Military medicine
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The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. ⋯ Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.
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Case Reports
Large Intra-Abdominal Desmoid Tumor in a Deployed Soldier Initially Presented With Chronic Diarrhea.
Diarrhea is a common condition seen among soldiers in both garrison and deployed environments. Although the vast majority of soldiers with diarrhea will recover uneventfully with supportive care, clinicians should also maintain suspicion for less common causes and perform a thorough physical exam. ⋯ This tumor may be associated with abdominal distension and gastrointestinal complaints. A large tumor can compress organs, causing local tissue damage and, in rare cases, death.
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This case discusses a 34-year-old active duty male who presented to the emergency department with a 2-week persistent headache. His initial review of symptoms was reassuring until a detailed neurologic examination on his second visit revealed a visual deficit in the left upper quadrant. ⋯ The patient was admitted for medical management and subsequently found to have suffered a small infarction of right lingual gyrus cortex on magnetic resonance imaging. This case illustrates the importance of maintaining a broad differential diagnosis and high index of suspicion in the patient with new focal neurologic findings in order to diagnose a potentially fatal disease.
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Brachytherapy, with external beam radiation, increases survival in the treatment of locally advanced cervical cancer (LACC). In 2016, Robin et al. reported only 44% of patients received standard-of-care (SOC) brachytherapy in the USA. The Pacific Island Health Care Project has provided humanitarian medical care to women from the U.S. Associated Pacific Islands (USAPI) for three decades at Tripler Army Medical Center (TAMC), a military health care system (MHS) facility. We evaluated whether this underserved and understudied patient population received SOC treatment for LACC at TAMC. ⋯ Women with cervical cancer from USAPI in the PIHCP program treated at TAMC received significantly higher rates of SOC radiation treatment than the U.S. population on average. This highlights the ability of PIHCP, through the MHS, to deliver SOC treatment for cervical cancer to an otherwise underserved patient population.
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Traumatic brain injury (TBI) entails chronic neurological symptoms and deficits, such as smell and taste impairment. In the general population, a prevalence of 13.5% for smell impairment, 17% for taste impairment, and 2.2% for both have been reported. Studies establishing prevalence of sensorial dysfunction in the U.S. general population showed that prevalence increased with age and was higher in ethnic minorities and men. To understand the mechanisms that lead to these deficits, the prevalence of sensory dysfunction was studied in the Veteran TBI population of the VA Caribbean Healthcare System (VACHS). The aims were to find the prevalence of sensorial dysfunction in smell and/or taste in TBI patients at the VACHS Polytrauma Clinic and its association with demographic characteristics and medical comorbidities. The hypothesis was that the prevalence of sensory dysfunction in smell and/or taste of VACHS Veterans (mostly Hispanics minority) with TBI will be higher than the one historically reported in the literature for the U.S. general population. ⋯ The investigators found that the prevalence of sensory dysfunction in smell and/or taste in VACHS Veterans with TBI was 38.3% (n = 31). A significant association was found between smell and/or taste dysfunction and being a combat veteran (P = .018). A marginally significant association to obesity was also observed (P = .053). To the scientific community, the results will serve as a base for sensorial dysfunction and TBI research given that this prevalence, and the correlation to demographics and comorbidities, has not been fully established in the Veteran population.