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Background: The Maintaining Internal Systems and Integrated Outside Networks (MISSION) Act of 2018 was created in response to reports of prolonged wait times for veterans accessing health care within the Veterans Affairs (VA) system. In Michigan, the MISSION Act Community Care Program led to an increased number of veterans receiving specialty care outside the VA system, in part due to the complicated process of coordinating specialty care within the VA system. From 2018 to 2020, the percentage of veterans referred to the VA Ann Arbor Healthcare System (AA) for specialty care from its two referring facilities, Battle Creek VA Medical Center (BC) and Saginaw VA Healthcare System (SAG), decreased from 54.4 to 27%., Objective: Improve the number of Michigan veterans choosing VA specialty care., Intervention: In 2021, three VA facilities in Michigan (AA, BC, and SAG) created a market-level referral system named the Michigan Market Referral Initiative (MMRCI). This unique approach used a centralized nurse-driven team to manage specialty referrals, working directly with the veteran to explore both VA and community care (CC) options., Main Measures: Referrals triaged and acceptance rates for VA care were tracked. The localized Standard Episode of Care model was used to estimate cost savings. Post-intervention AA patient wait times were compared to local CC wait times., Key Results: In the 14 months after implementation of the MMRCI, the rate of veteran retention increased by 32.4%. The estimated dollars retained within the VA by MMRCI efforts was $24,105,251 as of 7/1/2022. Post-intervention AA wait times were superior to community care except in 3 specialties., Conclusions: This multifacility effort is an example of a highly coordinated, veteran-centered collaboration that has led to successful retention of veterans within the VA system with resultant large-scale cost avoidance and comparable clinic wait times. Focusing on central care coordination and veteran engagement in the referral process are keys to its success, along with leveraging existing referral patterns between nearby VA facilities. This model could be extrapolated to other VA markets throughout the country where similar relationships exist., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: As the COVID-19 pandemic evolves, it is critical to understand characteristics that have allowed US healthcare systems, including the Veterans Affairs (VA) and non-federal hospitals, to mount an effective response in the setting of limited resources and unpredictable clinical demands generated by this system shock., Objective: To compare the impact of and response to resource shortages to both VA and non-federal healthcare systems during the COVID-19 pandemic., Design: Cross-sectional national survey administered April 2021 through May 2022., Participants: Lead infection preventionists from VA and non-federal hospitals across the US., Main Measures: Surveys collected hospital demographic factors along with 11 questions aimed at assessing the effectiveness of the hospital's COVID response., Key Results: The response rate was 56% (71/127) from VA and 47% (415/881) from non-federal hospitals. Compared to VA hospitals, non-federal hospitals had a larger average number of acute care (214 vs. 103 beds, p<.001) and intensive care unit (24 vs. 16, p<.001) beds. VA hospitals were more likely to report no shortages of personal protective equipment or medical supplies during the pandemic (17% vs. 9%, p=.03) and more frequently opened new units to care specifically for COVID patients (71% vs. 49%, p<.001) compared with non-federal hospitals. Non-federal hospitals more frequently experienced increased loss of staff due to resignations (76% vs. 53%, p=.001) and financial hardships stemming from the pandemic (58% vs. 7%, p<0.001)., Conclusions: In our survey-based national study, lead infection preventionists noted several distinct advantages in VA versus non-federal hospitals in their ability to expand bed capacity, retain staff, mitigate supply shortages, and avoid financial hardship. While these benefits appear to be inherent to the VA's structure, non-federal hospitals can adapt their infrastructure to better weather future system shocks., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

The question associated with efficacy and longevity of SARS-CoV-2 protection post-vaccination is paramount. The cPass surrogate virus neutralization test (sVNT) has gained popularity globally as a dual application assay for: 1. Accurate SARS-CoV-2 population surveillance (seroprevalence) analysis and 2. Revealing the presence of antibodies that block and effectively neutralize the interaction between the SARS-CoV-2 receptor binding domain and the host cell ACE2 receptor in recovered or vaccinated individuals. This study describes an approach for accurate quantification of neutralizing antibodies using the cPass sVNT with an automated workflow on the Tecan EVO and Dynex Agility platforms that is applicable to other liquid handling systems. This methodology was used to assess the stability of SARS-CoV-2 neutralizing antibodies between freeze/thaw and refrigerated sample storage conditions. Furthermore, a subset of twenty-five samples from SARS-CoV-2 infected/recovered individuals revealed a 600-fold difference in the neutralizing antibody response where low titers were represented in about half of the samples. Finally, pre- and post-vaccination samples were tested for neutralizing antibodies using the qualitative and semi-quantitative cPass sVNT protocols revealing undetectable or relatively low levels after the first vaccine dose and a decline in levels longitudinally over the months following the second dose. This wide range in neutralizing (blocking) antibodies from both natural infection and vaccination supports a differential immune response that may be attributed to several physiological and genetic factors underlining the potential for measuring SARS-CoV-2 neutralizing antibody titer levels post-vaccination to help ensure robust and prolonged immunity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: The seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) IgG antibody was evaluated among employees of a Veterans Affairs healthcare system to assess potential risk factors for transmission and infection., Methods: All employees were invited to participate in a questionnaire and serological survey to detect antibodies to SARS-CoV-2 as part of a facility-wide quality improvement and infection prevention initiative regardless of clinical or nonclinical duties. The initiative was conducted from June 8 to July 8, 2020., Results: Of the 2,900 employees, 51% participated in the study, revealing a positive SARS-CoV-2 seroprevalence of 4.9% (72 of 1,476; 95% CI, 3.8%-6.1%). There were no statistically significant differences in the presence of antibody based on gender, age, frontline worker status, job title, performance of aerosol-generating procedures, or exposure to known patients with coronavirus infectious disease 2019 (COVID-19) within the hospital. Employees who reported exposure to a known COVID-19 case outside work had a significantly higher seroprevalence at 14.8% (23 of 155) compared to those who did not 3.7% (48 of 1,296; OR, 4.53; 95% CI, 2.67-7.68; P < .0001). Notably, 29% of seropositive employees reported no history of symptoms for SARS-CoV-2 infection., Conclusions: The seroprevalence of SARS-CoV-2 among employees was not significantly different among those who provided direct patient care and those who did not, suggesting that facility-wide infection control measures were effective. Employees who reported direct personal contact with COVID-19-positive persons outside work were more likely to have SARS-CoV-2 antibodies. Employee exposure to SARS-CoV-2 outside work may introduce infection into hospitals.

Objective: To date, treatment options (i.e. psychotherapy, antidepressant medications) for patients with posttraumatic stress disorder (PTSD), are relatively few, and considering their limited efficacy, novel therapies have gained interest among researchers and treatment providers alike. Among patients with chronic pain (CP) about one third experience comorbid PTSD, which further complicates their already challenging pharmacological regimens. Low dose ketamine infusion has shown promise in PTSD, and in treatment of CP, however they have not been studied in comorbid population and under rigorous control conditions., Methods: We compared the effects of a single dose of either ketamine (0.5 mg/kg) or ketorolac (15 mg) over a 40-minute of IV infusion in CP patients with and without PTSD, in double blind, randomized study. Measures were collected before, during, one day and seven days after the infusion. A planned sample size of 40 patients randomly assigned to treatment order was estimated to provide 80% power to detect a hypothesized treatment difference after the infusion. Main Outcome and Measures: The primary outcome measures were change in PTSD symptom severity assessed with the Impact of Event Scale-Revised (IES-R) and Visual Analogue Scale (VAS) for pain administered by a study clinician 24 hours post infusion. Secondary outcome measures included Impact of Event Scale-Revised (IES-R), VAS and Brief Pain Inventory (Short Form) for pain 1 week after the infusion., Results: Both treatments offered comparable improvement of PTSD and CP symptoms that persisted for 7 days after the infusion. Patients with comorbid PTSD and CP experienced less dissociative side effects compared to the CP group. Surprisingly, ketorolac infusion resulted in dissociative symptoms in CP patients only., Conclusions: This first prospective study comparing effects of subanesthetic ketamine versus ketorolac infusions for comorbid PTSD and CP, suggests that both ketamine and ketorolac might offer meaningful and durable response for both PTSD and CP symptoms., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Competing Interests: Competing interests: None declared.

Although the VHA primarily relies on teams for anesthesia care, unsupervised certified registered nurse anesthetists also are used to meet veterans' surgical care needs., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

A novel interdisciplinary team approach within a primary care setting may be a promising model for delivering effective comprehensive treatment options for patients with chronic pain., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Background: Surgical patients with chronic obstructive pulmonary disease (COPD) are at increased risk of perioperative complications. In this study, we sought to quantify the benefit of avoiding general anesthesia in this patient population., Methods: Data from the National Surgical Quality Improvement Program database (2005-2010) were used for this review. Patients who met the National Surgical Quality Improvement Program definition for COPD and underwent surgery under general, spinal, epidural, or peripheral nerve block anesthesia were included in this study. For each primary current procedural terminology code with ≥ 1 general and ≥ 1 regional (spinal, epidural, or peripheral nerve block) anesthetic, regional patients were propensity score--matched to general anesthetic patients. Propensity scoring was calculated using all available demographic and comorbidity data. This match yielded 2644 patients who received regional anesthesia and 2644 matched general anesthetic patients. These groups were compared for morbidity and mortality., Results: Groups were well matched on demographics, comorbidities, and type of surgery. Compared with matched patients who received regional anesthesia, patients who received general anesthesia had a higher incidence of postoperative pneumonia (3.3% vs 2.3%, P = 0.0384, absolute difference with 95% confidence interval = 1.0% [0.09, 1.88]), prolonged ventilator dependence (2.1% vs 0.9%, P = 0.0008, difference = 1.2% [0.51, 1.84]), and unplanned postoperative intubation (2.6% vs 1.8%, P = 0.0487, difference = 0.8% [0.04, 1.62]). Composite morbidity was 15.4% in the general group versus 12.6% (P = 0.0038, difference = 2.8% [0.93, 4.67]). Composite morbidity not including pulmonary complications was 13.0% in the general group versus 11.1% (P = 0.0312, difference = 1.9% [0.21, 3.72]). Thirty-day mortality was similar (2.7% vs 3.0%, P = 0.6788, difference = 0.3% [-1.12, 0.67]). As a test for validity, we found a positive association between pulmonary end points because patients with 1 pulmonary complication were significantly more likely to have additional pulmonary complications., Conclusions: The use of regional anesthesia in patients with COPD is associated with lower incidences of composite morbidity, pneumonia, prolonged ventilator dependence, and unplanned postoperative intubation.

Background: The management of multiple endocrine neoplasia, type 1 (MEN-1) pancreatoduodenal neuroendocrine neoplasms (NENs) is controversial. An aggressive surgical approach is intended to control the functional syndromes and malignant potential for nodal or distant metastasis., Methods: The results of treating 39 patients with MEN-1 pancreatoduodenal NENs over a 35-year period are available from chart reviews and patient interviews. This study focuses on pattern of disease, disease recurrence, and long-term functional outcomes., Results: Between 1967 and 2003, 39 patients ages 19 to 58 years (mean age, 37) had abdominal operations for their pancreatoduodenal NENs: 26 with Zollinger-Ellison syndrome, 4 with hypoglycemia, 3 with both Zollinger-Ellison syndrome and hypoglycemia, and 6 with nonfunctional neoplasms. Fifteen of these 39 patients had malignant disease on initial abdominal operation; 24 of 39 patients have not required abdominal reoperation, 17 of whom have available follow-up data. Of these 17 patients, 11 have biochemical evidence of disease recurrence (increased serum concentrations of gastrin, insulin, or pancreatic polypeptide), while 6 have no biochemical evidence of recurrence. A total of 30 abdominal reoperations were performed in 15 patients; 14 of 15 patients undergoing 1 or more reoperations developed evident malignant disease by their most recent operation. Nine of 13 reoperative patients with follow-up data have evidence of disease recurrence. Functional outcomes available in 20 patients showed that 10 patients require insulin and that 6 require oral hypoglycemic medications. Ninety percent have no abdominal pain or nausea/vomiting, while 4 are unable to return to work secondary to this disease., Conclusions: Treatment of MEN-1 pancreatoduodenal NENs is met with frequent recurrence and some treatment-related morbidity and mortality. Most patients (22 of 39) eventually demonstrated malignant growth, but, with this strategy, few died of this disease.

The efficacy and tolerability of cefadroxil were assessed in a controlled comparison of high-compliance oral dosage regimens among 100 patients with urinary tract infections. Each patient was randomly assigned to one of three cefadroxil treatment groups: 2,000 mg. once daily, 1,000 mg. once daily, or 1,000 mg. twice daily. Urine cultures at five to nine days post-treatment revealed cures in 27 of 36 patients in the 2,000-mg. daily group, 32 of 36 patients in the 1,000-mg. daily group, and 27 of 28 patients taking 1,000 mg. twice daily. Recurrence rates were extremely low in all treatment groups, and only 3 patients had evidence of limited side effects. The benefits of a convenient and readily understood dosage schedule are discussed.

Immunostimulation with agents such as Bacillus Calmette-Guérin (BCG) may represent an adjunctive treatment modality in patients with cancer of the bladder. To investigate the effects of direct inoculation, BCG was injected into the bladder of sensitized (PPD) and nonsensitized dogs. A marked and predictable inflammatory reaction was seen in all of the sensitized and in some of the nonsensitized dogs. This reaction was characterized by an extensive histiocytic infiltration with varying proportions of polymorphonuclear leukocytes, plasma cells, and lymphocytes. Follow-up examination of one dog 7 weeks after initial biopsy showed that this marked inflammatory reaction had resolved. Our findings suggest that in the future nonspecific immunopotentiators may play a role in the treatment of cancer of the bladder.

An assay allowing quantitation of monocyte function, i.e., chemotaxis, was used to study the activity of monocytes in patients with neoplasms of the urinary tract. Twenty-four subjects with various stages of renal carcinoma exhibited a mean chemotactic defect of 34% (P less than 0.005) as compared to normal controls and patients hospitalized with nonneoplastic diseases. Twelve persons with transitional cell carcinoma of the bladder had a 29.8% (P less than 0.01) mean chemotactic defect as compared to the controls. There was no correlation between tumor stage and degree of chemotactic defect;--J Natl Cancer Inst 55: 1047-1054, 1975.

We evaluated 39 patients with various stages of bladder carcinoma to determine alterations in monocyte function. Since the monocyte plays an important role in the effector arm of the immune system defective function may explain the host's inability to destroy neoplastic cells. As a group these 39 patients demonstrated defective monocyte monocyte function. There was no correlation between tumor stage and degree of chemotactic defect. Patients with invasive carcinoma had a significant return of monocyte chemotactic response toward normal postoperatively (p less than 0.005). Monocyte function was improved also in 3 patients who received Bacillus Calmette-Guerin immunotherapy (p less than 0.05).