1alpha and HIF-2alpha levels and blocked the expression of VEGF. The JG-ODNs are novel anticancer agents that suppress tumor growth by inhibiting HIF-1.

Malignancy arising within cutaneous tattoos: case of dermatofibrosarcoma protuberans and review of literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor of the skin with high rates of local recurrence. Several reports describe a frequent history of local trauma. In one prior case, a DFSP arising in a tattoo site has been reported. Mohs micrographic surgery (MMS) has been used successfully for treatment. OBJECTIVE: To present a case of dermatofibrosarcoma protuberans arising in the site of a prior and current tattoo, and treated with Mohs micrographic surgery. METHODS: We present findings of a case of a DFSP arising in a tattoo and a review of Medline literature on the association between tattoos and cutaneous malignancy, and treatment of DFSP with MMS. RESULTS: Review of the literature confirms multiple reports of DFSP arising in sites of local trauma, as well as malignancies arising in sites of tattoos. The recurrence rate for MMS treatment of DFSP (0-6.6%) was found to be significantly lower than that for patients treated with wide local excision (13% to 95%). CONCLUSIONS: DFSP should be considered in the differential diagnosis of neoplasms arising within areas of tattoos. Sites of local trauma and tattoos may show predilection for benign and malignant changes and should be evaluated during regular skin exams. Review of the literature confirms MMS is an ideal treatment modality for DFSP as the tumor often extends far beyond clinical margins.

Veterans Health Administration's Whole Health System of Care: Supporting the Health, Well-Being, and Resiliency of Employees.

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA's Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

Epidermotropic metastatic mucoepidermoid carcinoma.

Mucoepidermoid carcinoma (MEC), an invasive malignant neoplasm composed of mucus-secreting, epidermoid, and intermediate cells in varying proportions, is the commonest malignant salivary gland neoplasm in adults. Cutaneous metastases from the same, although not entirely common, has been previously reported but are typically confined to dermis. In this report, we present a case of MEC presenting as a cutaneous metastasis. A histologic feature unique to this case was epidermotropism, previously not noted in either metastatic or primary MEC.

Rapid wound re-epithelialization and basal cell carcinoma clearance after Mohs micrographic surgery with postoperative photodynamic therapy.

BACKGROUND: Methyl aminolevulinic acid photodynamic therapy (MAL-PDT) has antitumor activity and may promote wound healing Superficial and nodular basal cell carcinomas (BCCs) have been successfully treated with MAL-PDT in prior reports. In vitro and animal studies have shown more rapid re-epithelialization and decreased myofibroblast response after treatment thus suggesting that PDT may play a possible role in promotion of wound healing. OBJECTIVES: To describe a novel case of a large multifocal BCC treated with postoperative PDT that showed results of tumor clearance and rapid re-epithelialization and to review the relevant literature. CASE REPORT: A patient presented for Mohs micrographic surgery (MMS) after recent biopsy revealed recurrent BCC. Mohs micrographic surgery was performed, where after six stages were taken, approximately 50% of the peripheral margins of the tumor remained positive for superficial BCC. Given the large size of the wound defect (12.5 cm x 9 cm) and superficial nature of the persistent tumor, the authors opted to treat the patient with adjuvant MAL-PDT in lieu of pursuing additional stages with MMS. The patient returned the following day for adjuvant therapy with MAL-PDT. Two consecutive treatments one week apart were given as an adjunctive treatment course for persistent BCC. At follow-up four weeks after the PDT treatment, the defect had fully re-epithelialized. In the authors' clinical practice, an untreated wound of this size typically heals in 10-12 weeks. The patient has been seen in six months of follow-up to date. Review of the literature relevant to use of MAL-PDT in treatment of basal cell carcinoma and literature describing effects of PDT on wound healing was performed. CONCLUSION: MAL-PDT may be an effective adjuvant tool against large multifocal BCCs for which surgery has not resulted in clearance. Treatment with PDT resulted in rapid re-epithelialization of the surgical wound in this case. This observation is supported by prior in vitro studies and in vivo animal experiments demonstrating more rapid re-epithelialization of wounds and decreased scarring response after PDT.